Failure to thrive Dr. Mohamed Haseen Basha Assistant professor ( Pediatrics) Faculty of Medicine Al Maarefa College of Science and Technology

Failure to thrive (FTT) Failure to thrive (FTT) results from inadequate usable calories necessary for a child’s metabolic and growth demands. Patients with FTT may either have growth deceleration, faltering growth, or even weight loss. Inadequate weight for corrected age, weight for height, and body mass index, as well as failure to gain adequate weight over a period of time, help define FTT. Growth parameters should be measured serially and plotted on growth charts appropriate for the child’s sex, age, and, if preterm, post conceptual age.

Definition Failure to Thrive weight for height ratio less than 2 SD (or <3 or 5 percentile) for age and gender weight crossing 2 major percentiles on the growth curve.

Failure to thrive Normal child

Etiology The most commonly used classifications are: Nonorganic FTT It encompasses FTT due to inadequate nutrition or insufficient emotional or physical nurturing without distinct pathophysiologic abnormality. This process has been described as a reactive attachment disorder and implies the absence of underlying organic disorders. Ex: Neglect or abuse (Psychosocial dwarfism) Hypervigilance (extreme parental attention) Poor nutrition (inexperienced or poorly educated parents or caregivers and poverty).

Organic FTT It is due to underlying disease process pertaining to Gastrointestinal: Gastroesophageal reflux, pyloric stenosis, malabsorptive condition, e.g. celiac disease, lactose intolerance, chronicliver disease, protein-losing enteropathy or food allergies. Pulmonary: Cystic fibrosis, Broncho pulmonary dysplasia, chronic hypoxic states. Endocrine: Hyperthyroidism, adrenal failure, diabetes mellitus, diabetes insipidus, hypopituitarism. Neurologic: Degenerative brain disease, cerebral palsy, mitochondrial disorders.

Metabolic and Genetic: Inborn errors of metabolism, Genetic syndromes, chromosomal defects, e.g. Prader-Willi Syndrome. Infectious: Parasitic infestations, tuberculosis, acquired and congenital immune-deficient states. Renal: Chronic renal failure, renal tubular acidosis, nephrogenic diabetes insipidus, recurrent urinary tract infections. Hematologic: Fanconi’s anemia.

Etiologic classifications of failure to thrive • Inadequate caloric intake or retention – Inadequate amount of food provided – Poor breastfeeding technique – Structural causes of poor feeding, e.g. cleft palate – Persistent vomiting – Anorexia of chronic disease • Inadequate absorption – Coeliac disease – Chronic liver disease – Pancreatic insufficiency, e.g. cystic fibrosis – Chronic diarrhea

• Excessive caloric utilization – Urinary tract infection – Chronic respiratory disease, e.g. cystic fibrosis – Congenital heart disease – Diabetes mellitus – Hyperthyroidism • Other medical causes – Genetic syndromes – Inborn errors of metabolism • Psychosocial factors – Parental depression – Coercive feeding – Distractions at meal times – Poverty – Behavioral disorders – Poor social support, Neglect – Family discord

Approach to FTT History Failure to thrive evaluation includes a detailed history and physical examination including anthropometry. History Prenatal and postnatal history: History of intrauterine infections (TORCH), Term or Preterm, Maternal age. Family history: History of neonatal deaths, Heights or weights of parents and siblings. Neonatal problems: Birth weight and length, Any feeding issues Familial and psychosocial factors: Poverty, homelessness, domestic violence, parental employment and parental substance abuse should be specifically enquired

Dietary history: The dietary history should assess adopted method of feeding. Breastfeeding frequency and duration. If the patient is on formula feeds, formula preparation, volume consumed and feeding techniques should be enquired. A detailed history of formula preparation may reveal a dilute formula that contains insufficient calories and excess water. Initiation and adequacy of complementary feeds should also be assessed. Quantitative calorie calculation is employed to quantify the deficit, if any. Following factors should be evaluated: ■ Lack of support system—relatives and friends ■ Psychiatric problems in the family ■ Severe illness or death in the family ■ Marital problems and parental discord.

Physical Examination

Anthropometry Detailed anthropometric measurements including weight, height, head circumference, etc. are required. Review child’s present and previous growth parameters. In the situations where previous record is not available, it is advisable to follow the child for weight gain. Detailed neurodevelopmental assessment should be performed

Specific behavior patterns like unusual watchfulness, decreased vocalization, lack of cuddliness, head banging, rocking movements and rumination should be looked for, which may give a positive clue for nonorganic FTT Dysmorphologic features, if any Signs of abuse and neglect, vitamin and nutrient deficiencies Systemic examination for the presence of any cardiac murmur, organomegaly, muscle tone abnormality and other neurologic findings are noticed.

Approach to Failure to Thrive Based on Signs and Symptoms

Investigations First line CBC ferritin ESR, CRP Urine analysis Complex metabolic panel to include glucose, creatinine, serum calcium, and liver function tests Lead level Anti-endomysial antibodies Thyroid function

Second line Urine microscopy and culture Allergy testing Serum amino acids Urine amino acids and organic acids Stool microscopy and culture Stool fat and elastase Sweat test PPD and HIV screen MRI Endoscopy with mucosal biopsies Impedance/pH probe Bone age Skeletal survey ECG, Echocardiogram

Management The major goals of management are: • Nutritional rehabilitation • Treating an organic cause, if detected • Managing psychosocial and developmental issues.

Treatment requires multidisciplinary approach by understanding all the elements that contribute to a child’s growth, child’s health and nutritional status, family issues and parent-child interaction. An appropriate feeding atmosphere at home is important for all the children with the failure to thrive. In mild malnutrition, the therapy should concentrate on the ways to increase oral caloric intake in an outpatient setting. Common indications for hospitalization are: • Weight for height less than 70% of the median • Non-response to outpatient management • Suspect abuse or neglect • Detailed evaluation for a suspected organic disorder.

Nutritional rehabilitation Nutritional inadequacy being the major contributor, Unless there is a strong suspicion of an organic cause, one should proceed directly for a 2-weeks’ trial feeding. Most children will require 1.5–2 times the expected intake for age to achieve optimal catch-up growth. An experienced dietician should be involved in planning and supervising the diet. Locally available and culturally acceptable food items are sufficient. Every effort should be made to feed the child orally. If oral feeding is inadequate, tube feeding may be tried for short periods. At the end of 2 weeks of trial feeding, the child is reassessed and weight gain recorded. A good intake during the feeding trial and a good response in terms of weight gain suggest that the primary problem was nutritional deprivation.

Organic Causes 20% cases of FTT are due to organic causes. • Diet in renal failure: Calories: RDA + 20% extra Protein allowance according to glomerular filtration rate (GFR) and weight Sodium restricted to 500 mg/day. • Diet in congestive cardiac failure (CCF): RDA or up to 10% of calories Sodium restricted to half to one gram per day. Diet in respiratory distress: 10–20% extra calories. Diet in pancreatic insufficiency: Fat as medium-chain triglyceride (MCT) or coconut oil can be given Pancreatic enzyme supplementation.

Failure of Nutritional Rehabilitation Further investigations are required for a child who fails to respond to the two weeks’ trial of feeding. A major concern remains the impact of poor growth and nutrition upon cognitive, behavioral and social development. There are reports of a significant association between the severity of growth deficiency and intelligence quotient (IQ). It is estimated that up to 55% of infants with FTT may have developmental delay, and that those with a history of FTT may continue to demonstrate learning difficulties and developmental delay 5 years after initial presentation. It requires dedicated efforts right from the care of pregnant females to promotion of breastfeeding, timely introduction and adequate complementary feeding and a loving and supportive environment for the children to reach their full potential, both physically and mentally.

Evaluation of FTT

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