Failure to thrive
Failure to thrive (FTT), more recently known as faltering weight or weight faltering, is a term used in pediatric medicine, as well as veterinary medicine (where it is also referred to as ill-thrift), to indicate insufficient weight gain or inappropriate weight loss. When not more precisely defined, the term refers to pediatric patients. In children, it is usually defined in terms of weight, and can be evaluated either by a low weight for the child's age, or by a low rate of increase in the weight.
|Failure to thrive|
|Classification and external resources|
The term ‘failure to thrive’ has been used vaguely and in different contexts to refer to different issues in pediatric growth. It is most commonly used to describe a failure to gain weight, but some providers have also used it to describe a failure to grow, or a failure to grow and to gain weight. As used by pediatricians, it covers poor physical growth of any cause and does not itself imply abnormal intellectual, social, or emotional development, although it can subsequently be a cause of such pathologies. The term has been used in different ways, and different objective standards have been defined. FTT is suggested by a fall in one or more weight centile spaces on a WHO growth chart depending on birth weight or when weight is below the 2nd percentile of weight for age irrespective of birth weight. In children whose birth weight was between the 9th and 91st percentile FTT is indicated by a drop across 2 or more centile spaces. Weight loss after birth is normal and most babies return to their birth weight by 3 weeks of age. Clinical assessment for FTT is recommended for babies who lose more than 10% of their birth weight or do not return to their birth weight after 3 weeks.
FTT may be evaluated through a multifaceted process, beginning with a patient history that notably includes diet history, which is a key element for identifying potential causes of FTT. Next, a complete physical examination may be done, with special attention being paid to identifying possible organic sources of FTT. This could include looking for dysmorphic features, abnormal breathing sounds, and signs of specific vitamin and mineral deficiencies. The physical exam may also reveal signs of possible child neglect or abuse. Based on the information gained from the history and physical examination, a workup can then be conducted, in which possible sources of FTT can be further probed, through blood work, X-rays, or other tests.
Traditionally, causes of FTT have been divided into endogenous and exogenous causes. These causes can be largely grouped into three categories: inadequate caloric intake, inadequate nutrient absorption, and increased metabolism. Initial investigation should consider physical causes, calorie intake, and psychosocial assessment.
- Endogenous (or "organic")
- Causes are due to physical or mental issues with the child itself. It can include various inborn errors of metabolism. Problems with the gastrointestinal system such as gas and acid reflux, are painful conditions which may make the child unwilling to take in sufficient nutrition. Cystic fibrosis, diarrhea, liver disease, anemia or iron deficiency, and coeliac disease make it more difficult for the body to absorb nutrition. Other causes include physical deformities such as cleft palate and tongue tie. Milk allergies can cause endogenous FTT. Also the metabolism may be raised by parasites, asthma, urinary tract infections, and other fever-inducing infections, hyperthyroidism or congenital heart disease so that it becomes difficult to get in sufficient calories to meet the higher caloric demands.
- Exogenous (or "nonorganic")
- Caused by caregiver's actions. Examples include physical inability to produce enough breastmilk, using only babies' cues to regulate breastfeeding so as to not offer a sufficient number of feeds (sleepy baby syndrome), inability to procure formula when needed, purposely limiting total caloric intake (often for what the caregiver views as a more aesthetically pleasing child), and not offering sufficient age-appropriate solid foods for babies and toddlers over the age of six months. A recent study on toddlers with exogenous FTT has found preliminary evidence suggesting that difficulty experienced during feeding times with this condition may in fact be impacted by preexisting sensory processing problems. Such difficulties with sensory processing are more commonly observed in toddlers who have a history of growth deficiency and feeding problems; however, further research is required in order to determine a causal relationship between sensory processing problems and nonorganic FTT. In developing countries, conflict settings and protracted emergencies, exogenous faltering may be caused by chronic food insecurity, lack of nutritional awareness, and other factors beyond the caregiver's control.
- However, to think of the terms as dichotomous can be misleading, since both endogenous and exogenous factors may co-exist. For instance a child who is not getting sufficient nutrition may act content so that caregivers do not offer feedings of sufficient frequency or volume, and a child with severe acid reflux who appears to be in pain while eating may make a caregiver hesitant to offer sufficient feedings.
Infants and children who have had unpleasant eating experiences (e.g. acid reflux or food intolerance) may be reluctant to eat their meals. Additionally, force feeding an infant or child can discourage proper self-feeding practices and in-turn cause undue stress on both the child and their parents. Psychosocial interventions can be targeted at encouraging the child to feed themselves during meals. Also, making mealtimes a positive, enjoyable experience through the use of positive reinforcement may improve eating habits in children who present with FTT. If behavioural issues persist and are affecting nutritional habits in children with FTT it is recommended that the child see a psychologist.
FTT was first introduced in the early 20th century to describe poor growth in orphan children but became associated with negative implications (such as maternal deprivation) that often incorrectly explained the underlying issues. Throughout the 20th century, FTT was expanded to include many different issues related to poor growth, which made it broadly applicable but non-specific. The current conceptualization of FTT acknowledges the complexity of faltering growth in children and has shed many of the negative stereotypes that plagued previous definitions.
- Shields, B.; Wacogne, I.; Wright, C. M. (25 September 2012). "Weight faltering and failure to thrive in infancy and early childhood". BMJ. 345 (sep25 1): e5931–e5931. doi:10.1136/bmj.e5931.
- "Failure to Thrive: Miscellaneous Disorders in Infants and Children: Merck Manual Professional". Retrieved 2010-03-23.
- Al Nofal, Alaa; Schwenk, W. Frederick (December 2013). "Growth failure in children: a symptom or a disease?". Nutrition in Clinical Practice: Official Publication of the American Society for Parenteral and Enteral Nutrition. 28 (6): 651–658. doi:10.1177/0884533613506015. ISSN 1941-2452. PMID 24170580.
- Hughes I (February 2007). "Confusing terminology attempts to define the undefinable". Arch. Dis. Child. 92 (2): 97–8. doi:10.1136/adc.2006.108423. PMC . PMID 17264278.
- Raynor P, Rudolf MC (May 2000). "Anthropometric indices of failure to thrive". Arch. Dis. Child. 82 (5): 364–5. doi:10.1136/adc.82.5.364. PMC . PMID 10799424.
- Olsen EM, Petersen J, Skovgaard AM, Weile B, Jørgensen T, Wright CM (February 2007). "Failure to thrive: the prevalence and concurrence of anthropometric criteria in a general infant population". Arch. Dis. Child. 92 (2): 109–14. doi:10.1136/adc.2005.080333. PMC . PMID 16531456.
- National Guideline Alliance (UK) (2017). Faltering Growth – recognition and management. National Institute for Health and Care Excellence: Clinical Guidelines. London: National Institute for Health and Care Excellence (UK). ISBN 9781473126930. PMID 28991420.
- "Weight-for-age Child growth standards". World Health Organization. Retrieved 2017-11-15.
- Marchand, Valérie; Canadian Paediatric Society, Nutrition and Gastroenterology Committee (October 2012). "The toddler who is falling off the growth chart". Paediatrics & Child Health. 17 (8): 447–454. ISSN 1205-7088. PMC . PMID 24082808.
- Homan, Gretchen J. (2016-08-15). "Failure to Thrive: A Practical Guide". American Family Physician. 94 (4): 295–299. ISSN 1532-0650. PMID 27548594.
- B. F. Habbick; J. W. Gerrard (1984). "Failure to thrive in the contented breast-fed baby". Can Med Assoc J. 131 (7): 765–768. PMC . PMID 6541091.
- Yi S. H.; Joung Y. S.; Chloe Y. H.; Kim E. H.; Kwon J. Y. (2015). "Sensory Processing Difficulties in Toddlers with Nonorganic Failure to Thrive and Feeding Problems". Journal of Pediatric Gastroenterology and Nutrition. 60 (6): 819–824. doi:10.1097/mpg.0000000000000707.
- Prendergast, Andrew J; Humphrey, Jean H (2014-04-01). "The stunting syndrome in developing countries". Paediatrics and International Child Health. 34 (4): 250–265. doi:10.1179/2046905514Y.0000000158. ISSN 2046-9047. PMC . PMID 25310000.
- Estrem, Hayley H.; Pados, Britt F.; Park, Jinhee; Knafl, Kathleen A.; Thoyre, Suzanne M. (January 2017). "Feeding problems in infancy and early childhood: evolutionary concept analysis". Journal of Advanced Nursing. 73 (1): 56–70. doi:10.1111/jan.13140. ISSN 1365-2648. PMID 27601073.