Update Management of Failure To Thrive
The objective parameter is usually the deceleration of growth height and weight. If FTT is severe, the parameter is poor brain growth as evidenced by head circumference. The diagnosis is based on growth parameters that fall over 2 or more percentiles, are persistently below the third or fifth percentiles, or are less than the 80th percentile of median weight for height measurement. Growth failure is now generally accepted to be overly simplistic and obsolete.
A good working definition of growth failure related to aberrant caregiving is the failure to maintain an established pattern of growth and development that responds to the provision of adequate nutritional and emotional needs of the patient. Most cases of FTT are not related to neglectful caregiving, although it may be a sign of maltreatment and should be considered during an evaluation for growth failure. A joint clinical report by the American Academy of Pediatrics Committee on Child Abuse and Neglect and the American Academy of Pediatrics Committee on Nutrition outlines 3 indicators of neglect: “Intentional withholding of food from the child; strong beliefs in health and/or nutrition regimens that jeopardize a child’s well-being; and family that is resistant to recommended interventions despite a multidisciplinary team approach.”
Observation of feeding is very important. Pay careful attention to the following:
- Maternal (caregiver) attachment during the feeding process; evaluation of signs of maternal attachment (eye contact, vocalizations, interpretation of cues)
- Evaluation of the child-parent dyad (eg, conflict over eating related to poor limit setting, lack of discipline, or meal time disruption)
- The perception of parents and/or caregivers regarding the problem
- Feeding techniques (forced feeding)
A 72-hour diet diary that includes the following can be helpful:
- Details relative to growth from breastfeeding or bottle-feeding
- Formula preparation and amounts provided
- Time and amount of feedings (eg, 5 oz of Enfamil; one-half jar of strained peaches)
- Behaviors of infant or child during feeding or nursing
Nutritional treatment is based on aggressive feeding to prevent cognitive loss. Most children require 100-120 kcal/kg/day, but this may be increased to achieve catch-up weight gain that is greater than normal. Other dietary instructions should include the following:
- Eliminate empty calories from items such as soda or other high sugar drinks.
- Schedule regular meals and snacks (usually 3 meals and 2 snacks per day). No grazing between meals.
- Offer solids before liquids.
- Consider fortifying calories with extra oils and carbohydrates.
- Increase protein.
- Consider vitamin and/or mineral supplements, especially zinc and iron.
- Provide support for the caregiver and offer suggestions for improving the feeding environment, such as the following:
- Avoid blaming the caregiver.
- Provide respite for the caregiver.
- Avoid distractions, such as television, at meal time.
- Offer a role model for the caregivers.
Psychosocial evaluation must be detailed and must provide an in-depth look at the functioning of the family and the child in the context of the family. Many impoverished and/or uneducated parents have children with growth failure; however, many have children with normal growth. The background of the parents and their attitudes and beliefs about child rearing may affect how their children are fed and how they grow. An appropriate beginning for this inquiry is to ask family members about their perception of the child’s growth failure and medical condition. Inquire about the caregivers’ level of concern and note whether it is discordant with the clinician’s level of concern. Often, a disturbance in bonding may be obvious, but signs of problems with attachment can also be subtle. Note whether caregivers are changed or substituted frequently at feeding times. Current and past social history of the family, at a minimum, should address the following:
- Finances and resources, living and childcare arrangements
- Abuse and neglect risk factors, including any physical or sexual abuse
- Domestic or interpersonal violence
- Substance abuse or addiction
- Mental health disorder, particularly depression and postpartum depression
- Eating disorder
- No medication is routinely needed unless an underlying condition is a factor (eg, infection, gastroesophageal reflux, cardiac or lung disease).
- Surgical care is most often not needed unless an underlying condition, such as cleft palate, must be repaired. Gastrostomy feeding tube placement may be needed in severe cases of malnutrition, especially in children with neurodevelopmental delay.