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Common Growth Concerns

What is Failure to Thrive?

Failure to thrive (FTT) is defined as a lack of normal expected growth or weight gain in a child, a condition affecting approximately 5-10% of children. FTT is not a disease or illness, but rather an indication that there is a problem with growth. There is no single measurement that determines with certainty whether or not a child has failure to thrive, it is more of a cluster of symptoms that in combination lead to a diagnosis. Since it’s not a disease or illness, what does failure to thrive mean? 

What is failure to thrive?

FTT is simply defined as when a child does not grow or develop properly or as expected. Generally children who are diagnosed with failure to thrive are at the 5th percentile or below on the growth chart. But, a diagnosis of failure to thrive also includes the cause of the poor growth. It is usually determined to be caused by not eating enough calories or being unable to properly process the calories that are eaten. It is usually diagnosed before 18 months of age, but can occur in a child of any age. FTT is more common in lower socioeconomic, urban or rural areas. If left untreated, it can result in developmental delays, illness, or permanent growth problems. 

FTT is diagnosed by a doctor by evaluating several different measurements. A few of these may include:

• Weight-for-age less than the 5th%

• Low weight-for-height ratio

• Height-for-age less than the 5th%

• Weight that suddenly drops more than 2% on growth curve

• A stall in linear growth

• Developmental delays or not meeting milestones

• Medical diagnosis or tests

• Socioeconomic or psychological problems affecting eating and food availability

It is important to note that low body weight or a short height-for-age does not immediately indicate failure to thrive. During the first year of life, 27% of infants have been found to meet at least one criteria for FTT, which is why doctors use multiple criteria to make an official diagnosis. An accurate diagnosis requires a full assessment of the child’s health, growth pattern, family dynamics, and medical history. Several other conditions can cause slow or delayed growth, such as premature birth, familial short stature, or constitutional growth delays, all of which should be ruled out before diagnosing FTT. If diagnosed, FTT must be treated immediately because it can cause permanent developmental delays and have a long-term impact on the child’s health.

FTT is usually caused by inadequate nutrition or the inability to utilize calories from food properly. It may be due to problems with feeding, such as poor sucking or swallowing in breastfeeding infants. Or improper preparation of formula. For older children, it may be triggered by a difficulty with transitioning to solids, excessive juice consumption, or a lack of knowledge about proper nutrition. Family problems or socioeconomic factors play a role in FTT, particularly poverty and financial difficulties leading to problems with food availability. Parents who struggle with mental health problems or substance abuse are more likely to have children with FTT. Children who are abused or neglected are four times more likely to have FTT. Lastly, diseases that cause problems with calorie absorption or utilization such as celiac disease, food allergies, chronic diarrhea, thyroid disease, or heart disease can also lead to FTT.

How is failure to thrive diagnosed?

If your child’s doctor suspects FTT, they will need to do a complete and through medical assessment of the child’s growth, health, and home environment. But, a diagnosis of failure to thrive often requires monitoring the child over time and is usually not determined with a single measurement or just one evaluation. A diagnosis of FTT will usually include:

Measurements of Growth

Doctors will usually start by taking several measurements of your child. The three most common are height (length), weight, and head circumference. They will then compare these measurements to the standard growth curve for children of the same sex and age. If available, they will also compare the current measurements to any previous measurements taken to determine if the child has grown or gained weight over time. 

They will use the growth history as well as the current height and weight to determine where your child falls along the growth curve when compared to other children. Generally, if a child is below the 5th percentile for weight or height, this may indicate FTT. It is also a red flag if the child has dropped more than two percentiles since the last measurement. 

Parent/Caregiver Interviews

Be prepared to answer a ton of questions about your child and your family. The doctor will try to get an understanding of the child’s life, including their overall health and development. They will ask specific questions about the child’s diet, behavior at home/school, milestones they have achieved, and medical history. They will ask about family medical history, overall growth patterns, and family dynamics. They may also ask questions about income, food availability, and family eating patterns. Doctors will also assess intellectual abilities, substance abuse, or mental health issues of the parents to determine if the parent is able to properly care for and feed the child. 

Medical history 

The doctor will ask if the child has any illnesses or other conditions that may affect their growth. They may assess the child for food allergies or intolerances. They will also likely ask about bowel habits, such as vomiting, diarrhea, or constipation. They will also take a detailed family history of any illnesses or diseases. 

Physical examination and tests 

In addition to growth, the doctor will conduct a physical exam that may include a variety of tests to rule out any illnesses, if they suspect it is causing the FTT.  Some of the tests may include: thyroid test, food allergy screening, stool test, and complete blood count. Sometimes doctors may also do x-rays to evaluate growth. They may also request information on bowel movements or changes in bowel habits to rule out any issues with absorption of food. During the physical exam the doctor is also trying to look for signs of any possible physical abuse or neglect which can be impacting the child’s growth. 

Developmental screenings

Children generally meet certain developmental milestones at specific ages. A failure to meet these milestones, such as walking, crawling, or rolling over, could indicate a problem with growth. The assessment will likely include an evaluation of the child’s development and if it is appropriate for their age.

Food/Feeding Assessment

Since FTT is usually related to an issue with calorie intake, determining how much a child is eating is a major component in the diagnosis and treatment. If the child is exclusively breastfed, the evaluation may include an assessment of proper latch-on technique and a pre/post feeding weight to assess intake. The doctor may request an evaluation by a lactation consultant to see if the mother is nursing correctly and producing enough milk. If the baby is formula fed, the doctor may request a demonstration of how the formula is being prepared and a log of how many ounces per day the baby is receiving.

Depending on the age of the child, they doctor may request a food or feeding log. For a child who eats solids, a food record detailing their daily diet may be requested to help assess if they are getting enough calories. If a child is older, the doctor may interview the child themselves about their eating patterns to determine if they are eating enough calories. They may also request to observe the child’s eating behaviors or have a specialist, such as an occupational or speech therapist, evaluate their behaviors around eating. 

How is failure-to-thrive treated?

In order to treat FTT the doctor must first identify the cause of the poor growth. The treatment will also be determined by the severity of the symptoms, health of the child, and the preferences of the parents or caregivers.  There are no medications for treating FTT, but treatment focuses on education of caregivers and helping correct the underlying issues that caused the FTT in the first place.

If the cause is determined to be poor nutrition or improper feeding, the doctor may recommend supplementation of the child’s diet or a meeting with a Registered Dietitian to help educate the parents on proper feeding. If the child is a breastfed infant, this may require instruction on proper breastfeeding, supplementation with formula, or working closely with a lactation consultant. If the infant is formula fed, instructions on how to increase caloric density will be discussed. If the child is older, parents will receive instructions on how to increase calories in food and to avoid excessive consumption of juice or water. The treatment will likely focus on providing nutrition for catch up growth and educating the parents on how to continue to provide an appropriate diet as the child grows.

If there is a psychological or economic component, the child or family may be referred to counseling or social programs to help. This may involve recommendations to seek help at food programs such as WIC or SNAP, if there is a lack of available food in the house.  

Most likely, treatment will require a multi-faceted approach over time to address all of the underlying causes that resulted in FTT. Depending on the cause of the FTT the child may be required to see several different specialists, such as speech therapists, occupational therapists, and physical therapists. They may also receive home nurse visits or be seen more frequently for doctor’s appointments. Depending on the severity, treatment may span several years until the child is back on track with their growth and development.

Very rarely children may be hospitalized for failure to thrive. This is considered if the child requires extensive feeding observation or intense supplementation. Hospitalization is also considered if there is significant evidence of abuse, neglect, injury, or severe malnutrition.

What does failure to thrive mean for your child long-term?

In many cases, FTT is resolvable if the underlying causes can be addressed. Many children are able to catch up in growth and develop normally. Most children have fully recovered from FTT by the age of 8, as long as they receive treatment. FTT has a larger risk of causing long-term consequences in low birth weight preterm infants or in children in developing countries who may not have the resources to receive treatment. If a child does not receive treatment soon enough, FTT can result in long-term complications that may include learning disabilities, short stature, and emotional problems.

Prevention is Key

Preventing FTT from developing in the first place is optimal. The best way to do this is to be in regular contact with your child’s pediatrician. Be sure to attend all scheduled appointments. If you believe there is a growth problem, then address it immediately. 

If the child is an infant, look for signs of excessive fussiness, too few wet diapers during the day, or a lack of rapid growth in the first few weeks of life. This may indicate a problem with feeding. See a lactation specialist or speak to your doctor if you think there is a problem with breastfeeding or you are unsure how to properly feed the baby formula.

If lack of resources to purchase food is the problem, get social assistance from WIC or SNAP as soon as possible. WIC is specifically designed to support women, infants, and children with proper nutrition. The important thing is to ask for help before food availability becomes a problem.

Although failure-to-thrive can become quite serious if left untreated, most children do make a full recovery once the cause is identified. With a bit of education about nutrition, a quick intervention, and possibly some social and economic support, many children can go on to live active and healthy lives.

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