Author:
Roger M.Barkin
Description
- Not a single disease, but a description of a group of signs and symptoms
- Inadequate physical growth:
- Usually diagnosed earlier than age 2 yr
- Broadly divided into:
- Organic (underlying medical condition)
- Nonorganic (no underlying medical condition)
- Found in all socioeconomic groups
- Poverty increases risk of failure to thrive (FTT)
- May result in long-term growth, behavioral, and developmental difficulties, particularly in children who fail to thrive in the first few months of life
Etiology
Many diseases with unique causes resulting in 1 or more of:
- Inadequate caloric intake
- Inadequate caloric absorption, malabsorption
- Excessive caloric expenditure
- These may be secondary to underlying chronic disease
Signs and Symptoms
- No universally accepted definition
- Failure to achieve or maintain a growth rate appropriate for age
- Weight <2 stand ard deviations below normal for age (corrected for prematurity) and sex
- Weight that crosses downward through 2 major percentiles (major percentiles are 5th, 10th, 25th, 50th, 75th, and 90th percentiles) on stand ard growth chart (see “Additional Reading”)
- There is an associated change in the velocity of growth of 1 or more growth parameters. Any of the 3 routinely monitored growth parameters may be impaired initially:
- Weight loss initially followed by impaired growth in length/height and finally head circumference usually caused with caloric inadequacy
- Primary length/height fall-off often associated with endocrinology problem
- Impairment in growth of head circumference commonly caused by CNS primary condition
- Although the pattern is usually one of slow decrease in growth velocity, an abrupt change may occur, usually indicative of an organic origin
- Can manifest as:
- Reduced muscle mass
- Loss of subcutaneous fat
- Alopecia
- Dermatitis
- Chronic disease
- Marasmus
- Kwashiorkor
- Associated endocrinologic findings
- Abnormal neurologic exam and development
- Decreased immunologic function and increased risk of infection
History
- Detailed feeding history:
- Breastfeeding:
- Prior breastfeeding experience
- Frequency of feedings
- Length of feedings
- Family support for breastfeeding
- Formula:
- Type of formula (milk, soy, elemental, preemie)
- How formula is prepared (ready to feed, powder, liquid concentrate)
- Frequency of feedings
- Volume per feeding
- Solid foods
- Vomiting associated with feeds
- Urine and stool output:
- Gestational history:
- Maternal medical complications
- Drug or alcohol use
- Birth history:
- Complications, intrauterine growth retardation, prematurity
- Birth weight
- Congenital anomalies
- Intrauterine exposures/infections
- Developmental history:
- Achievement of appropriate milestones
- Child's perceived temperament
- Psychosocial history:
- Family composition
- Family/social support
- Stresses
- Maternal depression
- Abuse or neglect
Physical Exam
- Weight, length/height, head circumference:
- Plotted on appropriate growth chart:
- Include as many prior growth points as possible
- Dysmorphic features:
- Cardiac disorders
- Pulmonary disorders
- GI disorders
- Skin exam to include signs of child abuse
Essential Workup
- Detailed history and physical exam
- Growth parameters plotted on appropriate growth charts
- Observation of family-child interaction
- Direct observation of feeding
- CBC, CRP, electrolytes, urinalysis and urine culture, and if indicated, lead level
Diagnostic Tests & Interpretation
Lab
- CBC:
- Anemia
- Infection
- Leukemia/malignancy
- Lead level
- Lead poisoning
- Chemistry panel (electrolytes, BUN, creatinine, glucose, liver function, protein, albumin, calcium, phosphate, magnesium):
- Hydration and acidosis
- Metabolic and endocrinologic disorders including thyroid disease. Often checking the routine newborn screening (NBS) is useful
- Diabetes mellitus
- Renal disease
- Blood gas analysis
- Renal tubular acidosis
- Inborn errors of metabolism
- Urinalysis with culture:
- HIV
- Stool studies including occult blood, culture, and ova and parasites
Diagnostic Procedures/Surgery
- pH probe:
- Sweat chloride test:
- Cystic fibrosis (may be part of NBS)
- Tuberculin skin testing
Differential Diagnosis
- Organic causes:
- GI:
- Malabsorption syndromes
- Celiac disease
- Cystic fibrosis
- Food allergy
- Inflammatory bowel disease
- Hepatobiliary disease
- Hepatitis
- Cirrhosis
- Biliary atresia
- Obstructive disease
- Pyloric stenosis
- Malrotation
- Hirschsprung disease
- Pancreatitis
- Short gut syndrome
- Gastroesophageal reflux
- Vitamin deficiencies
- Cardiac:
- Congenital heart disease
- Cyanotic
- Congestive
- Acquired heart disease
- Pulmonary:
- Bronchopulmonary dysplasia
- Obstructive sleep apnea
- Chronic lung disease
- Cystic fibrosis
- Hematologic/oncologic:
- Iron-deficiency anemia
- Thalassemia
- Lead poisoning
- Leukemia
- Renal:
- Chronic renal insufficiency
- Renal tubular acidosis
- Recurrent UTIs
- Neurologic/CNS:
- Immunologic:
- Endocrine:
- Diabetes mellitus
- Thyroid/parathyroid disease
- Adrenal disease
- Growth hormone deficiency
- Hypopituitarism
- Hypophosphatemic rickets
- Infectious:
- Genetic/congenital:
- Fetal alcohol syndrome
- Smith-Lemli-Opitz syndrome
- Cleft lip/palate
- Inborn errors of metabolism
- Many genetic syndromes can contribute
- Toxic
- Nonorganic causes:
- Parent-child dysfunction:
- Mother-infant bonding problems
- Maternal mental illness/substance abuse
- Inexperienced mother
- Breast-feeding difficulties
- Improper formula preparation
- Inadequate availability of formula
- Chaotic family environment
- Child abuse or neglect
- Munchhausen syndrome by proxy
Initial Stabilization/Therapy
- Check for hypoglycemia
- Fluid resuscitation when dehydrated
- Supportive/nonjudgmental environment
ED Treatment/Procedures
- Recognize/identify child with FTT
- Rule out organic abnormalities:
- Organic causes may have specific treatments
- Social services consult
- Breast-feeding consult:
- Advise on appropriate feeding
Medication
Dependent on underlying cause
Disposition
Admission Criteria
- Organic cause requiring medical admission or concomitant serious health condition
- Nonorganic causes to observe caregiver-child interaction
- Nonorganic causes to observe weight while monitoring oral intake. This is particularly appropriate in children <3-6 mo of age because of the potential impact upon cognitive development
- Suspected child abuse/neglect
- Severe dehydration, malnutrition, or electrolyte imbalance
- Failure to achieve expected growth parameters
- Weight gain despite several months of outpatient management
Discharge Criteria
- Case appropriately managed by primary care physician
- Follow-up is adequate to provide close monitoring of intake and growth
- Safe home environment. Cooperative parents
Issues for Referral
Interdisciplinary team or subspecialist, depending upon suspected etiology