Failure to thrive (peds)
Background
- Non-specific term indicating inappropriate weight loss or insufficient weight gain, due to insufficient caloric intake, insufficient caloric absorption, or excessive caloric demand.
- Defined as weighing <5th percentile for age and sex, or weight deceleration crossing two major growth lines on a growth chart.
- Does not imply a defect in social, intellectual, or emotional development, but if untreated may lead to any combination of those.
- Classically divided into endogenous (medical) and exogenous (psychosocial or environmental) causes
Clinical Features
Differential Diagnosis
Endogenous Causes
- GERD
- IBS
- Food allergy
- Malabsorption
- Pyloric stenosis
- Gastrointestinal atresia or malformation
- Inborn error of metabolism
- Thyroid disorder
- Chronic infection or immunodeficiency
- Chronic pulmonary disease
- Congenital heart disease or heart failure
- Malignancy
- Celiac disease
- Inflammatory bowel disease
Exogenous Causes
- Breastfeeding problem (latching, suckling, or swallowing)
- Improper formula preparation
- Caregiver depression
- Lack of food availability
- Cleft lip/palate
- Mood disorder
- Eating disorder
- Child neglect or abuse
Evaluation
- A detailed history and physical examination (including accurate height and weight) are usually sufficient to establish a cause. Over 80% of cases are due to insufficient caloric intake from exogenous causes.
- History should focus on breastfeeding technique, frequency, and duration, or amount of formula and method of preparation.
- Observed feeds can often be useful to identify problems.
- If an endogenous cause is suspected, specific lab tests or imaging studies may be helpful to evaluate for metabolic abnormalities, the presence of infections, malignancy, or anatomic malformations. Additional testing should be ordered on a case by case basis and is only recommended if a specific etiology is suspected.
Management
Disposition
- Most cases can be discharged with PCP follow up. PCPs can make appropriate referrals for nutritional counseling, lactation coaching, or formula supplementation.
- Indications for hospitalization include failure of outpatient management, suspicion of endogenous cause requiring urgent management, suspicion of abuse or neglect, signs of traumatic injury, severe psychosocial impairment of the caregiver, or evidence of serious malnutrition (<70th percent of predicted weight for length).