Failure to thrive (FTT) refers to inadequate growth in infants and children. It is defined as weight below the 3rd percentile on a growth chart or a significant drop off from a previously established growth curve. FTT can be organic, resulting from medical causes like prematurity or malnutrition, or inorganic, caused by non-medical factors like poor parenting or neglect. Evaluation involves a thorough history, physical exam, and basic lab tests. Treatment focuses on identifying and addressing the underlying cause while ensuring adequate calorie intake through increased feeding or supplementation. Early diagnosis and intervention are important to prevent long term developmental and health impacts of prolonged malnutrition.

1. FAILURE TO THRIVE
by
NIDHIL NARAYANAN
TBILISI STATE MEDICAL UNIVERSITY

2.  Failure to thrive (FTT) is a chronic, potentially life threatening disorder of
infants and children who fail to gain and may even lose weight. Children
are considered as failing to thrive when their rate of growth does not meet
the expected growth rate for a child of their age. More specifically, the
term characterized those whose weight is below the 3rd percentile on an
appropriate growth chart.
Introduction


3. 

4. 
 The deviation from a normal growth channel is actually more descriptive
of what is happening to an individual than a decrease in the actual
amount of weight. Any infant or child at the fifth percentile should alert
the caregiver that a problem exists. If the condition progresses, the
undernourished child may become irritable and/or apathetic and may
not reach typical developmental markers such as sitting up, walking,
and talking at the usual ages.

5.  FTT is a term used to describe inadequate growth or the
inability to maintain growth in childhood.
 Attained growth
• Weight<3rd percentile on standard growth chart.
• Weight for height<5th percentile on standard growth chart.
• Weight 20% or more below ideal weight for height.
 Rate of growth
• Less than 20g/day from birth to 3 months of age.
• Less than 15g/day from 3 months to 6 months of age.
• Fall off from previously established growth curve.
• Downward crossing of >2 major percentiles.
Definition


7.  Traditionally FTT has been classified as
Classification of FTT

1
2
2
•Organic
•Inorganic
•Mixed

8. 
Occurs when there is underlying medical cause
like:
 Premature birth.
 Maternal smoking, alcohol use or illicit drugs during
pregnancy.
 Mechanical problems present.
 Unexplained poor appetites that are unrelated to mechanical
problems.
 Inadequate intake also can result from metabolic
abnormalities.
 Poor absorption of food, inability of the body to use
absorbed nutrients or increased loss of nutrients.
Organic

9. 
Due to causes other than medical cause.
 Poor feeding skills on the part of the parent
 Dysfunctional family interactions
 Difficult parent-child interactions
 Lack of social support
 Lack of parenting preparation
 Family dysfunction, such as abuse or divorce
 Child neglect
 Emotional deprivation
Inorganic

10. 1
•Inadequate caloric intake
2
•Inadequate absorption
3
•Increased caloric requirement
4
•Excessive loss of calories
5
•Altered growth potential or regulation.
CAUSES OF FTT


11.  Incorrect formula preparation
 Neglect
 Excessive juice consumption
 Poverty
 Behavioral problem affecting eating
 Non-availability of food
 Misperceptions about diet and feeding practices
 Errors in formula reconstitution
1.Inadequate caloric intake

12.  Dysfunctional parent-child interaction, child abuse
and neglect
 Behavioral feeding problem
 Mechanical problems with sucking, swallowing
and feeding
 Primary neurological diseases
 Chronic systemic disease resulting in anorexia, food
refusal and neurological problems
Continue…


13. Cystic fibrosis
Celiac disease
Vitamin deficiencies
Hepatic diseases.
2. Inadequate absorption


14.  Hyperthyroidism
 Congenital heart disease
 Chronic immunodeficiency
 Chronic respiratory disease
 Neoplasm
 Chronic or recurrent infection
3.Increased caloric requirement


15.  Persistent vomiting
 Gastro esophageal reflux disease
 Gastrointestinal obstruction
 Increased intracranial pressure
 Renal losses—renal tubular acidosis
 Diabetes mellitus
 Inborn errors of metabolism
4. Excessive loss of calories


16. 
 Chromosomal abnormalities
 Endocrinopathies
5.Altered growth potential or regulation

17. CLINICAL FEATURES

 Height, weight, and head circumference do not match
standard growth charts
 Weight is lower than 3rd percentile
 Growth may have slowed or stopped after a previously
established growth curve
 Physical skills such as rolling over, sitting, standing and
walking decreased
 Mental and social skills decreased
 Secondary sexual characteristics delayed in adolescents.
Cont.….

18.  Constipation
 Excessivecrying
 Excessive sleepiness(lethargy)
 Irritability
 Minimalsmiling
 Avoidance of eyecontact
 Unresponsive

20. DIAGNOSTIC EVALUATION

History taking
Examination and Tests

21. 
 PRENATAL
 (INTRANATAL) LABOUR, DELIVERY, AND
NEONATAL EVENTS
 MEDICAL HISTORY OF CHILD
 SOCIAL HISTORY
 NUTRITIONAL HISTORY
History taking

22. Maternal medical history should include the following:
•Maternal age
•Gravidity
•Parity
•Abortions
•Pregnancy health history, including a detailed history
of weight gain, prenatal care, substance or cigarette
use, nutrition and unusual nutritional practices,
general complications, bleeding, infections, fevers,
and toxemia
•Labor and delivery and complications, if any

23. Neonatal medical history should include the following:
•Gestational age determined at birth
•Intrauterine growth rate (IUGR)
•Apgar scores
•Birth weight, length, and head circumference with
percentiles
•Neonatal course and complications, including
sepsis, jaundice, feeding intolerance, or feeding
difficulties
•Detailed medical history of newborn period
•Completed review of newborn screens
(eg, phenylketonuria [PKU], other inborn errors of
metabolism)

24. The infant's or child's history should include the following:
• Medical-based history to exclude medical causes
• Feeding and nutritional history
• Growth and developmental progress
Postnatal medical history should include the following:
• Immunizations
• Allergies
• Medications
• Food intolerance
• Weight loss
• Diarrhea
• Vomiting
• Dysphagia
• Snoring
• Sleep apnea
• Recurrent respiratory or other bacterial and viral infections
• Signs of immune deficiency
• Malabsorption symptoms and signs
• CNS abnormalities
• Developmental delay or delayed or regressed milestones

25. A detailed history of food intake from infancy through the current period
is vital, and feeding history should include the following:
• Age-adjusted and age-dependent dietary details - Milk, formula, solids,
vitamins, other supplements, food allergy or intolerance
• Feeding behaviors - Sucking, chewing, and swallowing difficulty; limited
food preference or negative responses to food and feeding; frequency
and timing of meals
• Caregivers' knowledge - Nutrition and feeding, dietary beliefs, religious
and cultural beliefs about food, any unusual diets that might be
inappropriate for a child
• Basic food and nutritional needs - Anything that prevents the family
from (or assists the family with) getting food (eg, finances,
transportation, subsidized programs); appropriate and safe preparation
of food by the caregiver (eg, clean water, housing or shelter, cooking
facility, refrigeration, cooking knowledge)
• Issues of nutritional ignorance (inadequate amounts or types of food,
unusual dietary beliefs)
• Review of all developmental milestones for infancy and childhood,
looking for either failure to attain or regression from the norm at specific
ages.

26.  Physical examination
 Denver Developmental Screening Test
 A growth chart outlining all types of growth
 Complete blood count (CBC)
 Electrolyte balance
 Hemoglobin electrophoresis
 Hormone studies, including thyroid function tests
 X-rays to determine bone age
 Urinalysis
Examination andTests


27. Most infants and children with growth failure related to
environmental factors need very limited laboratory
screenings. In the young infant or child, a few prudent
baseline tests maybe indicated.
Initial and follow-up newborn screening tests, as follows:
•CBC count - WBC and RBC indices for possible indication
of occult infection, microcytic or hemolytic anemias, or
immune deficiency
•Urinalysis and culture - Hydration status (if warranted)
with specific gravity, evidence of infection, renal tubular
acidosis
•Renal function - Serum electrolytes, BUN, and creatinine
levels
•Liver function - Liver function tests considered in
children with signs of protein wasting or organomegaly

28. Additional testing as needed or
indicated, as follows:
•Human immunodeficiency virus
(HIV) testing if risk factors are
noted or if history and
examination are at all
suggestive
•Sweat test for cystic fibrosis
•Zinc level reported to be low in
malnourished infants and
children
•Metabolic and endocrinology
screening (only as needed)
•Tuberculosis testing
•Stool studies

29. •Imaging studies are not routinely needed.
•Perform skeletal survey for occult trauma if physical
abuse is suspected or signs are present upon
examination.
•Head CT scanning or MRI studies are indicated if
examination reveals microcephaly, macrocephaly, or
congenital malformation or if abusive head trauma is
a concern.
•Perform bone age studies of wrists in children who
have constitutionally short stature or are extremely
malnourished; in patients in whom bone density or
ricks is a concern, perform knee studies, wrist studies,
or both.

30. Degree of Failure to Thrive
Growth
parameter
Mild Moderate Severe
Weight 75-90% 60-74% <60%
Height 90-95% 85-89% <60%
Wt/Ht ratio 81-90% 70-80% <70%
ASSESSMENT OF DEGREE OF FTT


31. MANAGEMENT

 Children with FTT require 50% of Recommended Dietary
Allowance (RDA) of calories for catch up growth.
 Correction of any underlying disease
 Improvement in care-giver skills.
 Regular and effective follow up
 Treatment may also involve improving the family relationships
and living conditions.
Cont.….

32.  Feeding interval should not be greater than 4 hours & a
maximum time allowed for sucking should be 20 minutes.
 Eliminating distractive events
 Avoiding excessive fruit juices
 For older & young children meals should be last for 30
minutes, solid foods should be offered before liquid,
environmental distraction should be minimized.

33. 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

34. FURTHER CARE
o Failure to thrive (FTT) is considered a medical emergency in infants or
toddlers who weigh less than 70% of the predicted weight for length.
o Watch for refeeding syndrome.
o Most infants and children younger than 1-2 years can be treated with a
coordinated outpatient care plan. Far fewer patients are hospitalized as
inpatients today because of the development of appropriate and focus-
specific outpatient care clinics and poor reimbursement for inpatient care.
o Patients with severe malnourishment who have had either no previous
workup or for whom outpatient care has failed may require hospitalization.
o Hospitalization may be required in cases of suspected abuse or neglect, as
well as for patients who are perceived to be in an unsafe environment.
Foster care placement may be a subsequent requirement.
o Nasogastric and gastrostomy tubes should be reserved for the most severe
cases.

35. PROGNOIS
• Early diagnosis is crucial. Growth, development and behavior
can be affected.
• Prognosis should be guarded for infants and children with
severe malnutrition. If abuse and neglect are comorbid in a case
of FTT, the degree of risk and risk factors for poor outcome
increase in complexity and potential for poor outcome
increases.
• With early intervention and treatment, the overall outcome can
be promising for infants and children who respond to the
nutritional and environmental interventions needed. Nutritional
and growth improvement alone does not mean that all problems
are resolved.

36. PREVENTION
• Prevention of growth failure related to parental neglect and family
and/or social dysfunction can be viewed on primary, secondary, and
tertiary levels.
• Primary prevention involves careful assessment and monitoring of all
families in primary care practice for any risk factors as reviewed
above.
• Secondary prevention involves monitoring and intervention when
these risk factors or situations are identified in a family or child.
Consider early intervention as a mode of prevention in cases in which
the goal is preventing the potential morbidity of growth failure.
• Tertiary prevention involves cases that have been identified and
where intervention has begun to address the growth failure. Prevent
further growth failure, with the resultant developmental disability
and poor outcome morbidity, by creating and implementing a care
plan that involves detailed review

37. 
 Failure to thrive is a descriptive term, not a specific
diagnosis. FTT is result of inadequate usable calories necessary
for a child’s metabolic and growth demands. Simplified approach
to FTT by detailed history, thorough Physical Examination with
primary care giver, initial investigation includesCBC, ESR,
urinalysis, urine culture, stool for ova and cyst of parasites.Trail of
nutritional therapy with calorie-dense diet.
CONCLUSION

38. 
BIBLIOGRAPHY
• Dorothy R. Marlow,Textbook of Pediatric nursing,Saunders publisher,
6th edition, page no. 677-684
• MarilynJ Hockenberry, Essential of pediatric nursing, Mosby
publisher, 8th edition, page no.396-400
• IAPTextbook of pediatrics, 5th addition, page no.113
• http://www.healthofchildren.com/E-F/Failure-to-Thrive.html
• http://www.modernmedicalguide.com/failure-to-thrive/
• https://emedicine.medscape.com/article/915575-followup#e5

39. QUESTIONS
Which of the following defines failure to thrive?
• A. Weight curve has fallen by two major percentiles from previous
rate of growth
• B. Loss of 20% of either body weight, head circumference or height
• C.Weight curve has fallen three major percentiles from previous
growth rate
• D. A child below the 2nd percentile all three categorie

40. The MOST profound consequence of undernutrition is
•A. premature death
•B. repeated infections
•C. stunting
•D. cell damage
•E. developmental delay

41. The MOST commonly used index for nutritional status
is
•A. height-for-age
•B. weight-for-height
•C. body mass index
•D. mid-upper arm circumference
•E. weight-for-age