Failure to thrive

Definition

Failure to thrive (FTT) is a term used to describe children whose physical growth over time is inadequate when compared to a standard growth chart.

Description

There is no universally accepted definition of failure to thrive, though it has been recognized as a medical condition since the early 1900s. It describes a condition rather than a specific disease. Children are considered as failing to thrive when their rate of growth does not meet the expected growth rate for a child their age. The difficulty lies in knowing what rate of growth is expected for any individual child, since many factors, including race and genetics, may influence growth.

Recognizing abnormal growth requires an understanding of normal infant growth. Infants normally lose up to 10 percent of their weight in the first few days of life. However, this weight should be regained within two weeks. The average full-term baby doubles its birth weight by six months and has tripled it by one year. Children with failure to thrive are often not meeting those milestones. If a baby continues to lose weight or does not gain weight as expected, he or she is probably not thriving.

Children who fail to thrive are either not receiving or have an inability to take in or retain adequate nutrition in order to gain weight and grow. If the condition progresses, the undernourished child may become irritable and/or apathetic and may not reach typical developmental markers such as sitting up, walking, and talking at the usual ages.

Demographics

The incidence of growth failure of American children is difficult to assess. Failure to thrive is believed to affect up to 5 percent of the population but is most common in the first six months of a child's life. It is commonly seen in babies born prematurely. Most diagnoses of failure to thrive are made in infants and toddlers in the first few years of life. An estimated 10 percent of children seen in primary care settings have symptoms of failure to thrive. The condition can appear in all socioeconomic groups, although it is seen more frequently in those families experiencing poverty. There is an increased incidence among children receiving Medicaid, those living in rural areas, and in children who are homeless.

Causes and symptoms

Failure to thrive may have several underlying causes. The causes of failure to thrive are typically differentiated into organic and non-organic. Organic causes are those caused by an underlying medical disorder. Inorganic causes are those caused by a caregiver's actions. However, these definitions are simplified, as both medical and behavioral causes often appear together.

Organic causes of failure to thrive may include:

• premature birth, especially if the fetus had intrauterine growth retardation
• maternal smoking , alcohol use, or illicit drugs during pregnancy
• mechanical problems present, resulting from a poor ability to suck or swallow, for example, presence of cleft lip and cleft palate
• unexplained poor appetites that are unrelated to mechanical problems or structural abnormalities, for example, breathing difficulties that can result from congestive heart failure (Any difficulty in breathing makes eating more difficult and can result in FTT. Inadequate intake also can result from metabolic abnormalities, excessive vomiting caused by obstruction of the gastrointestinal tract, or kidney dysfunction. In addition, gastroesophageal reflux causing regurgitation of formula or refusal of feeding.)
• poor absorption of food, inability of the body to use absorbed nutrients, or increased loss of nutrients

Some examples of non-organic causes of failure to thrive are:

• poor feeding skills on the part of the parent
• dysfunctional family interactions
• difficult parent-child interactions
• lack of social support
• lack of parenting preparation
• family dysfunction, such as abuse or divorce
• child neglect
• emotional deprivation

Studies show that only between 5 percent and 26 percent of FTT cases are due to a purely organic cause. Children in abusive or neglectful families are at higher risk of FTT, but these cases make up only a small proportion of the total. The most common cause of failure to thrive is malnutrition , either as part of an organic problem or simply because of an energy imbalance.

The following symptoms are possible indications of failure to thrive:

• delayed social and mental skills
• delayed development of secondary sexual traits in adolescents
• height, weight, and head circumference in an infant or young child not progressing as expected on growth charts
• edema (swelling)
• wasting
• enlarged liver
• rashes or changes in the skin
• changes in hair texture

When to call the doctor

Parents should notify their physician if their child does not seem to be developing at a normal pace. If parents notice a drop in weight or if the baby does not want to eat, the doctor should be notified. A major change in eating patterns also warrants contact.

Diagnosis

If a child fails to gain weight for three months in a row during the first year of life, physicians normally become concerned. The most important part of a physician's evaluation is taking a detailed history. Prenatal history is important, and the doctor will want to know if the pregnant mother smoked, consumed alcohol, used any medications, or had any illness during the pregnancy. The doctor will also want a dietary history, to determine if there have been any feeding problems. A history of how formula is mixed is important, because improperly prepared formula can result in failure to thrive. Parents will also be asked about whether the child had any illnesses, as some can cause a problem with the growth potential of children. A family and social history will also be done.

Doctors diagnose failure to thrive by plotting the child's weight, length, and head circumference on standard growth charts. Children who fall below a particular weight range for their age or who dip below two or more percentile curves on the chart over a short period of time will likely have a more thorough evaluation to find out if there is a problem. A complete blood count, various serum chemical and electrolyte tests, and a urinalysis may be helpful in discovering any underlying medical disorders. The doctor will want to determine if the child is receiving enough nourishment. To do this, the parents will be asked to record what the child eats each day, and a subsequent calorie count will be done. The doctor may also talk to the parents to help identify any home problems like financial difficulties, household stress, or neglect.

It is important to remember that some children will normally fall below the standards on growth charts. If children are full of energy, interacting normally with their parents, and show no signs of illness, then they are probably not failing to thrive and are just smaller children.

Once the diagnosis of failure to thrive has been made, the physician will attempt to determine if it is from an organic or non-organic cause.

Treatment

Because there are numerous factors that may contribute to a failure to thrive diagnosis, children diagnosed with the disorder sometimes have an entire medical team working on the case. If there is an underlying physical cause, correcting that problem may reverse the condition. The doctor will recommend high-calorie foods and place the child on a high-density formula like Pediasure. More severe cases may involve tube feedings, which can take place at home. A child with extreme failure to thrive may need hospitalization , during which he or she can be fed and monitored continuously. This will give the treatment team an opportunity to also observe the caregiver's interactions with the child.

The duration of treatment will vary from child to child. Weight gain takes time, so several months may go by before a child returns to his normal weight range. Children requiring hospitalization usually stay for approximately two weeks or more to get them out of danger, but many months can pass before the symptoms of malnutrition disappear.

Nutritional concerns

The long-term goal for every child with FTT is to provide adequate energy intake for growth. Therefore, even if no causative factor is uncovered for a child with FTT, aggressive dietary management is the key to successful treatment. Proper feeding can be achieved through infant formulas that are adjusted to meet the child's specific nutrient needs. Infants may be given concentrated formulas, assuming their kidney function is normal. In cases of kidney disorders, increasing the fat content of the formula may be useful as a way of delivering additional calories. Older children with FTT may benefit from adding cheese, sour cream, butter, margarine, or peanut butter to meals. Also, high-calorie shakes can be used to supplement meals. Multivitamin and mineral supplements, including iron and zinc, usually are recommended to all undernourished children. Tube feeding is usually not indicated except for severe cases of malnutrition.

Prognosis

Whether FTT results from organic or non-organic reasons, children with this condition require aggressive calorie supplementation. Some cases may lead to significant developmental delays in children. The cognitive outcome of children who have had FTT is not clear, and this may lead to emotional and behavioral problems later. However, carefully looking for the causes of failure to thrive and implementing calorie supplementation is important for obtaining a positive outcome in these children.

Prevention

Initial failure to thrive caused by physical defects cannot be prevented but can often be corrected before they become a danger to the child. Maternal education as well as emotional and economic support systems may help to prevent failure to thrive in those cases where is no physical deformity.

Parental concerns

Parents who note any of the symptoms of failure to thrive should report them to their child's physician so that treatment can begin.

Resources

BOOKS

Bremmer, J. Gavin, et al. The Blackwell Handbook of Infant Development. Oxford, UK: Blackwell Publishing, 2004.

Slater, Alan, et al. Introduction to Infant Development. Oxford, UK: Oxford University Press, 2002.

PERIODICALS

"Failure to Thrive." Update (June 17, 2004): 567.

Krugman, Scott D., and Howard Dubowitz. "Failure to Thrive." American Family Physician 68 (September 1, 2003): 5, 879–84.

WEB SITES

Bassali, Reda W., and John Benjamin. "Failure to Thrive." Emedicine , August 11, 2004. Available online at http://www.emedicine.com/ped/topic738.htm (accessed January 11, 2005).

"Failure to Thrive." Kidshealth.org , February 2001. Available online at http://www.kidshealth.org/parent/growth/growth/failure_thrive.html (accessed January 11, 2005).

"Failure to Thrive." MedlinePlus , November 3, 2002. Available online at http://www.nlm.nih.gov/medlineplus/ency/article/000991.htm (accessed January 11, 2005).

Deanna M. Swartout-Corbeil, RN