Failure to Thrive (FTT)

Failure to Thrive (FTT)

·        = Failure to gain weight normally (< 3^rd percentile, or falling serial measurements) [cf Stunted growth

§  failure to gain height]

·        If also failure of linear growth Þ long standing problem (weight always falls first, then length, then head circumference falls last)

·        History:

o  What goes in (diet): 

·        What and how much (and does it actually go in, or is it just offered?). Milk, other drinks, meat, fruit and vegetables, cereals and breads, lollies

§  Assess parents knowledge base

§  Feeding difficulties: appetite, behavioural, structural, swallowing

o   What comes out (poos) – especially steatorrhoea.  People usually overestimate vomit

o   Chronic illness: cardiac, renal, neurological

o   PMH: ABFWIMPS

o   Development

o   Social history: especially PND, other psych stresses, violence, drugs and alcohol

·        Examination:

o   End of bed: fat, thin, energy, pallor, well/sick, dysmorphisms

o   Muscle and fat stores – look for scraggy buttocks

o   Signs of abuse and injury

o   Signs of chronic disease: 

§  Cyanosis due to heart: L ® R shunt and heart failure or cyanotic lesion (R ® L shunt)

§  Respiratory: clubbing, nasal polyps (CF, asthma)

§  Gut: coeliac (not if breast feed) – distended abdomen and thin legs

§  Renal: blood pressure

o   Assess suck, chew, swallow 

o   Rickets (¯vitamin D), anaemia (¯Fe), Bruising (¯vitamin K), dermatitis & neuropathy (¯Vitamin B) (all late signs)

·        Differential:

o   Parent‟s expectations: In the 2^nd year of life: ¯appetite, ¯rate of growth, ­activity are all normal. Parents may need reassurance

o   Non-organic failure to thrive: 

§  Inadequate parenting/poor nutrition the most common cause (will feed and gain weight well while in hospital). 

§  Usually complex situation: eg young mum, unwanted pregnancy, obstetric problems, poor bonding, bottle feed, maternal depression, etc.

§  Is the milk being made up properly, any strange stuff (eg tea, Milo, etc) 

§  To cheek for attachment: observe mum chatting to baby while they dress – is she talking to the baby

o   Organic causes:

§  ¯Intake secondary to:

·        Underfeeding (eg engorged breasts ® poor latching on, inverted nipples)

·        Congenital abnormalities (eg cleft palate)

·        Dyspnoea (eg chronic heart failure, CF, chronic URTIs)

·        Neurological lesions (eg pseudobulbar palsy)

·        Behavioural factors (eg alert, restless)

§  Abnormal losses: 

·        Vomiting: need to be severe and persistent to ® FTT. Eg pyloric stenosis, chronic UTIs, renal disorders 

·        Stools: diarrhoea, steatorrhoea

·        Urine: eg diabetes, renal failure, diabetes insipidous, adrenal insufficiency

§  Failure of utilisation:

·        Chronic infection (eg Tb, UTIs, immune disorders)

·        Metabolic disorders (eg phenylketonurea)

·        Endocrine disorders (eg hypothyroidism) 

·         Constitutional and genetic abnormalities: Short stature, Down‟s, Turner‟s, Achondroplasia

§  Increased requirements: Chronic lung disease, heart disease, etc 

§  Macrosomic babies (ie mum diabetic) will loose excess weight after birth ® looks like failure to thrive 

·        Management: 

o   If non-organic failure to thrive, then educate regarding a baby‟s dietary needs.

o   Investigations: rarely necessary.  Maybe Fe for anaemia