Failure to thrive
Failure to thrive (FTT), also known as weight faltering or faltering growth, indicates insufficient weight gain or absence of appropriate physical growth in children.[2][3] FTT is usually defined in terms of weight, and can be evaluated either by a low weight for the child's age, or by a low rate of increase in the weight.[4]
Failure to thrive
Faltering weight, weight faltering[1]
The term failure to thrive has been used in different ways,[5] as there is no single objective standard or universally accepted definition for when to diagnose FTT.[6][7] One definition describes FTT as a fall in one or more weight centile spaces on a World Health Organization (WHO) growth chart depending on birth weight or when weight is below the 2nd percentile of weight for age irrespective of birth weight.[8][9] Another definition of FTT is a weight for age that is consistently below the 5th percentile or weight for age that falls by at least two major percentile lines on a growth chart.[10] While weight loss after birth is normal and most babies return to their birth weight by three weeks of age, clinical assessment for FTT is recommended for babies who lose more than 10% of their birth weight or do not return to their birth weight after three weeks.[8] Failure to thrive is not a specific disease, but a sign of inadequate weight gain.[11]
In veterinary medicine, FTT is also referred to as ill-thrift.
Signs and symptoms[edit]
Failure to thrive is most commonly diagnosed before two years of age, when growth rates are highest, though FTT can present among children and adolescents of any age.[12] Caretakers may express concern about poor weight gain or smaller size compared to peers of a similar age.[13] Physicians often identify failure to thrive during routine office visits, when a child's growth parameters such as height and weight are not increasing appropriately on growth curves.[13] Other signs and symptoms may vary widely depending on the etiology of FTT. It is also important to differentiate stunting from wasting, as they can indicate different causes of FTT. "Wasting" refers to a deceleration in stature more than 2 standard deviations from median weight-for-height, whereas "stunting" is a drop of more than 2 standard deviations from the median height-for-age.[14]
The characteristic pattern seen with children with inadequate nutritional intake is an initial deceleration in weight gain, followed several weeks to months later by a deceleration in stature, and finally a deceleration in head circumference.[15] Inadequate caloric intake could be caused by lack of access to food, or caretakers may notice picky eating habits, low appetite, or food refusal.[13][16] FTT caused by malnutrition could also yield physical findings that indicate potential vitamin and mineral deficiencies, such as scaling skin, spoon-shaped nails, cheilosis, or neuropathy.[15] Lack of food intake by a child could also be due to psychosocial factors related to the child or family. It is vital to screen patients and their caretakers for psychiatric conditions such as depression or anxiety, as well as screen children for signs and symptoms of child abuse, neglect, or emotional deprivation.[16][17][18]
Children who have FTT caused by a genetic or medical problem may have differences in growth patterns compared to children with FTT due to inadequate food intake. A decrease in length with a proportional drop in weight can be related to long-standing nutritional factors as well as genetic or endocrine causes.[15] Head circumference, as well, can be an indicator for the etiology of FTT. If head circumference is affected initially in addition to weight or length, other factors are more likely causes than inadequate intake. Some of these include intrauterine infection, teratogens, and some congenital syndromes.[15]
Children who have a medical condition causing FTT may have additional signs and symptoms specific to their condition. Fetal alcohol syndrome (FAS) has been associated with FTT, and can present with characteristic findings including microcephaly, short palpebral fissures, a smooth philtrum and a thin vermillion border.[19] Disorders that cause difficulties absorbing or digesting nutrients, such as Crohn's disease, cystic fibrosis, or celiac disease, can present with abdominal symptoms. Symptoms can include abdominal pain, abdominal distention, hyperactive bowel sounds, bloody stools, or diarrhea.[15][16]
The diagnosis of FTT relies on plotting the child's height and weight on a validated growth chart, such as the World Health Organization (WHO) growth charts[62] for children younger than two years old or the U.S. Centers for Disease Control and Prevention (CDC) growth charts[63] for patients between the ages of two and twenty years old.[3] While there is no universally accepted definition for failure to thrive, the following are examples of diagnostic criteria for FTT:
After detection, the underlying cause of FTT must be diagnosed by a medical provider through a multifaceted process. Without determining what causes the growth problem, FTT is a wastebasket diagnosis.[64] This process begins with evaluating the patient's medical history. The medical provider will ask about complications during pregnancy and birth, health during early infancy, previous or current medical conditions of the child, and developmental milestones that have been reached or not reached by the child.[20] The child's feeding and diet history, including overall caloric intake and eating habits, is also assessed to help identify potential causes of FTT.[65][66] Additionally, medical providers will inquire about any medical conditions that other members of the family may have, as well as assess the psychological and social circumstances of the child and family.[20]
Next, a complete physical examination may be done, with special attention being paid to identifying possible organic sources of FTT.[65] This could include looking for dysmorphic features (differences in physical features, such as an especially large or small head, that may indicate an underlying medical disorder), abnormal breathing sounds, and signs of specific vitamin and mineral deficiencies.[65] The physical exam may also reveal signs of possible child neglect or abuse.[65]
Based on the information gained from the history and physical examination, a workup can then be conducted, in which possible sources of FTT can be further probed through blood work, x-rays, or other tests.[65] Laboratory workup should be done in response to specific history and physical examination findings. Medical providers should take care not to order unnecessary tests, especially given estimates that the usefulness of laboratory investigations for children with failure to thrive is 1.4%.[20] Initial bloodwork may include a complete blood count (CBC) with differential to see if there are abnormalities in the number of blood cells, a complete metabolic panel to look for electrolyte derangements, a thyroid function test to assess thyroid hormone activity, and a urinalysis to test for infections or diseases related to the kidneys or urinary tract.[67] If indicated, anti-TTG IgA antibodies can be used to assess for celiac disease, and a sweat chloride test can be used to screen for cystic fibrosis.[67] If no cause is discovered, a stool examination could be indicated, which would give information about the function of gastrointestinal organs.[67] C-reactive protein and erythrocyte sedimentation rate (ESR) can also be used look for signs of inflammation, which may indicate an infection or inflammatory disorder.[67]
Prognosis[edit]
Children with failure to thrive are at an increased risk for long-term growth, cognitive, and behavioral complications.[56] Studies have shown that children with failure to thrive during infancy were shorter and lower weight at school-age than their peers. Failure to thrive may also result in children not achieving their growth potential, as estimated by mid-parental height.[56][73] Longitudinal studies have also demonstrated slightly lower IQs (3–5 points) and poorer arithmetic performance in children with a history failure to thrive, compared to peers receiving adequate nutrition as infants and toddlers.[23][74] Early intervention and restoration of adequate nutrition has been shown to reduce the likelihood of long-term sequelae, however, studies have shown that failure to thrive may cause persistent behavioral problems, despite appropriate treatment.[56]
History[edit]
FTT was first introduced in the early 20th century to describe poor growth in orphan children but became associated with negative implications (such as maternal deprivation) that often incorrectly explained the underlying issues.[75] Throughout the 20th century, FTT was expanded to include many different issues related to poor growth, which made it broadly applicable but non-specific.[75] It was often used to blame the mother.[64] The current conceptualization of FTT acknowledges the complexity of faltering growth in children and has shed many of the negative stereotypes that plagued previous definitions.[75]
In older adults[edit]
The same label is given to older adults, as a synonym for frailty syndrome and functional decline.[76] They may struggle with instrumental activities of daily living (e.g., preparing meals for themselves), be at high risk for hospital admission, and need significant discharge planning to support a safe and healthy return home.[76]