Failure to Thrive in Infants and Toddlers

Abstract

Failure to thrive (FTT) is a broad term that is used to document an abnormal pattern of weight gain over time. There is no single definition for FTT, but all proposed definitions use anthropometric parameters such as weight gain or weight for length. The term FTT has been falling out of favor, and the term weight/growth faltering is becoming more common to describe this clinical entity. The underlying problem in FTT is inadequate usable calories. The primary mechanisms leading to FTT are impaired absorption, increased metabolic demands, and inadequate caloric intake. Inadequate caloric intake is the most common of these mechanisms, although FTT is often a combination of the three. The diagnostic evaluation of FTT must take into account the multifactorial nature of this clinical sign. A comprehensive history is essential for diagnosis and should include specific questions about the child’s living situation and feeding habits. The physical examination must include accurate weight and length measurements. Clinicians should look for signs of abuse or neglect, dysmorphic features, abnormal skin or nail findings, digital clubbing, or other signs of chronic disease. Laboratory investigations are rarely revealing in FTT but should be considered if there is a high index of suspicion for underlying disease. Treatment in FTT favors a multidisciplinary approach. The primary goal of treatment is restoration of normal growth velocity. Children with FTT are at increased risk for growth and cognitive problems in later childhood, although the clinical significance of these findings is not well understood. The mainstay of treatment is increasing calories in the diet. Enteral feeding, orally or via a tube, is always preferred over parenteral feeding due to a better safety profile, ease of feeding, and lower cost. Parenteral nutrition is an acceptable way to meet caloric needs in infants and children when enteral nutrition is not possible. Children with FTT and malnutrition should be monitored closely for refeeding syndrome, which results from fluid and electrolyte shifts in malnourished children. In general, FTT can be treated on an outpatient basis with close follow-up. Indications for hospitalization include severe malnutrition/dehydration and concern for child endangerment. This review contains 7 figures, 8 tables and 26 references Key words: enteral feeding, failure to thrive, growth charts, nutrition, parenteral nutrition, poor weight gain, tube feeding, weight loss