A Synopsis of AFPs "Failure to Thrive: An update"

Failure to Thrive: An Update
SARAH Z. COLE, DO, Mercy Family Medicine Residency, St. John’s Mercy Medical Center, St. Louis, Missouri, JASON S. LANHAM, MAJ, MC, USA, Eisenhower Army Medical Center, Ft. Gordon, Georgia
http://www.aafp.org/afp/2011/0401/p829.pdf
Am Fam Physician. 2011 Apr 1;83(7):829-834.

     Failure to thrive (FTT) is defined as a child's lack of appropriate growth or growth maintenance when values are plotted on standardized growth charts. There are common criteria to diagnose FTT. The parameters are:

< 5%ile of BMI, weight, weight velocity, OR length for age,
Weight gain dropping past 2 major %ile lines,
Weight < 75% of median weight for age OR length.

A child with true FTT should have a combination of more than one of the above criteria. Weight for length is the best indicator for nutritional treatment. Some patients, such as premature infants, those with small parents, or who were LGA babies may deviate from the charts. 
     The most common cause seen in the office is due to inadequate calorie intake. Inadequate absorption and excessive caloric expenditure are also issues. Inadequate caloric intake can be due to improper breastfeeding technique, problems transitioning to solid food, insufficient calorie consumption, excessive juice drinking, or parents not giving high calorie foods (baby diets).  GERD, IBS, or improper formula preparation can also be the culprit. Parents may not be knowledgeable about proper nutrition, not capable of understanding nutrition, or simply not being able to afford it. Neglect or abuse could also be the cause. Inadequate calorie absorption can occur through emesis, celiac disease, chronic diarrhea, food allergies, or inborn metabolic errors. Excessive caloric expenditure could be from thyroid disease, chronic pulmonary disease, congenital heart disease, malignancy or immunodeficiency.
     A detailed history is as important as with any other patient. Questions should be asked about eating habits, proper latching techniques, and a quantification as to how much the patient consumes during breast feeds. If the patient is a toddler, it is important to differentiate between a picky eater and a toddler who is refusing food.  Food journals and measuring caloric intake can be helpful as well.  A review of symptoms that detects recurrent infections, respiratory problems, vomiting, diarrhea, may be due to an organic problem. Red flag signs for an organic cause include:

cardiac findings, 
developmental delay, 
dysmorphic features,
failure to gain weight even with proper calorie intake,
recurrent respiratory, urinary or mucocutaneous infections,
or recurrent vomiting, diarrhea, or dehydration.

When these red flags are seen, lab testing should be considered. Studies show that when an organic symptom was not found, almost all of the patients were determined to have a behavioral cause for the FTT. A psychosocial history is important from the caregiver and the child, if possible. 
     During a physical examination, proper weight and height measurements should be rechecked. The physician should have the infant undressed for an accurate weight and to observe for signs of abuse or neglect. Positive signs of malnutrition through neglect or abuse will necessitate a hospital admission. 
     Treatment consists of treating the organic cause of FTT. If there is no organic cause, the parent should be given guidance for catch up growth and counseling.  Calorie dense food or formulas, or formula supplementation in breast fed infants can help. The patient should avoid excessive juice or milk. Gravies, sauces, and butter can be added to increase calories to meals. Medications such as megestrol or cyproheptadine promote weight gain, but have not been studied for cases of FTT.
     If untreated, malnutrition can lead to developmental and cognitive problems. Low birth weight preterm infants with FTT have long term problems such as poor academic performance and lower cognitive abilities. They have a smaller statute as well. Results of whether normal birth weight infants who become FTT have long term issues are mixed. Some studies show poorer math skills and shorter statue, while others show no change in IQ. Regardless of the studies, proper prevention is the key to reducing long lasting effects in these patients.