Failure to Thrive

Failure to thrive is failure to gain in height and weight at the expected rate, the expected rate usually being that indicated by charts for height and weight related to age and sex in reference populations. Since it is often easier to measure weight than height in small children and since weight can be lost as well as not gained, whereas height gain can only be absent or slowed, assessment of failure to thrive is frequently made on weight progress alone. Although a child may be low weight for height and age, this does not necessarily imply failure to thrive since some 'normal' children are always small, perhaps because of genetic endowment. They grow with normal velocity but at the lower extreme of normal population distribution. Thus, following weight gain over time is essential for diagnosis of failure to thrive (Figure 1).

Failure to thrive can result from a wide range of underlying medical problems as outlined in Table 2.

Figure 1 Failure to thrive: figurative growth chart for increase in either weight or height of four children with abnormal growth showing normal population growth as median and ± standard deviations (SD) , failure to thrive in above average child with growth falling below the median and then showing complete catch up growth;-----, failure to thrive in a child growing below the median with failure to thrive, falling below "2SD and then showing complete catch up;

-, child with failure to thrive and failure to complete catch up so growth continues at about average rate but child remains below previous SD position; — ■ — ■ — -, child gaining throughout at normal velocity but starting below "2SD and remaining below -2SD in size, i.e., 'small normal'.

Figure 1 Failure to thrive: figurative growth chart for increase in either weight or height of four children with abnormal growth showing normal population growth as median and ± standard deviations (SD) , failure to thrive in above average child with growth falling below the median and then showing complete catch up growth;-----, failure to thrive in a child growing below the median with failure to thrive, falling below "2SD and then showing complete catch up;

-, child with failure to thrive and failure to complete catch up so growth continues at about average rate but child remains below previous SD position; — ■ — ■ — -, child gaining throughout at normal velocity but starting below "2SD and remaining below -2SD in size, i.e., 'small normal'.

Table 2 Some causes of failure to thrive according to pathophysiology

Basic cause of FTT

Clinical situation

Medical condition

Too little energy taken in

Inadequate food energy offered

Poverty; ignorance of child's needs; lack of understanding of progression of weaning process

Significant feeding difficulties

Neurological and other conditions affecting motor coordination of chewing and swallowing, especially hypertonic cerebral palsy

Energy density of food

Strict vegetarian diet; excessive and inappropriate parental

inappropriately low

concern to feed 'healthy diet'

Poor appetite

Anorexia due to infection or other illness

Vomiting

Esophageal reflux, infection, metabolic disturbance

Too much energy lost from

Energy lost as sugar in urine

Diabetes mellitus

the body

Protein lost as protein in urine

Nephrotic syndrome

Severe eczema

Failure to absorb

Malnutrition syndromes

Gluten-sensitive enteropathy/celiac syndrome Cystic fibrosis Protein-losing enteropathy Lactose intolerance

Failure to utilize

Chronic illness

Chronic infection Urinary tract infection Other hidden infections Cyanotic congenital heart disease Inborn errors of metabolism Severe mental retardation Deficiency of other essential nutrients

Increased requirements

Elevated BMR

Thyrotoxicosis

Congenital heart disease with left to right shunts and high output state

Increased growth rates

Catch up growth following period of failure to thrive

Increased activity as increased

Cystic fibrosis

respiratory rate

Congenital heart disease

Increased activity

Uncontrolled hyperactive behavior

BMR, basal metabolic rate.

BMR, basal metabolic rate.

Some children have no recognizable pathological abnormalities and yet they fail to thrive. In some children inappropriate management of the feeding problems described earlier underlies poor growth. Others may be underfed because of poverty, ignorance, or incompetence amongst carers. Some parents, anxious to forestall obesity or cancer and cardiovascular conditions in later life, feed diets that are too restricted in nutrient quantity or variety for normal growth, or which follow rigidly the dietary recommendations intended for adults. In the so-called muesli belt syndrome, skimmed milk, wholemeal cereals, and low-sugar low-fat foods dominate.

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