Celiac disease Food intolerance Child neglect Delayed introduction of age-appropriate foods Juice consumption disease; and dysmorphic features that may suggest a genetic or teratogenic cause for growth failure. A complete neurologic examination may reveal spasticity or hypotonia, which can have untoward effects on feeding and growth. Physical findings related to malnutrition include decreased subcutaneous fat, decreased muscle mass, dermatitis, hepatomegaly, cheilosis, or edema (see Chapter 30). Additionally children with FTT have more otitis media, respiratory, and gastrointestinal infections than age-matched controls; severely malnourished children are at risk for a variety of serious infections.
The history and physical examination findings should guidethe laboratory evaluation. Simple screening tests are recommended to identify common illnesses that cause growth failureand to search for medical problems resulting from malnutrition. Initial tests may include a complete blood count; screening for iron deficiency anemia and lead toxicity; urinalysis,urine culture, and serum electrolytes to assess renal infection ordysfunction; thyroid stimulating hormone; liver function tests;and a protein purified derivative test to screen for tuberculosis.Human immunodeficiency virus testing may also be indicated.For children with diarrhea, abdominal pain, or malodorousstools, a stool sample for culture and ova and parasites may be indicated. A review of the child’s newborn screen may also bewarranted. Observation during feeding and home visitation, ifpossible, is of great diagnostic value in assessing feeding problems, food preferences, mealtime distractions, unusual or disruptive parent-child interactions, and the home environment.
Treatment must address the child’s nutritional requirementsand the social issues of the family. Initial treatment should focuson the nutritional and medical management of the child whileengaging the family in the treatment plan. Parents of malnourished children may feel personally responsible and threatenedby the diagnosis of FTT. Parents may be so depressed or dysfunctional they cannot focus on their child’s needs; they maynot recognize the psychosocial and family contributors to themalnutrition. These issues can have a profound effect on thesuccess of treatment, and they need to be addressed.
Children with mild malnutrition whose cause is easily identified can be managed by the primary care physician and family. In more challenging cases, a multidisciplinary team, including pediatricians, nutritionists, developmental specialists, nurses, and social workers, improves nutritional outcome in children with FTT. Most children with FTT can be treated in the outpatient setting. Children with severe malnutrition, underlying diagnoses that require hospitalization for evaluation or treatment, or whose safety is in jeopardy because of maltreatment require hospitalization. Admitting children to the hospital to induce and document weight gain is not recommended unless intensive outpatient evaluation and intervention has failed or the social circumstances are a contraindication for attempting outpatient management.
Nutritional management is the cornerstone of treatment, regardless of the etiology. Children with FTT may require more than 1.5 times the expected calorie and protein intake for their age for catch-up growth. Children with FTT who are anorexic and picky eaters may not be able to consume this amount in volume and require calorically dense foods. For formula-fed infants, the concentration of formula can be adjusted appropriately (Table 21-3). For toddlers dietary changes should include increasing the caloric density of favorite foods by adding butter, oil, sour cream, peanut butter, or other high-calorie foods. High-calorie oral supplements (30 cal/oz) are often well tolerated by toddlers. In some cases, specific carbohydrate, fat, or protein additives are used to boost calories by increasing calories without increasing volume requirements. Additionally vitamin and mineral supplementation is needed, especially during catch-up growth. In general the simplest and least costly approach to dietary change is warranted.