Failure to Thrive (FTT) - Op Ghai Essential Pediatrics

Definition

• Weight for age below the 3rd percentile (some texts use 5th percentile) on standard growth charts on two or more occasions
• Crossing two or more major centile lines downward on a growth chart
• Weight less than 80% of the median weight for age (Gomez classification)
• Rate of weight gain significantly lower than expected for age

Classification

1. Organic FTT (~30%)

• Inadequate intake: cleft palate, oral motor dysfunction, congenital heart disease (fatigue during feeds), pyloric stenosis
• Malabsorption: celiac disease, cystic fibrosis, inflammatory bowel disease, cow's milk protein intolerance, giardiasis
• Increased metabolic demand: chronic infections (TB, HIV), congenital heart disease, hyperthyroidism, malignancy
• Endocrine: hypothyroidism, growth hormone deficiency, renal tubular acidosis
• Chromosomal/genetic: Down syndrome, Turner syndrome

2. Non-Organic FTT (~70%)

• Poverty and food insecurity
• Psychosocial deprivation, neglect, or poor caregiver-infant interaction
• Maternal depression
• Incorrect preparation of formula
• Restricted or inappropriate diets imposed by caregivers
• Feeding aversion or behavioral feeding difficulties

3. Mixed FTT

Evaluation

History

• Detailed dietary history (24-hour recall, feeding frequency, volume)
• Feeding behavior (refusal, vomiting, choking)
• Stooling and urine output
• Developmental milestones
• Family history, socioeconomic status
• Maternal mental health and caregiver-child interaction

Physical Examination

• Accurate anthropometry (weight, length, head circumference) plotted on growth charts
• Signs of specific nutritional deficiencies (rickets, vitamin A deficiency, iron deficiency)
• Dysmorphic features suggesting chromosomal causes
• Signs of underlying organic disease (organomegaly, cardiac murmurs, neurological signs)
• Observation of a feed

Investigations

• Complete blood count, peripheral smear
• Urine analysis and urine culture
• Blood urea nitrogen, creatinine, electrolytes
• Thyroid function tests (T4/TSH)
• Serum albumin/prealbumin (nutritional markers)
• Stool for ova, cysts, and fat globules
• Chest X-ray (if TB suspected)
• Further tests guided by clinical findings (sweat chloride, anti-tTG antibody, etc.)

Management

1. Nutritional Rehabilitation

• Calculate catch-up growth requirement: uses the formula based on recommended calories for the expected weight for height (not actual weight), typically 120-150 kcal/kg/day of expected weight
• Start with small, frequent, high-calorie feeds; avoid forcing
• Preferred route: oral feeding whenever possible
• Use energy-dense foods: add fats/oils, fortified porridges
• For infants: increase concentration of formula or use energy-supplemented breast milk
• Nasogastric or parenteral nutrition only if oral intake is impossible or severely compromised

2. Micronutrient Supplementation

• Iron supplementation (common deficiency)
• Zinc supplementation (accelerates catch-up growth)
• Vitamin A, D, multivitamins as indicated
• Correct any documented deficiency

3. Treatment of Underlying Cause

• Identify and treat organic conditions (e.g., treat TB, correct CHD, gluten-free diet for celiac)
• Treat infections (e.g., giardiasis, UTI)

4. Psychosocial and Environmental Interventions

• Parental counseling and education on proper feeding practices
• Improve caregiver-child interaction - positive feeding environment
• Address maternal depression if present
• Refer to social services if neglect or poverty is the cause
• Home visits by a health visitor or community health worker

5. Developmental Stimulation

• Children with FTT are at risk for developmental delay
• Early developmental stimulation and play therapy should be initiated alongside nutritional rehabilitation

6. Monitoring

• Weigh weekly during active rehabilitation
• Plot on growth chart at every visit to document catch-up
• Reassess dietary intake and feeding behavior regularly
• Monitor for refeeding syndrome when initiating feeds in severely malnourished children

7. Hospitalization Indications

• Severe malnutrition (Grade III/Gomez <60% expected weight)
• Dangerous electrolyte imbalances
• Failure of outpatient management
• Suspected abuse or neglect requiring safety evaluation
• Need for nasogastric tube feeds
• Diagnostic uncertainty requiring close observation

Prognosis

• Persistent short stature
• Cognitive deficits and poor school performance
• Emotional and behavioral problems