1. Telehealth Rounds Friday, April 7th, 2017
Failure to Thrive
Telehealth Rounds
Friday, April 7th, 2017

2. Objectives Definition of failure to thrive
Review the use of WHO Growth Charts
Patterns of normal growth
Become comfortable with the differential diagnosis of FTT
Develop an approach to the child with failure to thrive
When to refer to a pediatrician

3. Definitions
Failure to thrive is can be considered to be a symptom and suggests inadequate caloric intake to meet the child’s requirements
Growth curves
Crossing more than 2 percentiles
Plotting below the 3rd percentile (weight-for-age or weight- for-length)
Typically see FTT in children under the age of 2 years
The definition is not entirely clear – no consensus –
Growth curve definitions are challenging – crossing 2 lines on the WHO curves is a more significant drop and should be evaluated – some children may be persistently on the 3rd or 5th percentile which could be normal for their genetic potential
Weight typically decreased before length. HC is typically the last measure to be affected.
Weight deceleration is the most common (versus weight loss)
The growth TREND is much more important than a single plotted value

4. Long-term consequences
Nutrient deficiency
Reduced final adult height
Developmental, behavioural and cognitive effects are unclear

5. WHO Growth Charts
The GOLD STANDARD for assessment of growth in children
Growth standards based on healthy, well-nourished children
6 different countries
Breastfed infants
Five percentiles (3rd, 15th, 50th, 85th, 97th)
Growth charts are used to regularly plot height, weight and HC (if <2y) – their use helps to identify early concerns with a child’s health (either over or under nutrition)
WHO charts have been recommended since 2010 by the CPS (but have been available since 2007)
CDC charts should no longer be used (not all children were healthy, US data only, fewer breastfed infants) – used to have 6 percentiles

7. Normal Growth Intrauterine vs. extra-uterine environment
Breastfed vs. formula fed infants
Caloric requirements:
kcal/kg/day for the first year
Birth weight:
Often reflects placental function and the intrauterine environment more than genetic potential
Ie: smoking, diabetes, maternal diet, drug use, prematurity, post-dates
Extrauterine environment:
Regain birth weight by days of life
BW typically has doubled by 4-6 months
Breast fed infant gain weight more rapidly over first 6 months
Breastfeeding difficulties are common and can prevent optimal growth
Formula fed babies typically gain more weight between 6-12 months of age
EBM/Formula = 67kcal/100ml

8. Differential Diagnosis
Inadequate calorie intake
Feeding difficulties – ie: ARFID, oral-motor challenges, autism
Social factors
Poor appetite (ie: Genetic syndromes)
Impaired calorie utilization or absorption (ie: malabsorption)
Cow’s milk protein allergy
Celiac disease
Cystic fibrosis
Type 1 diabetes
Can use a broad categorical approach
Calorie intake:
Breastfeeding difficulties
Improper formula preparation
Parental feeding expectations/practices
Food insecurity
Calorie utilization
Celiac disease (usually presents after 1 year of age
CF – a negative NBS does not rule it out, not screened for in Quebec patients

9. Differential Diagnosis (2)
Increased metabolic demand
Systemic illness (malignancy, CF, CHD, renal disease, BPD)
Genetic syndromes (RSS, Turner’s)
Intrauterine growth restriction (IUGR)

10. Patterns of FTT to help with diagnosis
Adjusting towards genetic potential
Usually both height and weight affected
Inadequate caloric intake
Weight affected primarily
Endocrinopathy
Height affected primarily

11. Approach to FTT History
Pregnancy history: growth, gestational age, maternal GDM, HTN, infections, maternal smoking
Birth weight
Past medical history
Developmental concerns
Obviously also take a medical history
Do a systems-based ROS looking for

12. Approach to FTT Feeding history (what, when, where)
Breast, formula or a combination (frequency, duration, volumes, fdg difficulties)
Vomiting, gagging, choking
Stools (mucous, blood, frequency, steatorrhea)
Feeding behaviours
Food allergies
Stress related to feeding/eating

13. Approach to FTT Family History CMPA Food allergies Celiac disease
Inflammatory bowel disease, JIA, renal disease
Constitutional growth delay
Genetic syndromes

14. Approach to FTT Social History Stressors
Parent experience/family values or cultural beliefs
Parental mental health
Substance use
Parental education level
Social support system
Psychosocial stressors are a major contributor to FTT in children

15. Review of systems Temperament Sleep Parental attachment/stress
Voiding and stooling patterns
System-based screen for underlying illness

16. Approach to FTT
Ensure that measurements are accurate and plot them on the WHO growth charts
Calculate the midparental height to help determine genetic potential
Maternal height (cm) + paternal height (cm) +/- 13cm / 2
Add 13cm if the child is male, subtract 13cm if the child is female
Plot the midparental height on the growth chart for children years

17. Physical Exam General appearance
Look for features of genetic syndromes
Muscle wasting, decreased subcutaneous fat
Signs of neglect or abuse
Identify signs of chronic disease (ie: heart murmur, abdominal mass, pallor, distended abdomen)
Neglect: severe diaper rash, eczema, poor hygiene, bruising, torn frenulum

18. Investigations Basic investigations CBC, renal and liver panels
Iron studies
inflammatory markers
Albumin
TSH
Urinalysis
Consider in special cases only:
Sweat test
Bone age
Vitamin levels
Fecal elastase
Serum immunoglobulins
Celiac screen
HIV serology
Step-wise approach to minimize unnecessary testing
Use the history and physical to guide you.
Often no investigations are require initially
Urinalysis for RTA
Additional tests:
Sweat test for CF
Bone age for growth hormone deficiency
Vitamin levels for fat malabsorption
Fecal elastase for pancreatic insufficiency

19. Management Optimize nutritional intake Education & reassurance
Follow growth closely
Additional specialists may be required
Psychologist
Occupational therapist
Optimize nutritional intake
Lactation consultant for breastfeeding difficulties
Formula supplementation
Dietitian consultation
Toddler feeding strategies – ’The Division of Responsibility’
Assess patient every 2-3 months until an acceptable growth trend is present, then follow less closely

20. Management – Behavioural Strategies
Structured mealtimes at the table
Reduce meal time distractions
Allow children to feed themselves
Offer a ‘tasting’ menu and then provide additional helpings if the child desires
Solids before liquids
Positive reinforcement

21. Pediatric Referral
When no etiology can be identified and there is significant growth failure
If you suspect a genetic syndrome
If you suspect an endocrinopathy
When there is significant parental stress and concern

22. Take Away Points
The WHO growth charts are the gold standard for tracking growth
Crossing percentiles in growth during the first 2-3 years of age is common but is not typical after 3 years of age
The differential diagnosis can be simplified by thinking about inadequate calories in, inadequate absorption or increased metabolic demand
The most common cause of FTT is inadequate caloric intake – assessment by a dietitian is almost always helpful
The majority of infants and children will require minimal investigations

23. Resources
WHO Growth Curves available online at Infant/WHO-Growth-Charts.aspx
Dieititians of Canada Handout “Is my child growing well”, available online at b7-b12f-b9fccb26745c/ChildGrowth2014_E.pdf.aspx

24. Questions?

25. References
Position Statement: Promoting optimal monitoring of child growth in Canada: Using the new World Health Organization growth charts. Canadian Pediatric Society. Published June 1, Accessed online on April 4, 2017:
The toddler who is falling off the growth chart. Canadian Pediatric Society. Published Oct 1, Accessed online on April 4, 2017:
Failure to thrive: Current Clinical Concepts. Pediatrics in Review (2011). Volume 32, Issue 3.
Failure to thrive. Chapter 41. Nelson’s Textbook of Pediatrics, 20th Edition. P 250 -