A 12-year-old African American boy with cerebral palsy-quadriplegia was brought to clinic as mother was having progressive difficulty feeding him (Figure 53-1). He had not been seen in the office since age 9 years when he plotted at the 20th percentile for both weight and length on the cerebral palsy-quadriplegia growth chart. Mother stated that she was having difficulty obtaining his supplemental 1.5cal/cc supplement that had been prescribed and her son was becoming progressively more selective regarding intake of solids. School officials also reported feeding difficulty. On examination, he appeared emaciated. Length, weight, and BMI were far below the 5th percentile. Labs including a celiac antibody panel, comprehensive metabolic panel, CBC with differential, sedimentation rate, and thyroid function studies were normal with the exception of mild lymphopenia and a low pre-albumin. Swallow evaluation showed oropharyngeal dysphagia characterized by residuals and delay in swallow onset. A trial of nasogastric (NG) feeds resulted in rapid weight gain with good tolerance. A gastrostomy was subsequently placed for supplemental feeds. Close follow-up was scheduled with the nutritional support team, his physician, and social services.
Failure to thrive (FTT) is a clinical sign, rather than a diagnosis. A wide variety of medical conditions and psychosocial factors contribute to FTT. Potential long-term complications of FTT include permanent cognitive impairment with decreased IQ, short stature, and serious infections due to immune deficiency.
Occurs more commonly in children living in poverty.
Affects 5 to 10 percent of children in the primary care setting.1
Up to 50 percent of children with FTT are not identified by health care providers.
More than 90 percent of cases are purely nutritional, with no identifiable underlying medical condition.
Causes of FTT are currently classified into the following categories: inadequate caloric intake, inadequate absorption or increased losses, increased metabolic needs, or ineffective utilization.1,2
Behavioral problems interfering with meals/inappropriate feeding habits.
Dysfunctional parent-child relationship.
Neglect (Figure 53-2).
Poverty.
Inadequate lactation.
Improper formula preparation.
Suck/swallow dysfunction (esophageal motility dysfunction, CNS, neuromuscular, anatomic-cleft lip, or palate) (Figure 53-3).
Feeding fatigue (anemia, genetic syndrome, cerebral palsy, neuromuscular disease, CNS structural abnormality).
Feeding refusal (reflux or eosinophilic esophagitis, aspiration).
Recurrent emesis.
Necrotizing enterocolitis.
Protein malabsorption (cow milk protein allergy, enterokinase deficiency).
Pancreatic insufficiency (cystic fibrosis, chronic pancreatitis, Shwachman-Diamond syndrome).
Liver disease.
Celiac disease—See Chapter 60, Celiac Disease.
GI tract infections.
Carbohydrate malabsorption.
Short bowel syndrome.
Inflammatory bowel disease—See Chapter 59, Inflammatory Bowel Disease.
Congenital heart disease—See Chapters 42 and 43, Acyanotic Congenital Heart Disease and Cyanotic Congenital Heart Disease.
Chronic lung disease.
Chronic systemic infection (congenital infections, HIV)—See Chapter 187, Congenital Infections.
Chronic metabolic disorder (adrenal insufficiency, diabetes mellitus, hyperthyroidism, inborn errors of metabolism) (Figures 53-4 and 53-5).
Kidney disease (renal tubular acidosis).
Chronic systemic disease (systemic lupus erythematosus, juvenile idiopathic arthritis)—See Chapters 172 and 173, Juvenile Idiopathic Arthritis and Lupus—Systemic and Cutaneous.
Malignancy.
Inflammatory bowel disease—See Chapter 59, Inflammatory Bowel Disease.
Genetic Syndromes (Trisomy 21, Turner, Russell-Silver syndromes)—See Chapters 221 to 228.
FIGURE 53-5
Hepatosplenomegaly and abdominal distension in a young infant who has severe developmental delay. This infant was diagnosed with Niemann-Pick syndrome, a lysosomal storage disorder. (Used with permission from Cleveland Clinic Children’s Photo Files.)
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