Failure to Thrive

What is Failure to Thrive?

Failure to thrive (FTT) is a term often used to describe children who don’t gain weight as expected. There’s some debate about the precise definition of this condition, but it’s generally agreed that a child might have FTT if their weight for their age is less than the 5th percentile, if their weight percentile drops by more than 2 major lines on a growth chart, or if they weigh less than 80% of the expected weight for their height or length.

Adjustments should be made for babies born prematurely, and we look at the first 2 years of life. A child’s weight percentile dropping off is usually more of a concern, compared to a child who has consistently been on the lower end of the scale. This condition has been proposed to be renamed as “weight faltering,” which gives a clearer picture of the problem: the child isn’t taking in enough nourishment to gain a healthy amount of weight.

The diagnosis of FTT or weight faltering is made by regularly tracking a child’s weight and height over time. Z-scores, which show how much a child’s weight for height differs from the average, can be more helpful than mere percentiles. This is because they give a more precise picture, especially for children with extremely low weight percentiles.

FTT is a major risk for malnutrition. If the z-score is very low, the risk for severe malnutrition is high. Therefore, spotting and assessing FTT, making sure the child gets adequate nutrition, and treating any underlying medical conditions are crucial. If it’s undiagnosed and untreated, FTT can result in poor growth, developmental delays, and other negative long-term effects in children.

More and more, people are realizing that not all calories are the same. The real goal is to make sure children get enough beneficial nutrients, vitamins, and minerals for healthy development, besides just gaining weight. Studies have shown that poor nutrition has a greater impact on mental development in younger patients. In these studies, FTT was linked with lower IQs, issues such as Attention-Deficit Hyperactivity Disorder (ADHD), learning disabilities, and difficulties with communication.

What Causes Failure to Thrive?

Failure to Thrive (FTT) or weight faltering is a condition of poor weight gain in children that is usually a sign of a deeper issue. This could be due to anything that disrupts the balance between the nutrients a child gets and the energy they need, leading to poor weight gain if it’s not resolved. Understanding the various causes can help in figuring out the best way to manage and treat this condition.

It can be helpful to think of these causes in three broad categories. First, we might consider whether the issue is due to a medical issue, a non-medical reason resulting in not getting enough food, or a combination of the two. Instances where a child isn’t getting enough calories to gain weight for non-medical reasons are often the most common and can be caused by many factors. An example of this would be incorrect preparation of baby formula, challenges with breastfeeding, parents not knowing the right amount to feed their child, a child refusing to eat or showing strange eating behaviors, and unfortunately, sometimes even neglect or abuse. By asking about a child’s feeding habits, family life, and behaviors, it becomes easier to identify indicators of non-medical reasons leading to a low food intake.

While these non-medical causes are often to blame, it’s crucial to remember that many external factors like the family’s environment and financial situation can contribute to FTT as well. Recognizing this, the role of the doctor includes identifying these challenges and connecting families with helpful resources in their community when necessary. While it’s helpful to think in terms of medical and non-medical causes, often the true cause involves both affecting the child’s growth.

After finding out if it is a medical or a non-medical reason or a mix of both, it’s useful to divide the issue into three main categories: not enough food intake, too many calories lost or poorly absorbed, and the body’s excessive caloric demand.

Within the ‘Not enough food intake’ category, there can be various medical and non-medical causes. Medical causes could include physical issues that stop a child from being able to eat enough. For example, kids with problems in their mouth or face or who have a hard time swallowing food, or those who are vomiting because of a physical issue may all struggle to eat enough food. Other non-medical factors can cause or worsen these issues.

Coming to the ‘Too many calories lost or poorly absorbed category, this usually blames medical problems and these are typically conditions relating to digesting food. Conditions like inflammatory bowel disease, celiac disease, milk-protein allergy, and damage to the pancreas like cystic fibrosis cause poor absorption of food. Non-medical issues can also make these conditions worse.

Finally, in the ‘Increased caloric demand’ category, the issue usually arises from long-term medical problems. Conditions like heart disease present from birth, kidney or liver disease, low iron levels, cancer, or long-term infections can cause a child’s body to need more energy than a healthy child’s. Non-medical factors can also influence these conditions. This underscores the importance of a comprehensive food and family assessment for any child presenting with FTT.

Risk Factors and Frequency for Failure to Thrive

FTT, or “failure to thrive” is a medical condition that can affect children of all ages, genders, and ethnic backgrounds. However, it’s typically diagnosed in children under the age of 2. This condition can be linked to long-term negative effects on a child’s physical and mental development. FTT can vary in how often it happens; it’s estimated to occur in about 5% – 10% of kids seeing a doctor in wealthy countries. For less wealthy areas, the rate might be as high as 20% – 30%.

The main cause of FTT – making up 86% of cases – is simply not getting enough calories. Most of these cases don’t have a clear reason. The rest are caused by specific health conditions, like acute illness, problems in the digestive system, genetic issues, or inflammation in the body. Research has found that FTT more often leads to further health issues in certain groups: kids diagnosed at an age younger than 6 months, those who were born prematurely, and those who had a very sharp decrease in their weight or height development. These children also tend to need hospital care more often.

Certain risk factors make a child more likely to be diagnosed with FTT. These include being born prematurely, having a low birth weight, developmental delays, birth defects, or chronic illnesses. Socioeconomic factors also affect a child’s risk, such as lower family income, the parents’ level of education, a high level of stress at home, behavioral health conditions in the parents, and substance abuse by the parents. Factors around feeding are also influential, like the child’s eating behaviors, family’s feeding routines, beliefs about nutrition, and food allergies or restrictive eating patterns.

Signs and Symptoms of Failure to Thrive

Failure to Thrive (FTT), or weight faltering, is a condition where a child’s growth is significantly below the normal or expected range for their age. It’s often identified at routine check-ups, as it’s more common to notice poor weight gain than specific signs or symptoms of an underlying illness. Here are some aspects to consider if it’s determined that a child meets the criteria for FTT:

Feeding History

• Types, amounts, and frequency of food given.
• For infants, if they are feeding overnight or only during the day.
• For breastfed babies, the duration of feeds, mother’s milk supply, the baby’s capability to drink milk from the breast, and pumping schedules.
• For formula-fed babies, the type of formula and mixing methods used.
• For bottle-fed infants, the type of bottle and nipple flow rate.
• For older children, information on food preferences, any swallowing difficulty, abdominal pain, or vomiting during feeds.
• Any cultural, economic, religious, or allergy-related nuances around feeding habits.

Elimination History

• Details about how often the child is having bowel movements and what it looks like.
• Any red flags like blood in the stool, unusually smelly stools, new toilet accidents in older kids.
• Urine output as a sign of hydration and any symptoms of urinary infection.

Birth, Past Medical, and Developmental History

• Any history of premature birth or complications at birth.
• Mother’s prenatal history around any exposures to harmful substances or infections.
• Developmental milestones and any delays therein.
• Historical information about any medical conditions the child might have.

Review of Systems

• A comprehensive review to look for any signs of illness that might be causing the poor weight gain.

Family Medical and Social History

• Medical history of the family, including a history of siblings with chronic medical conditions or a history of FTT.
• food preferences in the family that may influence what’s available in the child’s diet.
• Family dynamics, social support networks and environmental exposures.

Physical Examination

• Checking the rate of weight gain or loss since the last visit.
• A thorough physical exam to look for any abnormal physical signs.

Testing for Failure to Thrive

When checking a child for potential issues with growth (known as ‘Failure to Thrive’ or FTT), doctors will first look at measurements such as their weight and height. These measurements help the doctor understand whether your child is growing as expected for their age. Any significant weight loss since their last check-up can raise a warning flag. This will be investigated further as healthy children do not usually lose weight. The doctor will also take into account other factors that might affect their weight, like what clothes they were wearing during the past measurement, any recent illnesses, etc.

Your doctor will also check your child’s weight to length/height z-score, which helps identify the risk and potential seriousness of malnutrition. Grades of malnutrition are classified into mild, moderate, and severe based on different z-score ranges. A handy tool called Semi-Objective Failure to Thrive (SOFTT) may be used to help with this assessment.

If your child seems to be losing weight or not gaining as much as expected, a doctor’s approach might begin with a detailed history and physical exam. This would include going over the child’s eating habits, any notable health history, and anything unusual that might suggest a physical cause for the poor weight gain. If appropriate, the doctor may also observe a feeding session. If no significant findings are identified, the doctor might work with the family to set nutritional goals, schedule follow-up appointments, and perform limited initial laboratory tests to avoid unnecessary testing.

If your child appears unwell, has had severe weight loss, or if they have not been able to put on weight following initial diet changes, lab tests might be needed. The lab tests could include a complete blood count to check for anemia, a test for iron levels, and a metabolic panel to check hydration, kidney, and liver function. If severe malnutrition is identified, additional markers for this, like prealbumin, might be tested.

Other tests might be appropriate if there is a history of issues with stool or blood/mucus in the stool, such as stool studies. A urine test can also be helpful to screen for kidney diseases and chronic infection. Thyroid function, another known newborn metabolic test, and other more specialized tests may be ordered based on the results of these initial tests. Depending on these results, imaging might also be used to aid evaluation.

It’s important to remember that FTT can be caused by many factors, not just obvious physical issues. Sometimes, it can be due to things like lack of parental education about feeding, poor feeding skills, or limited access to healthy food. In some cases, FTT might be due to neglect or even abuse. If there are signs of this, the doctor will investigate further and may involve social services.

Treatment Options for Failure to Thrive

If a child isn’t gaining weight as expected, it’s important to find out why and address those reasons. The first step is a thorough check-up by a doctor and, if necessary, tests that might help identify any underlying conditions causing the weight issue. The care plan should then be tailored to these underlying causes, wherever possible.

Nutrition is a particularly important focus. A healthcare team can calculate how many calories the child needs each day, consider any micronutrient deficiencies needing to be addressed, and put together a plan to meet these nutritional needs. It’s important to specifically tailor this plan to the child’s age and any other underlying health conditions. Nutritional needs can differ depending on whether the child is being breastfed, formula-fed, or has started eating solid food.

This might involve feeding the child more frequently or giving them more food each time. If using formula, it’s important to make sure that it’s mixed exactly according to the instructions. If breastfeeding and the milk supply is a problem, assistance can be provided to increase it. If the child is already eating solid food, giving them calorie-dense foods (high in fats, oils, and proteins) can help them gain weight. Nutrition shakes or similar products might also be an option, although the preference is to use whole foods where possible. It’s also important to keep any food allergies, personal preferences, and cultural factors in mind when coming up with these plans.

Improving the routine around feeding at home can also be crucial. This might mean setting specific times for meals and snacks, minimizing empty calories, and eating together as a family. It’s also important to limit the stress and pressure around eating, which can help build a healthier relationship with food. Open discussions about diet and potential barriers, such as food insecurity, can also be beneficial.

If weight gain issues relate to an underlying medical condition, specific therapies may be needed in addition to improving nutrition. These might involve starting new medications, avoiding allergens, having surgery to correct an anatomical issue, or undergoing behavioral/developmental therapies.

Most children who aren’t gaining weight as they should can be cared for at home, but more severe cases might necessitate a hospital stay. This can be helpful when a severe medical condition is suspected, when weight loss is severe,
or when efforts to help the child gain weight at home have not been successful.
In the hospital, nutritional intake and weight gain can be closely monitored, and tests and consultations can be arranged more quickly if needed. Occasionally, tubes might be inserted to help with feeding, or special nutrition (TPN) given by a drip might be necessary.

What else can Failure to Thrive be?

Understanding why a child or infant may not be gaining weight or even losing weight is a complex issue. It can often involve many factors and medical conditions. As a primary concern, FTT (Failure to Thrive) or weight faltering usually refers to such poor weight gain or loss. Malnutrition could be severe in these patients, leading to a reduction in their growth rate or head size. That’s why when a child exhibits a significant lack of growth, it is essential to consider whether it’s due to FTT or if the child is naturally short and not malnourished. We diagnose short stature when a child is significantly below the average height for their age and sex.

Many factors can lead to short stature, including growth hormone deficiency, delayed growth, inherited short stature, or idiopathic short stature. Besides, other evaluations may include imaging of bone age, testing hormone levels, and checking insulin growth factor (IGF-1). Various diseases linked to poor growth include Cushing Syndrome, thyroid dysfunction, hypopituitarism, and numerous genetic conditions. Also, extensive medical treatments, such as systemic corticosteroid exposure, could cause short stature.

Common considerations for short stature (without malnutrition) could include:

• Constitutional delay of growth
• Familial short stature
• Growth hormone deficiency
• Idiopathic short stature
• Cushing Syndrome
• Hypothyroidism
• Hypopituitarism
• Achondroplasia
• Noonan Syndrome
• Prader-Willi Syndrome
• Russel Silver Syndrome
• SHOX Deficiency
• Trisomy 21, 13, 18
• Turner Syndrome
• Williams Syndrome
• Small for gestational age
• Fetal exposure to harmful substances, such as in fetal alcohol syndrome
• Causes related to medical treatment, like prolonged exposure to systemic corticosteroids

If doctors can’t link the patient’s history, physical examination, and growth parameters to any of these conditions, they consider other possibilities for FTT. They may evaluate whether the child’s poor weight gain is due to insufficient calorie intake, excessive loss/malabsorption of calories, or increased systemic calorie needs. The majority of patients with FTT have some non-organic element as an underlying cause.

For FTT/weight faltering, the following factors and conditions are typically considered:

• Inadequate Caloric Intake: cleft lip/palate, swallowing or other oral-motor dysfunction, esophageal strictures/achalasia, GERD, low muscle tone or other developmental delays leading to feeding difficulties, pyloric stenosis, mental health conditions like bulimia or anorexia.
• Excessive Caloric Loss/Malabsorption: celiac disease, chronic diarrhea, cystic fibrosis or other pancreatic dysfunction, eosinophilic esophagitis/colitis, inflammatory bowel disease like Crohn’s disease or ulcerative colitis, milk-protein or other food allergies, laxative abuse, protein-losing enteropathies, short gut syndrome.
• Increased Systemic Caloric Requirements: anemia, chronic lung, kidney, or liver disease, chronic infections like HIV, tuberculosis, hepatitis, urinary tract infections, enteric pathogens, TORCH infections, congenital heart disease, endocrine disorders like hyperthyroidism, inborn defects of metabolism, cancer, being born prematurely, rheumatologic conditions.
• Inorganic causes: challenges with breastfeeding or formula feeding, difficulty transitioning to solid foods, infant refusing dense calorie options, restrictive dietary choices, lack of knowledge about nutritional requirements, maladaptive feeding behaviors, food insecurity, family/psychosocial stressors, child abuse/neglect.

What to expect with Failure to Thrive

The long-term outlook for weight loss or slow weight gain (also known as FTT/weight faltering) often depends on what’s causing the poor nutrition. In most cases, once it’s noticed that the person isn’t growing at the right pace and action is taken to help them get more calories, the person usually starts gaining weight. The sooner these helpful actions are taken, the better the results tend to be in the long run.

For people whose underweight condition comes from an issue that doesn’t have to do with a physical illness, they can often get back on the right track if changes are made to their diet to increase the number of calories they’re getting, and if they improve the way that they eat based on advice from their doctors. Almost everyone in this situation can maintain a healthy growth pattern if these recommendations are followed. However, if these changes can’t be made because the person or their parents don’t understand the recommendations, don’t have the needed resources to make the changes, if there are physical cause for the poor weight gain that weren’t noticed before, or if the person or their parents don’t follow the doctor’s guidance, the outlook can vary.

For people who are underweight or not gaining weight fast enough because of a medical condition, the outlook can vary and often depends a lot on what’s likely to happen with the medical condition causing the issue. The specific treatments need to address the root cause of the issue, and if there are effective treatments for the condition, patients tend to respond favorably. Along with treating the underlying condition, getting enough nutrition is very important. With this support, most patients can continue to grow at a healthy pace, keeping in mind the limitations caused by their medical condition.

Possible Complications When Diagnosed with Failure to Thrive

Failure to thrive (FTT) or lack of weight gain can worsen malnutrition, which carries several negative outcomes. These could include loss of body mass, muscle weakness, electrolyte imbalances, micronutrient deficits, weakened immunity leading to infections, delayed healing of wounds, and extended hospital stays. For people suffering from moderate to severe malnutrition, reintroducing calories to their diet needs careful monitoring to avoid a condition called refeeding syndrome. This situation requires identifying the high-risk individuals, slowly reintroducing food and hydrating fluids and vigilantly checking for any electrolyte imbalances.

Most individuals who had to stay at a hospital for addressing FTT showed a good response and could continue treatment back home. However, there exists a risk of needing to return to the hospital, with one study showing that 14% of patients had to be readmitted. Those who were more likely to need readmission include patients with at least one complex chronic condition, a history of being born prematurely or people coming from families with a low socioeconomic status.

In cases where patients can’t get enough calories from eating normally, they may need a feeding tube (nasogastric or gastrostomy tubes). Depending on what’s causing the FTT, this could be just a temporary measure until they can get enough calories from eating normally. However, some patients may need to rely on gastrostomy tubes for their lifelong nutritional needs due to underlying medical conditions.

Finally, if FTT isn’t addressed, it can lead to long-lasting neurodevelopmental issues. These include lower IQ, increased chance of attention-deficit hyperactivity disorder (ADHD), learning disabilities, and poor communication skills. Very young children, especially those less than two months old, are at the greatest risk of these neurodevelopmental outcomes.

Key Risks:

• Worsening malnutrition
• Loss of body mass, muscle weakness, and electrolyte imbalances
• Weakened immunity leading to infections
• Refeeding syndrome when reintroducing calories
• Chances of readmission to hospital
• Needing a feeding tube
• Long-term neurodevelopmental problems such as lower IQ and ADHD

Preventing Failure to Thrive

Checking a child’s growth progress, or ‘anthropometric data’, at regular doctor visits is very important. Gathering several measurements over time and having regular discussions with families can help doctors spot if a child isn’t gaining enough weight or growing as expected, an issue known as ‘FTT’ or ‘weight faltering’. This provides a chance to teach parents about this issue.

The most common reason for FTT is simply that the child isn’t eating enough calories. This can be due to a number of reasons, meaning it’s important for doctors to work closely with families to teach them about their child’s nutritional needs and the typical challenges that might arise with feeding at different ages.

In addition to educating families about their child’s calorie and nutritional needs, doctors should also provide strategies for creating an environment supportive of proper feeding. It’s also important to understand that while some parents might know about their child’s nutritional needs, they might not have the resources to meet those needs. For these families, connecting them with available community and social services that can assist them is vital for the successful prevention and treatment of FTT.