Faltering growth (failure to thrive)
Faltering growth, also known as
failure to thrive (FTT), is when there is a failure to grow at the expected
rate (i.e. growth ‘falls away’ from stan-dardized weight or height centile).
Weight is the most sensitive indicator in infants and young children, whilst
height is a better in the older child. Under stress, head circumference growth
is more preserved than linear growth, which in turn, is more than weight gain.
In infancy, birth weight reflects
the intrauterine environment. It is a poor guide to the child’s correct
‘genetic potential’ and weight may naturally fall until the correct ‘level’ is
attained. In a well, happy child consider constitu-tional small stature
(characterized by normal growth velocity in a healthy child of small stature
parents).
95% of true FTT is due to not
enough food being offered or taken. In developing countries poverty is the main
cause. In the UK, causes include socioeconomic difficulties, emotional deprivation,
unskilled feeding, or a particular belief system regarding appropriate
nutrition.
Organic causes include:
•
Decreased
appetite, e.g. psychological or secondary to chronic illness.
•
Inability
to ingest, e.g. GI structural or neurological problems.
•
Excessive
food loss, e.g. severe vomiting (gastro-oesophageal reflux disease (GORD),
pyloric stenosis, dysmotility), diabetes mellitus (urine).
•
Malabsorption.
•
Increased
energy requirements, e.g. congenital heart disease, cystic fibrosis,
malignancy, sepsis.
•
Impaired
utilization, e.g. various syndromes, IEM, endocrinopathies.
Causes may overlap, e.g. in cystic
fibrosis there is simultaneous malabsorp-tion, increased energy requirements,
anorexia, and chronic infection.
•
Detailed history: including age of onset of FTT, and
timing of weaning. Consider asking
paediatric dietitian to perform detailed dietary history.
•
Full examination: including accurate measurement of
growth.
•
If organic disease possible: basic investigations should
include:
•
FBC, ESR/CRP,
U&E, creatinine, total protein and albumin, Ca2+, PO43
– , LFT;
•
immunoglobulins;
•
coeliac
antibody screen;
•
urinalysis,
including M, C&S.
•
Further investigations: are indicated if there are
suggestive symptoms or the faltering growth is severe,
and include: IEM screen; karyotype; serum lead (pica); sweat test; upper
endoscopy and small intestinal biopsy; CXR; bone age, skeletal survey (NAI);
abdominal US; head CT/ MRI; oesophageal pH monitoring; ECG; faecal occult
blood.
•
If non-organic disease: is likely, seek dietary advice,
preferably by a paediatric dietitian:
•
If FTT
resolves in the next few weeks, give positive reinforcement and supervise
subsequent growth as an outpatient.
•
If FTT
persists, admit to hospital for basic investigations and observe the response
to supervised adequate dietary input. Adequate growth in hospital suggests a
non-organic cause; explore and support family dynamics.
•
Should
FTT occur again at home after improvement in hospital, and then refer to social
services for family assessment and appropriate intervention.
•
If FTT
continues in hospital despite adequate dietary input, occult organic disease is
most likely and requires extensive investigation as above.
•
Provide
dietetic input, whatever the cause, to support nutritional correction and
education.
•
Identify
and correct associated comorbidities, e.g. developmental delay or early
presentation of neurological disorder such as cerebral palsy; fall off in head
growth is suggestive.
The prognosis depends on the
severity of FTT. It is good if mild. Severe FTT, whatever the cause, may be
associated with later developmental and behavioural impairment.
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