Weight that decreases from a disproportionately high percentile to one that is proportional causes no concern, but weight that decreases to a disproportionately low percentile is of concern. Allowances must be made for prematurity; weight corrections are needed until 24 months of age, height corrections until 40 months of age, and head circumference corrections until 18 months of age. Although some growth variants can be difficult to distinguish from FTT, growth velocity and height-for-weight determinations can be useful in distinguishing the cause. In children with FTT, malnutrition initially results in wasting (deficiency in weight gain). Stunting (deficiency in linear growth) generally occurs after months of malnutrition, and head circumference is spared except with chronic, severe malnutrition. FTT that is symmetric (proportional weight, height/length, and head circumference) suggests long-standing malnutrition, chromosomal abnormalities, congenital infection, or teratogenic exposures. FTT is a common problem in pediatrics, affecting 5% to 10% of young children, 3% to 5% of children admitted to hospitals, and 15% of children living in poverty and foster care.
Because possible causes of growth failure are diverse and oftenmultifactorial, the management of FTT begins with a carefulsearch for its etiology (Table 21-1). The common causes ofFTT vary by age, which should be reflected in the evaluation(Table 21-2). In most cases, a comprehensive history and physical examination are sufficient to suggest or eliminate medicaldisease as the primary cause of FTT. Medical diseases are diagnosed in fewer than 50% of children hospitalized for growthfailure and even less frequently in children managed in the outpatient setting. Growth failure is often a manifestation of moreextensive family problems. It is clinically useful to categorize thecauses of malnutrition into inadequate nutritional intake, inadequate nutrient absorption, or increased metabolic demand.
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Failure to Thrive
A medical history should include prenatal history prematurity, birth size (weight, length, and head circumference), as well as family and travel history. Indicators of medical diseases, such as vomiting, diarrhea, fever, respiratory symptoms, and fatigue, should be noted. A careful diet history is essential. Lactation problems in breastfed infants and improper formula preparation are frequent causes of growth failure early in infancy. It is crucial to evaluate intake of solid foods and liquids for older infants and children. Due to parental dietary beliefs, some children have inappropriately restricted diets; others drink excessive amounts of fruit juice, leading to malabsorption or anorexia. The child’s daily meal schedule (timing, frequency, location) should also be noted. Mealtime practices, especially distractions that interfere with completing meals, can influence growth. A complete psychosocial assessment of the child and family is required. Child factors (temperament, development), parental factors (depression, domestic violence, social isolation, mental retardation, substance abuse), and environmental and societal factors (poverty, unemployment, illiteracy, lead toxicity) all may contribute to growth failure.
A complete physical examination and developmental screening should assess signs of inflicted injury; oral or dental problems; indicators of pulmonary, cardiac, or gastrointestinal
Cystic fibrosis and other causes of pancreatic insufficiency Celiac disease Other malabsorption syndromes Gastrointestinal reflux
Chromosomal abnormalities, genetic syndromes Congenital heart disease Gastrointestinal abnormalities (e.g., pyloric stenosis, malrotation) Vascular rings Upper airway obstruction Dental caries Congenital immunodeficiency syndromes
Human immunodeficiency virus Tuberculosis Hepatitis Urinary tract infection, chronic sinusitis, parasitic infection
Thyroid disease Adrenal or pituitary disease Aminoaciduria, organic aciduria Galactosemia