Failure to thrive

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

Various definition such as weight for age less than the 5th percentile for age, weight for height less than the 5th percentile for age or a drop in more than two percentiles on the growth chart may be used. The initial approach involves a thorough history and physical examination. The most common presenting complaint is poor growth and failure to gain weight. Nutritional interventions such as regular breastfeeding, eating with the child, measuring the caloric requirement of the child or ensuring the child eats with an upright posture should be added to psychological interventions like parent education and maintaining a discord free family environment.

Amidst rapidly rising infant and child death rates, Dr. Henry Dwight was the first to add a clean environment and constant supervision to the management strategy of failure to thrive patients. As time has progressed, red flags and the present strategy of nutritional rehabilitation followed by a vigilant and prolonged follow up period has been developed.

There is no established classification system for failure to thrive. Based on cause, it may be divided into organic and non-organic failure to thrive.

The most common cause of failure to thrive is inadequate calorie intake. This may be secondary to psychological causes, poor environmental status, poor calorie absorption and underlying medical conditions that cause excessive energy expenditure.

Causes of failure to thrive are mainly organic and non-organic. Organic causes are further divided into inadequate calorie intake, inadequate calories absorption and increased calorie expenditure.

It is important to differentiate failure to thrive into organic and non-organic causes. Furthermore, using the concepts of bone age, chronological age, catch up growth and catch down growth, conditions such as constitutional growth delay and familial short stature should also be considered.

The prevalence of failure to thrive depends on the development status of the country. Studies have suggested a prevalence rate of approximately 5% in the United States of America.

It is important to differentiate risk factors from causes. Major risk factors to be considered include an unsafe, dirty environment, history of parental psychiatric illness, substance abuse, marital conflict, low birth weight, chromosomal disorders and dental caries.

There are no established screening protocols established for failure to thrive.

The most common presenting complaint is poor growth and failure to gain weight. The patient may have more specific complaints depending on the underlying cause. A few important complications include a diminished final weight and height, vitamin deficiencies and an increase risk of recurrence of failure to thrive. Not much data is available on the prognosis of failure to thrive as it is a multifactorial process. However, the duration of malnutrition is directly proportional to the cognitive and physical decline of the patient.

There is no diagnostic study of choice for failure to thrive. Various definition such as weight for age less than the 5th percentile for age, weight for height less than the 5th percentile for age or a drop in more than two percentiles on the growth chart may be used. The initial approach involves a thorough history and physical examination. This will help narrow the diagnosis, identify red flags and then determine the need for hospitalization.

The most common presenting complaint is poor growth and failure to gain weight. The patient may have more specific complaints depending on the underlying cause. A few important complications include a diminished final weight and height, vitamin deficiencies and an increase risk of recurrence of failure to thrive. Not much data is available on the prognosis of failure to thrive as it is a multifactorial process. However, the duration of malnutrition is directly proportional to the cognitive and physical decline of the patient.

The patient encounter provides a good opportunity to not only physically examine the patient, but to also notice the interaction between the parents and the child. Murmurs, structural deformities such as cleft lip or palate, crackles secondary to a cystic fibrosis related pneumonia or rashes secondary to physical abuse are some important positive findings. With proper technique, anthropometric measurements should be plotted and compared with previous measurements.

Lab investigations are ordered based on the initial history and physical examination findings.it may be ordered to uncover conditions such as iron deficiency anemia secondary to malabsorption, hyperthyroidism, renal failure or an underlying malignancy.

There are no specific ECG findings associated with failure to thrive.

X-rays are useful in diagnosing organic causes of failure to thrive. Listing down each organic cause is beyond the scope of this microchapter.

Echocardiography and ultrasounds are useful in diagnosing organic causes of failure to thrive.

CTs are useful in diagnosing organic causes of failure to thrive.

MRIs are useful in diagnosing organic causes of failure to thrive. Listing down each organic cause is beyond the scope of this microchapter.

Barium swallow may be helpful in the diagnosis of failure to thrive.

There are no other diagnostic studies associated with failure to thrive.

Appetite stimulants such as cryptoheptadine and progesterones may be employed in patients with failure to thrive. However, these are not recommended. Medical therapy employed also depends on the underlying organic cause.

Nutritional interventions such as regular breastfeeding, eating with the child, measuring the caloric requirement of the child or ensuring the child eats with an upright posture should be added to psychological interventions like parent education and maintaining a discord free family environment.

Surgery may be employed for certain organic causes of failure to thrive such as a renal transplant, small intestinal bowel obstruction, thyroidectomy or closure devices placed for congenital heart diseases.

Regular anthropometric measurements added to an adequate, balanced diet and a healthy environment are some important primary preventive strategies.

There are no established measures for the secondary prevention of failure to thrive.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

Amidst rapidly rising infant and child death rates, Dr. Henry Dwight was the first to add a clean environment and constant supervision to the management strategy of failure to thrive patients. As time has progressed, red flags and the present strategy of nutritional rehabilitation followed by a vigilant and prolonged follow up period has been developed.

• In the early 1900s, infant and child death rates in the United States were skyrocketing.
• In 1915, an American pediatrician, Dr. Henry Dwight Chapin, institutionalized marasmic infants under constant medical and nursing supervision. ^[1]
  • He reported decreased mortality rates with this strategy of a multidisciplinary approach, nutritional rehabilitation and maintaining a proper home environment.
• In 1952, Rene Spitz used the term ‘hospitalism’ for children who presented with growth failure, malnutrition and anaclitic depression.
  • He noticed a synergy between caloric deprivation and lack of emotional stimulation causing failure to thrive.
• In 1957, Coleman and Provence concluded that failure to thrive could only be avoided in the complete absence of emotional or caloric deprivation and in the presence of a good home environment. ^[2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

There is no established classification system for failure to thrive. Based on cause, it may be divided into organic and non-organic failure to thrive.

• There is no established classification for failure to thrive.
• Based on cause, failure to thrive is divided into^[1][2][3]:
  1. Organic causes
  2. Non-organic causes
• Organic causes are further divided into those that are due to:
  1. Inadequate calorie intake
  2. Excessive calorie expenditure
  3. Inadequate calorie absorption

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

The most common cause of failure to thrive is inadequate calorie intake. This may be secondary to psychological causes, poor environmental status, poor calorie absorption and underlying medical conditions that cause excessive energy expenditure.

• The most common cause of failure to thrive is inadequate calorie intake. ^[1]
• This may be secondary to psychological causes, poor environmental status, poor calorie absorption and underlying medical conditions that cause excessive energy expenditure. ^[2]
• The pathophysiology of failure to thrive is a culmination of environmental, psychological, pathological and nutritional factors.
• In terms of the pathophysiology, failure to thrive is a contributing rather than an exclusive cause of the patient’s over all condition.
  • A healthy, disease free, stressor-free, clean environment should be maintained for adequate growth of the child. Absence of this contributes to failure to thrive. ^[3]
  • Increased parental conflict, decreased discipline where feeding techniques are concerned, poor education, separation, emotional deprivation, use of alcohol, tobacco or illicit drugs are psychological contributors to failure to thrive.
• It is beyond the scope of this page to explain the pathophysiology of every organic cause.^[4]
• However, malabsorption syndromes, cystic fibrosis, pancreatic insufficiency, malignancies, congenital heart disease, immunodeficiencies causing recurrent infections, intestinal obstructions and chronic respiratory disease are some common organic pathologies that cause either impaired calorie absorption or increased calorie demand.
• But irrespective of the cause, all patients have one thing in common, a treatment strategy which is based on calorie catch up growth and a subsequent prolonged follow up period.
• It is a learning process for the parents and emotions may get the better of them initially. Slow, apathetic babies may be ignored whereas voraciously feeding small for gestational ages may be handled aggressively as they are anxiety/tension provoking.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

Causes of failure to thrive are mainly organic and non-organic. Organic causes are further divided into inadequate calorie intake, inadequate calories absorption and increased calorie expenditure.

• The most common cause of failure to thrive is inadequate calorie intake. ^[1][2]
• Causes can broadly be divided into organic and non-organic causes. ^[3]

1. Non organic causes include^[4]:
   1. Social, psychological, and environmental factors
   2. Non accidental trauma – subdural hematoma
   3. Low socioeconomic status
   4. Child neglect, abuse, and poor parent-child interaction
   5. Poverty
   6. Poorly educated parents
2. Organic causes can further be subdivided into; ^[5][6][7]
   1. Inadequate caloric intake
   2. Excessive calorie expenditure “Failure To Thrive – StatPearls – NCBI Bookshelf”.
   3. Inadequate calorie absorption “Failure to Thrive: A Practical Guide – American Family Physician”.

Inadequate calorie intake	Excessive calorie expenditure	Inadequate calorie absorption
Poverty and inadequate food storage Feeding difficulties- poor infant feeding technique, improperly reconstituted formula, uninhibited access to high calorie food, behavioral problems related to feeding Inadequate breast milk production, breastfeeding failure, errors in artificial feeding, poor latch/suck strength Mechanical or structural problems with swallowing; cleft lip, cleft palate, neuromuscular disease, motor neuron disease Prenatal insult – worsening of prematurity or intrauterine growth restriction Erratic diets – unorthodox beliefs, Munchausen syndrome by proxy Systemic diseases causing decreased appetite, anorexia, and food refusal.	Chromosomal conditions – trisomy 13,trisomy 18, trisomy 21, Turner’s syndrome Congenital heart disease – cyanotic and non-cyanotic heart diseases. Teratogenic exposures – anti-epileptics, tetracyclines Endocrine dysfunction – growth hormone deficiency, type 1 Diabetes mellitus Cirrhosis of liver Chronic respiratory illness, intrauterine infections Malignancy Thyroid dysfunction Renal tubular acidosis, Renal failure Increased Intracranial pressure Immunodficiency syndrome causing recurrent infections, e.g. HIV	Bowel obstruction – Ladd bands, paralytic ileus, small intestinal bowel obstruction Necrotizing enterocolitis /Short bowel syndrome Pyloric stenosis Gastro-esophagal reflux disease Cystic fibrosis Pancreatic insufficiency Malabsorption Pancreatic insufficiency, Celiac disease Giardiasis Inflammatory bowel disease Inborn errors of metabolism – amino acid disorders, lysosomal storage diseases Enzyme deficiencies Biliary atresia Cow’s milk protein allergy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

It is important to differentiate failure to thrive into organic and non-organic causes. Furthermore, using the concepts of bone age, chronological age, catch up growth and catch down growth, conditions such as constitutional growth delay and familial short stature should also be considered.

• The differential diagnoses of failure to thrive ranges from gastro-esophageal reflux disease to pediatric HIV infections.
• Measuring bone age and comparing it with chronological age can help the physician differentiate between syndromes like constitutional growth delay and familial short stature. ^[1]
  • Constitutional growth delay– patients have a low weight for age, low height for age and bone age < chronological age early on in their lives. This is followed by a growth spurt during adolescence where catch up takes place. Infants have a more severe catch down growth. ^[2]
  • Familial short stature– parents have a positive family history and their bone age matches their chronological age. Children have a projected adult height that is within their anticipated adult height, based on their mid parental height.

^[3]

• • Chromosomal disorders- special considerations should be made when measuring infants with disorders such as trisomy 13, trisomy 21, Turner syndrome or premature infant with a history of intrauterine growth restriction.
  • Catch down growth – A sudden drop over two major percentiles may be noted after an initial high rate of growth. The infant may simply be adjusting it’s growth rate to match it’s genetic potential.
• A thorough history and physical examination will help the physician to differentiate between organic and non- organic causes.
• Non-organic causes include^[4][5][6]:

1. Social, psychological, and environmental factors
2. Non accidental trauma – subdural hematoma
3. Low socioeconomic status
4. Child neglect, abuse, and poor parent-child interaction
5. Poverty
6. Poorly educated parents

• Organic causes can further be subdivided into;
  1. Inadequate caloric intake
  2. Excessive calorie expenditure
  3. Inadequate calorie absorption

Inadequate calorie intake	Excessive calorie expenditure	Inadequate calorie absorption
Poverty and inadequate food storage Feeding difficulties- poor infant feeding technique, improperly reconstituted formula, uninhibited access to high calorie food, behavioral problems related to feeding Inadequate breast milk production, breastfeeding failure, errors in artificial feeding, poor latch/suck strength Mechanical or structural problems with swallowing; cleft lip, cleft palate, neuromuscular disease, motor neuron disease Prenatal insult – worsening of prematurity or intrauterine growth restriction Erratic diets – unorthodox beliefs, Munchausen syndrome by proxy Systemic diseases causing decreased appetite, anorexia, and food refusal.	Chromosomal conditions – trisomy 13,trisomy 18, trisomy 21, Turner’s syndrome Congenital heart disease – cyanotic and non-cyanotic heart diseases. Teratogenic exposures – anti-epileptics, tetracyclines Endocrine dysfunction – growth hormone deficiency, type 1 Diabetes mellitus Cirrhosis of liver Chronic respiratory illness, intrauterine infections Malignancy Thyroid dysfunction Renal tubular acidosis, Renal failure Increased Intracranial pressure Immunodficiency syndrome causing recurrent infections, e.g. HIV	Bowel obstruction – Ladd bands, paralytic ileus, small intestinal bowel obstruction Necrotizing enterocolitis /Short bowel syndrome Pyloric stenosis Gastro-esophagal reflux disease Cystic fibrosis Pancreatic insufficiency Malabsorption Pancreatic insufficiency, Celiac disease Giardiasis Inflammatory bowel disease Inborn errors of metabolism – amino acid disorders, lysosomal storage diseases Enzyme deficiencies Biliary atresia Cow’s milk protein allergy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

The prevalence of failure to thrive depends on the development status of the country. Studies have suggested a prevalence rate of approximately 5% in the United States of America.

• A study in India found that 40% of the population were affected by mild to moderate malnutrition whereas western literature suggests a prevalence of 8% in the pediatric population. ^[1]
• Failure to thrive is seen more in children < 2 years of age and during their teenage years when the growth rate of the child is at it’s highest.
• The incidence of non-organic failure to thrive has been reported to be somewhere between 30%-50% in the failure to thrive patients. ^[2]
• There is no gender or race predisposition.
• It is found in those families who suffer from a lack of financial resources/education and are burdened with additional stressors like family discord, infidelity, psychiatric conditions, alcohol or drug abuse, etcetera. “Failure to Thrive: A Practical Guide – American Family Physician”.
• Gretchen Homan et al reported that failure to thrive is prevalent in up to 10% of children in primary care and approximately 5% of those who are hospitalized.
• Another study suggested that failure to thrive accounts for up to 5% of the pediatric admissions for children less than 2 years of age.
• 15-30% of children seen by acute care services suffer from growth deficits. “Failure To Thrive – StatPearls – NCBI Bookshelf”.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

It is important to differentiate risk factors from causes. Major risk factors to be considered include an unsafe, dirty environment, history of parental psychiatric illness, substance abuse, marital conflict, low birth weight, chromosomal disorders and dental caries.

• Risk factors may be environmental, psychological or pathological. “Failure to Thrive: A Practical Guide – American Family Physician”.
• These include^[1][2][3][4] :
  1. Family dysfunction – financial difficulties, marital feuds, infidelity, geographic moves
  2. Lack of support systems – relatives, neighbors, or friends
  3. Poor parenting skills,
  4. Parents with psychiatric illnesses (e.g. postpartum depression) or those with a history of substance abuse
  5. Medical Conditions predisposing to increase calorie expenditure and decreased calorie absorption/intake. (refer to the ‘causes’ microchapter of this page)
  6. Low birth weight
  7. Dental caries
  8. Tongue tie
  9. Prematurity

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

There are no established screening protocols established for failure to thrive.

• There are no established screening protocols established for failure to thrive.
• Screening mainly involves frequent monitoring of anthropometric measurements such as weight for age, height for age, weight for height and head circumference.
• One should also enquire about environmental, psychological and nutritional factors that contribute to failure to thrive at each well child visit.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

The most common presenting complaint is poor growth and failure to gain weight. The patient may have more specific complaints depending on the underlying cause. A few important complications include a diminished final weight and height, vitamin deficiencies and an increase risk of recurrence of failure to thrive. Not much data is available on the prognosis of failure to thrive as it is a multifactorial process. However, the duration of malnutrition is directly proportional to the cognitive and physical decline of the patient.

• Though the scope for differentials and investigations is broad, nothing is more specific and time efficient in diagnosing a patient with failure to thrive than an accurate history.
• Patients typically present with weight loss, signs of malnutrition and specific manifestations of environmental/psychological/ organic causes. ^[1]
• Given the various psychological and environmental influences on failure to thrive, a physician should take a detailed history with a slight degree of skepticism.
• To obtain a complete picture, history taking should be performed when both parents are present. Hearing what only one parent has to say is analogous to examining a patient without a stethoscope. ^[1]
• If the child is hospitalized, then a second history is often more valuable than the first as the physician may ask questions that did not spring to mind the first time along. Keen attention should be paid to the parents’ ability to provide details but also their attitudes to the entire history taking process. “Failure to Thrive: A Practical Guide – American Family Physician”.
• The following are important history taking questions: “Failure To Thrive – StatPearls – NCBI Bookshelf”. ^{[2] [3][4]}
• The chief complaints commonly are:
  1. Poor weight gain, poor growth, baby not getting enough milk, crying too often, and refusing feeds
  2. Recurrent respiratory infections, gastroenteritis, fussiness, fatigue, irritability, stomatitis, cheilosis –vitamin deficiency or immunodeficiency syndromes, recurrent exposure to a parent who may be a primary contact.
  3. Urinary symptoms – frequency, urgency, foul smell, dysuria, fever of unknown origin, change in color
  4. Bowel habits – stool frequency, stool consistency, recurrent episodes of vomiting, blood or mucus in stool
  5. Poor development in terms or work habits or performance in school.
  6. Growth pattern –
  • Children with no remarkable history findings and a normal physical/behavioral examination may have a decreased growth of two major percentiles as they begin to match their genetic potential which may be set at a lower growth rate – Catch down growth.
  • Compare bone age and chronological age of the patient to differentiate between constitutional growth delay and familial short stature.

• Failure to thrive is a contributing rather than an exclusive cause of the complications seen.
• Each case of failure to thrive is different as there are psychological, environmental, and pathological components to it. There are very few long-term outcome studies for one to comment with certainty.
• Complications include: ^[1][5][2][4]
  1. Poor weight gain
  2. Short stature
  3. Anti-social personality
  4. Highrisk of recurrent infections
  5. Development delay; educational and behavioral problems.
  6. Malnutrition, vitamin deficiencies – pallor, rickets, stomatitis, cheilosis, edema, dermatitis.
  7. Cognitive skill deficits, poor work habits
  8. Future recurrence of failure to thrive
  9. Aggressive nutritional rehabilitation may cause refeeding syndrome; seizures, arrythmias, encephalopathy, circulatory decompensation, etcetera.
  10. Decreased weight, height and head circumference.
• The prognosis of the child depends on the severity and duration of malnutrition. However, failure to thrive is not associated with a decrease in the intelligent quotient.

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