sign in sign up
<<
Home , Malnutrition

SPECIAL ISSUE ARTICLE Clinical Review of in Pediatric Patients Catherine Larson-Nath, MD; and Vincent F. Biank, MD, MS

carried with him throughout the day. The ABSTRACT family was busy, and both parents worked Failure to thrive (FTT) is a common problem that occurs when caloric intake is insuffi- different schedules, so they did not eat cient to maintain growth. For the majority of children it can be reversed with behavioral meals together. The patient did not have modifications and increased caloric provisions. In a minority of cases, FTT is the symptom any vomiting, abdominal pain, , of underlying organic . Routine evaluation with laboratory tests, imagining studies, or constipation. He had been previously and endoscopy results in an etiology of FTT in <1.4% of cases, and when investigations healthy and his family history was unre- are positive the organic etiology is most often suspected based on history and/or physical markable. His mother was 5 feet tall and examination. Therefore, these evaluations should be limited to those children with clear his father was 5 feet, 7 inches tall. Aside symptoms of organic disease and those who fail to grow with behavioral and nutritional from being thin, the patient had a normal interventions. [Pediatr Ann. 2016;45(2):e46-e49.] physical examination. You diagnosed the with FTT due to his weight-for length z-score of <-2 and ailure to thrive (FTT) is a state of ILLUSTRATIVE CASE his drop in weight-for-length z-score by under- that occurs when A 16-month-old boy presented with >2. He will meet his mid-parental height Fcaloric intake is insufficient to poor growth. Since birth, his z-scores for and did not have signs or symptoms of maintain growth. However, it may repre- weight and length had been approximately organic disease. You recommended that sent a symptom of an underlying systemic -1.5 and -1.3, respectively, and his weight- the family not allow the patient to “graze” disease or be a sign of inadequate caloric for-length z-score had been around -0.8 on and beverages throughout the day provisions for a child due to psychosocial over the same time period. At his current and instead provide him with 3 meals and or environmental factors. FTT is a com- visit, he weighed 7.9 kg (z-score of -2.58), 2 snacks per day that are served at a table mon problem encountered by clinicians, his length was 77 cm (z-score of -1.24), his with the family eating together. In addi- representing 5% to 10% of patients seen in weight-for-length z-score was -2.82, and tion, you advise the removal of juice from the outpatient setting.1,2 Depending on the his occipital-frontal circumference (OFC) his and only allowing water between criteria used, a Danish birth cohort dem- was 45 cm (z-score of -1.53). His parents meals and snacks. onstrated rates of FTT ranging from 1.3% described the patient as a picky eater. His At a follow-up examination 2 months to 22.2%.3 Despite the frequency of this favorite were chips and fruit snacks. later, the family had been able to imple- diagnosis, there has been much debate on He drank 16 oz of whole milk per day and ment your recommendations and his the definition of FTT. 30 oz of juice from a sippy cup that he weight had improved to 8.9 kg (z-score of -1.85), his length to 78.9 cm (z-score of -1.25), and his weight-for-length z-score to -1.74. Catherine Larson-Nath, MD, is an Assistant Professor, Department of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Minnesota. Vincent F. Biank, MD, MS, is a Clinical Assistant DEFINITION OF FAILURE TO THRIVE Professor of Pediatrics, University of Chicago, Pritzker School of ; and the Chief, Pediatric Gas- Currently, there are several criterion troenterology, Hepatology and Nutrition, NorthShore University HealthSystem. proposed to diagnose FTT (Table 1). How- Address correspondence to Catherine Larson-Nath, MD, Department of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Minnesota, 2450 Riverside Avenue, Minneapolis, MN 55454; ever, all the definitions of FTT require the email: [email protected]. children be plotted on an appropriate-for- Disclosure: The authors have no relevant financial relationships to disclose. age growth chart. Specifically, for children doi: 10.3928/00904481-20160114-01 younger than age 2 years a World Health

e46 Copyright © SLACK Incorporated SPECIAL ISSUE ARTICLE

TABLE 1. TABLE 2. Organization (WHO) growth chart should be used, and for children age 2 years and Etiologies of Failure to Traditional Definitions of older a US Centers for Disease Control Thrive Failure to Thrive (CDC) chart should be used. Inadequate intake Weight <75% of median weight-for-age 3 Olsen et al. have shown that the cri- Lack of food availability Weight <80% of median weight-for-length teria in Table 1 are not sensitive or spe- BMI for age <5th percentile cific in identifying all children with FTT. Difficulties with breast-feeding Weight for age <5th percentile There are many reasons that children may Improper formula preparation Length for age <5th percentile look like they have FTT but are actually Cleft lip and or palate Weight deceleration across >2 major growing at their potential; therefore, mul- Developmental delay percentiles since birth tiple factors need to be considered when Conditional in the lowest 5% using WHO growth velocity standards diagnosing a child with FTT. For instance, Inadequate absorption many children born large for gestational Celiac disease Abbreviations: BMI, ; WHO, World Health Organization. age will drop percentiles after birth to Pancreatic insufficiency reach their appropriate growth curve. Inflammatory bowel disease Twenty-five percent of normal children Eosinophilic esophagitis or gastroenteri- Up to 86% of children hospitalized with will drop more than 2 major percentile tis/ FTT have nonorganic etiologies of their lines,4 and 13% of children born small Cow’s milk enterocolitis FTT, and this percentage is likely higher in for gestational age will not have catch- Congenital diarrhea the outpatient setting.9 More recently, the di- up growth.5 Children with small parents Increased caloric expenditure chotomization of FTT into pure organic and will have lower genetic potential for Congenital heart disease nonorganic etiologies has been questioned. height, and children from families with Renal disease (eg, renal tubular acidosis) Even with organic FTT, behavioral aspects a history of constitutional growth delay Chronic pulmonary disease (eg, cystic often present. More specifically, organic are more likely to be small. In addition, fibrosis) pathology does not rule out the possibility some normal children will naturally be Laryngomalacia that environmental factors are also contrib- below the lowest major percentile for Malignancy uting to a child’s poor growth. Therefore, in age. Although there are many impostors many cases, a combination of organic and of FTT, some children who have chronic disease nonorganic factors contribute to a child’s poor growth may appear normal in regard poor growth.6,10-12 Etiologies of FTT may, to body mass index (BMI) and weight or also allow for better tracking of growth therefore, be categorized into inadequate ca- length once their height has started to be changes (for example, if a z-score improve- loric intake, inadequate caloric absorption, affected by under-nutrition. Therefore, the ment from -3.5 to -3 would not be observed or increased caloric expenditure (Table 3). preferred method for determining poor using percentile standards). As with percen- growth/malnutrition is through the use of tiles, absolute z-scores cannot be used for APPROACH TO THE PATIENT WITH anthropometric z-scores (Table 2).6,7 a child on the growth curve who is falter- POOR GROWTH Z-scores are standard deviations scores ing and for whom deceleration of z-scores The key to diagnosing FTT and eluci- and allow for more precision in describ- needs to be considered. Z-score calculators dating an etiology is a detailed history and ing poor growth, especially at the extremes for both WHO and CDC growth charts can physical examination. A detailed feeding of the growth curve. The 50th percentile be found online.8 history is required to determine if there are is equivalent to a z-score of 0 and the 3rd risk factors for organic disease causing a percentile is equivalent to a z-score of -1.89. CAUSES OF FAILURE TO THRIVE child to have FTT. Important considerations When using a percentile chart, the most ac- Traditional thinking dichotomizes the regarding feeding history include prepara- curate any child may be described is <3rd etiology of FTT into organic and non- tion of formula, duration and frequency of percentile. Percentiles do not differentiate organic categories. Organic etiologies are feeding and meals, feeding environment, between a child with a z-score of -2.5 and reversible with treatment of the underlying and signs of distress with feeding such one with a z-score of -3.5 when the later disease, whereas nonorganic etiologies of as coughing or gagging. Intake, includ- child is at more nutritional risk. Z-scores FTT improve with behavioral interventions. ing types and variety of foods the child is

PEDIATRIC ANNALS • Vol. 45, No. 2, 2016 e47 SPECIAL ISSUE ARTICLE

TABLE 3. Therefore, unless there are striking findings based on history and examination to sug- Failure to Thrive Defined by Malnutrition Z-Scores gest an organic etiology, behavioral inter- ventions and increased calories should be Anthropometric Moderate the first-line treatment in managing FTT. Measurements Mild Malnutrition Malnutrition Severe Malnutrition If behavioral and nutritional interven- Weight-for-height/BMI -1 to -1.9 -2 to -2.9 ≤ -3 tions fail, further evaluation should be con- z-score sidered. Laboratory evaluations that many Length/height z-score - - -3 ≤ be considered include complete Mid-upper arm circum- -1 to -1.9 -2 to -2.9 ≤ -3 count, electrolytes, blood urea nitrogen, ference z-score albumin, celiac screening if exposed to Weight gain velocitya <75% expected <50% expected <25% expected gluten (anti-transglutaminase immuno- (<2 years) globulin A and immunoglobulin A level), (≥2 years) 5% body weight 7.5% body weight 10% body weight and erythrocyte sedimentation rate. Imag- Deceleration of weight- -1 z-score -2 z-scores -3 z-scores ing studies that may be considered include for-length z-score an upper gastrointestinal fluoroscopy series Abbreviation: BMI, body mass index. aBased on World Health Organization data.20 for persistent vomiting (beyond normal in- Adapted from a consensus statement from the American Society for Parenteral and Enteral Nutrition.7 fant reflux) to assess for malrotation, head imaging, echocardiogram, and chest X-ray. Genetic screening may be necessary if the consuming and volume of liquids, paying Social history should focus on who physical examination suggests a genetic particular attention to juice, soda, milk, and feeds the child and the environment in etiology. water, must also be ascertained. This is of- which the child eats, and should also tease ten best done through a 24-hour food recall out any difficulties accessing food. INTERVENTIONS or 3-day food diary. Accurate anthropometric measurements Interventions in a child with FTT are Past medical history is important to ob- are a critical part of the physical examina- aimed at optimizing growth, including tain, including any chronic illnesses, histo- tion in a patient with FTT. For children catch-up growth, through behavioral inter- ry of frequent , and developmen- younger than age 2 years, weight should be ventions and increased caloric provision tal delay. Important family history factors obtained nude or in a clean, dry diaper. For (Table 4). include a history of constitutional growth children age 2 years or older, weight should Behavioral interventions are mostly de- delay in parents. In cases of constitutional be obtained in light clothing without shoes. rived from the feeding-disorder literature. growth delay, after about age 6 months, A length board should be used up until age Meals should be provided at an appropri- a child will most often be proportionally 2 years to obtain length, and a stadiometer ate location such as in a highchair or at a small with low weights, lengths, and OFCs, should be used for children age 2 years or table, depending on the developmental sta- whereas children with FTT will tend to older. Beyond anthropometric measure- tus of the child. Meals and snacks should have their weight drop off first, then their ments, a detailed physical examination be structured and at appropriate frequency height, and lastly OFC. Mid-parental height looking for signs of organic disease and for the child’s age. Young infants should is also important to calculate to assess if a neglect is important in guiding the provider feed no less frequently than every 3 hours child would reach their genetic potential by when evaluating a child with FTT. and older children should have 3 meals and continuing on their current growth curve. 2 snacks a day. Mealtimes should be lim- Mid-parental height is calculated by the EVALUATION ited to no more than 20 to 30 minutes and following equation, and a child should fall Evaluation of FTT through laboratory children should not be allowed to “graze” within 8.5 cm of their mid-parental height tests, imaging, and endoscopy rarely un- throughout the day. Only water should be once they reach their adult height: covers an etiology of FTT. Studies have provided between meals and snacks to en- shown that 0.8% to 1.4% of tests lead to courage at mealtimes. No juice or an organic etiology of FTT, and in these sweetened beverages should be provided as (Maternal Height [in cm] + Paternal Height studies all etiologies were expected based juice is low in calories (15 kcal/oz) and [in cm] [+5 cm if male; -5 cm if female] / 2) on history and physical examination.9,13 has been shown to contribute to FTT.14

e48 Copyright © SLACK Incorporated SPECIAL ISSUE ARTICLE

Paediatr Suppl. 1994;399:64-70; discussion TABLE 4. For infants, increased caloric provision 71. may be as simple as assuring that formula Interventions in Failure to 6. Markowitz R, Watkins J, Duggan C. Failure is being mixed properly. It also can be ob- Thrive to thrive: malnutrition in the pediatric outpa- tained by fortifying formula or breast-milk tient setting. In: Walker WA, ed. Nutrition in Behavioral Pediatrics. 3rd ed. Hamilton, ON: BC Deck- to 22, 24, or 27 kcal/oz. For older children, er; 2008:479-489. Eliminate grazing increased calories can be obtained by add- 7. Becker P, Carney LN, Corkins MR, et al. ing and oils to foods or by providing Meals and snacks at appropriate frequency Consensus statement of the Academy of Nu- for child’s age trition and Dietetics/American Society for increased-caloric beverages. Increased- Limit mealtimes to 20-30 minutes Parenteral and Enteral Nutrition: indicators caloric beverages should only be used if recommended for the identification and doc- Provide meals in a developmentally ap- behavioral interventions do not improve umentation of pediatric malnutrition (under- propriate location (eg, highchair) nutrition). Nutr Clin Pract. 2015;30(1):147- weight gain; they should be provided with No juice or -sweetened beverages 161. meals and snacks, and should be offered Only water between meals and snacks 8. Centers for Disease Control and Prevention. Growth charts. http://www.cdc.gov/growth- for the shortest time possible. Nutritional If these measures are not effective, then charts/. Accessed January 27, 2016. Assure proper preparation of formula 9. Berwick DM, Levy JC, Kleinerman R. Fail- hospitalization may be considered. The pri- Fortify formula or breast-milk to 22, 24, or ure to thrive: diagnostic yield of hospitalisa- mary goal of hospitalization is to observe 27 kcal/oz tion. Arch Dis Child. 1982;57(5):347-351. parent-child interactions and implementa- 10. Schwartz ID. Failure to thrive: an old nem- Add oils and fats to foods esis in the new millennium. Pediatr Rev. tion of behavioral interventions. Studies Provide increased caloric beverage with 2000;21(8):257-264. have shown short-term benefits of hos- meals and/or snacksa 11. Gahagan S. Failure to thrive: a conse- quence of undernutrition. Pediatr Rev. pitalization for FTT in regard to catch-up a Increased-caloric beverages should only be used when 2006;27(1):e1-11. growth, but evidence of sustained long- other interventions have failed and should be used for the shortest time possible. 12. Jaffe AC. Failure to thrive: current clinical term benefits are lacking.15 Any child who concepts. Pediatr Rev. 2011;32(3):100-107. does not show growth while hospitalized 13. Sills RH. Failure to thrive. The role of clini- warrants further evaluation through labora- cal and laboratory evaluation. Am J Dis Child. 1978;132(10):967-969. tory tests, imaging, and endoscopy as in- tions and increased caloric provision. 14. Smith MM, Lifshitz F. Excess fruit juice dicated and may benefit from enteral tube Further evaluation, including laboratory consumption as a contributing factor in placement. testing, imaging, and endoscopy should be nonorganic failure to thrive. Pediatrics. 1994;93(3):438-443. limited to those children with significant 15. Fryer GE. The efficacy of hospitalization of OUTCOMES findings on clinical examination and those nonorganic failure-to-thrive children: a meta- In the developing world, untreated mal- children who fail behavioral management. analysis. Child Abuse Negl. 1988;12(3):375- 381. nutrition clearly results in poorer outcomes 16. Fink G, Rockers PC. Childhood growth, with regard to growth and development.16 REFERENCES schooling, and cognitive development: fur- Studies regarding long-term growth out- 1. Mitchell WG, Gorrell RW, Greenberg RA. ther evidence from the Young study. Failure-to-thrive: a study in a primary care comes of children with FTT in the devel- Am J Clin Nutr. 2014;100(1):182-188. setting. Epidemiology and follow-up. Pedi- 17. Black MM, Dubowitz H, Krishnakumar A, oped world are limited, but point toward atrics. 1980;65(5):971-977. Starr RH. Early intervention and recovery lower mean weights and heights.17 Infancy 2. Daniel M, Kleis L, Cemeroglu AP. Etiology among children with failure to thrive: fol- and childhood are critical times for neuro- of failure to thrive in infants and toddlers low-up at age 8. Pediatrics. 2007;120(1):59- referred to a pediatric endocrinology outpa- 69. logic development, although the effects of tient . Clin Pediatr. 2008;47(8):762- 18. Black MM, Dubowitz H, Hutcheson J, FTT on this development are not clearly 765. Berenson-Howard J, Starr RH. A random- understood. Children with FTT have been 3. Olsen EM, Petersen J, Skovgaard AM, Weile ized clinical trial of home intervention for B, Jorgensen T, Wright CM. Failure to thrive: children with failure to thrive. Pediatrics. shown to have similar to slightly lower the prevalence and concurrence of anthropo- 1995;95(6):807-814. IQs than those without FTT, but they have metric criteria in a general infant population. 19. Corbett SS, Drewett RF. To what extent is more trouble with math.18,19 Arch Dis Child. 2006;92(2):109-114. failure to thrive in infancy associated with 4. Bennett WE, Hendrix KS, Thompson RT, poorer cognitive development? A review and Carroll AE, Downs SM. The natural history meta-analysis. J Child Psychol Psychiatry. CONCLUSION of weight percentile changes in the first year 2004;45(3):641-654. FTT is a common problem seen by the of . JAMA Pediatr. 2014;168(7):681-682. 20. World Health Organization. Child growth primary care provider. Most cases of FTT 5. Albertsson-Wikland K, Karlberg J. Natural standards. http://www.who.int/childgrowth/ growth in children born small for gestational standards/w_velocity/en/. Accessed January can be reversed with behavioral interven- age with and without catch-up growth. Acta 27, 2016.

PEDIATRIC ANNALS • Vol. 45, No. 2, 2016 e49