Failure to Thrive
Deborah A. Frank
I. Description of the problem. Failure to thrive (FTT) refers to children, usually younger than 5 years, whose growth persistently and significantly deviates from the norms for their age and sex on the National Center for Health Statistics (NCHS) growth charts.
A. Epidemiology. Nutritional growth failure is seen in 8%-12% of children of low-income families. However, the prevalence of FTT in the general population is unknown.
B. Family transmission/genetics. Familial short stature may be considered when the child’s weight is appropriate to height and when linear growth velocity parallels the normal curve on the growth chart. It is, however, perilous to assume that poor growth, particularly low weight for height, in children is secondary to familial predisposition for several reasons:
Parental height may be a poor guide of the child’s growth potential if parents themselves were nutritionally deprived as children and therefore did not attain their optimal growth (as is often the case with immigrant and impoverished families).
The parents may have an eating disorder and be excessively concerned with obesity.
The child may share an organic problem with the parents (e.g., celiac disease).
C. Etiology.
1. “Organic” versus “nonorganic.” Traditionally, the etiology of FTT was considered either organic or nonorganic. However, this dichotomy is of limited use since children with so-called nonorganic FTT are suffering from malnutrition, a serious organic insult, whereas children with major organic diagnoses may, in part, have growth failure attributable to social and nutritional factors. Diagnostically and therapeutically, it is useful to assess each child and family along four parameters: (1) medical, (2) nutritional, (3) developmental, and (4) social. Problems in any or all of these areas may interact to produce growth failure. For example, a temperamentally passive child with iron deficiency may fail to receive frequent enough feedings from an exhausted mother who has other more demanding children.
2. Psychosocial causes.
a. Child may fail to thrive in families of any social class when parents’ emotional and material resources are diverted or not available from for the care of the child. This can occur because of poverty, parental depression, maladaptive parenting practices, family discord, substance abuse, domestic violence, or acute reaction to a recent loss or trauma (such as death of grandparent or unemployment), or depletion of a caregiver’s energy by another chronically ill family member of any age, but including other children with special healthcare needs.
b. FTT does not necessarily imply parental neglect or pathology. Feeding disorders can reflect numerous medical stressors (see below) or can develop in physically well children when not eating serves other purposes (e.g., to express anger, to exert autonomy from overly intrusive caretakers, to gain the attention of otherwise abstracted caretakers, or to divert adults from conflict with each other).
c. Children with preexisting minor developmental deficits (e.g., subtle oral motor difficulties, hypersensitivity to stimulation) may develop feeding problems that lead to nutritional FTT. Apathy and irritability associated with malnutrition may exacerbate parent-child interactional dysfunction and lead to further feeding difficulties.
d. Children living in poverty are often at nutritional risk because of inadequate food supplies in the home (“food insecurity”), homelessness, overcrowding, and the inability of federal feeding programs (e.g., SNAP (Supplemental Nutrition Assistance Program-formerly food stamps) supplemental food program for women, infants, and children (WIC), child care, or school meals) to reach many of the eligible families. In other cases, the benefit levels of such programs are insufficient to meet the nutritional needs of at-risk children.
Table 42-1. Often inapparent medical causes of FTT
Infectious
Giardiasis (other parasites, e.g., nematodes)
Chronic urinary tract infection
Chronic sinusitis
HIV
Mechanical
Adenoid and/or tonsillar hypertrophy
Dental lesions
Vascular slings
Gastroesophageal reflux
Neurologic
Oral motor dysfunction (gagging, tactile hypersensitivity, decreased or increased oral tone)
Toxic/metabolic
Lead toxicity
Iron deficiency
Zinc deficiency
Rickets
Inborn errors of metabolism
Gastrointestinal
Celiac disease
Malabsorption (various causes including cystic fibrosis)
Chronic constipation
Allergic
Food allergies (often presents as FTT with atopic dermatitis)
3. Medical causes.
a. The organic causes of FTT encompass a whole textbook of pediatrics. Usually most are suggested by a careful history and physical examination, but some are occult (Table 42-1). Inborn errors of metabolism are rare but catastrophic cause of FTT, often with an associated history of seizures, recurrent dehydration, or developmental regression.
b. Perinatal risk factors include prematurity and intrauterine growth retardation (IUGR). IUGR with dysmorphic features suggests a growth-retarding syndrome (genetic, congenital, or related to teratogen exposure).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
