Failure to Thrive

Question 1

What is Failure to Thrive? According to RCH what is the new age term that should be used in place of Failure to Thrive?

Answer 1

Failure to thrive has been replaced by Poor Growth. It is less emotive and is not misleading and apparently won’t cause distress to parents.

Poor Growth generally describes a child whose current weight, or rate of weight gain is significantly below that of the expected similar children at that same age and sex.

Question 2

What are 5 of the Red Flags with Poor Growth/Failure to Thrive? (there are 9)

Answer 2

Signs of abuse or neglect
Poor carer understanding e.g. non-English speaking, intellectual disability
Signs of family vulnerability e.g. drug and alcohol abuse, domestic violence, social isolation, no family support
Signs of poor attachment
Parental mental health issues
Already/previously case managed by child protection services
Did not attend or cancelled previous appointments
Signs of dehydration
Signs of malnutrition or significant illness

Question 3

There are 5 broad bands of causes to be weary of when assessing a patient who has had Failure to Thrive. What are they?

Answer 3

Inadequate caloric intake/retention
Psychosocial Factors
Inadequate Absorption
Excessive caloric utilisation
Other medical causes

Question 4

Name 5 causes of Poor Growth related to inadequate caloric intake/retention.

Answer 4

Inadequate nutrition (breastmilk, formula and/or food)
Breast feeding difficulties
Restricted diet (e.g. low fat, vegan)
Structural causes of poor feeding eg. cleft palate
Persistent vomiting
Anorexia of chronic disease
Error in infant formula dilution
Early (before 4 months) or delayed introduction of solids

Question 5

Name 5 causes of Poor Growth related to Psychosocial Factors.

Answer 5

Parental depression, anxiety or other mood disorders
Substance abuse of one or both parents
Attachment difficulties
Disability or chronic illness of one or both parents
Coercive feeding (including feeding child whilst asleep)
Difficulties at meal times
Poverty
Behavioural disorders
Poor social support
Poor carer understanding
Exposure to traumatic incident/family violence
Neglect of this infant or siblings
Current or past Child Protection involvement

Question 6

Name 5 causes of Poor Growth related to Inadequate absorption.

Answer 6

Coeliac disease
Chronic liver disease
Pancreatic insufficiency eg. Cystic fibrosis
Chronic diarrhoea
Cow milk protein intolerance

Question 7

Name 5 causes of Poor Growth related to Excessive caloric utilisation.

Answer 7

Chronic illness
Urinary tract infection
Chronic Respiratory disease eg. Cystic Fibrosis
Congenital heart disease
Diabetes Mellitus
Hyperthyroidism

Question 8

How do you initially assess a child for Poor Growth?

Answer 8

Adequacy of growth is assessed by plotting serial measurements on a centile weight chart/growth chart. This is usually done alongside height and head circumference.

Note: A child who is tracking downward in the centiles over time may have poor growth but a child who is in the 3rd centile for weight, height and head circumference may look like a baby with poor growth but could be a healthy baby.

Question 9

When assessing a preterm baby what is important to remember? This consideration, how long do you continue accommodating this factor? (#sneakyqs)

Answer 9

With a pre-term baby it is important to correct the measurements for the child based on how preterm they are. This correction is made up till the child is 2 years old.

Question 10

When/how often do you weigh an infant?

Answer 10

It is important to weigh an infant under 3 months, every week.

However, do not weigh any child more than once a week because each child will go through fluctuations in weight velocity and excessive weighing is one way of causing unnecessary anxiety.

Question 11

What is average weight gain/week in age groups 0-3 months, 3-6 months, 6-12 months?

Answer 11

0-3 months – 150-200g/week
3-6 months – 100-150g/week
6-12 months – 70-90 g/week

Question 12

What is mid-parental height and how do you calculate it?

Answer 12

This is the child’s anticipated growth target and therefore the percentile to which the child should potentially be tracking at.

For boys – (Father’s Height + Mothers Height + 13)/2
For girls - (Father’s Height + Mothers Height - 13)/2

Question 13

What is the most important part of the history in a child you suspect as Poor Growth? On top of that, what are 5 other questions you can consider asking? (There are a lot…soz long answer)

Answer 13

A feeding history is critical when assessing this child. Nutrition is after all the main driver of child growth.

Infants: Ask about breastfeeding, formula feeding, timing of introduction of solids and types of foods offered
Toddlers: Food behaviours, Milk volume, Eating solids?

Other Questions
Antenatal complications and maternal health.
Birth weight, length and head circumference.
Significant intercurrent illnesses coinciding with onset of poor growth.
Vomiting and diarrhoea.
Developmental delay, regression or syndromal causes of poor growth.
Mid-parental height and the family history of childhood weight gain.
Lack of financial resources for food requirements, lack of suitable housing.
Lack of family/community supports, Refugee or recent immigrant background.
Parental mental health problems.
Community Services History – particularly failure to engage with MCH Services and local GP.
Failure to attend hospital or community services appointments.
Previous history of child protection involvement.

Question 14

What are things to look for on examination in a child that has failure to thrive? (think broader than just medical reasons here)

Answer 14

Initially on inspection/observation see if the child does look sick, scrawny for his/her age, irritable or lethargic.

After this initial observation, generally inspect to see if the child has any evidence of loss of muscle bulk, subcutaneous fat stores; especially in the upper arm, buttocks and thighs.

After this initial inspect, conduct a thorough examination with particular attention to underlying diagnoses. While doing this, look for signs of child abuse/neglect and observe the child-parent interactions and their communications.

In younger infants, it may be worth observing a feed.

Question 15

There is a mneumonic for the clinical signs of Poor Growth found on examination. What is it and what are the signs?

Answer 15

SMALL KID
S – Subcutaneous fat loss
M – Muscle atrophy
A – Alopecia 
L – Lethargy 
L – Lagging behind normal

K – Kwashiokor (severe protein energy malnutrition characterised by oedema, irritability, anorexia etc.)
I – Infection (recurrent)
D - Dermatitis

Question 16

What investigations are important in the assessment of a child who has Poor Growth?

Answer 16

Important to note here that if the child is otherwise healthy and developing normally with no other suggestive features on history or examination, investigations are really not that necessary.

However, if there is some concern regarding the cause of the child’s failure to thrive then the first line investigations listed below are in order to determine the cause.

FBE, ESR
UEC, LFT
Iron studies
Calcium, phosphate
Thyroid function
Blood glucose
Urine for microscopy and culture
Coeliac screen if on solid feeds containing gluten
Stool microscopy and culture
Stool for fat globules and fatty acid crystals

Question 17

What is the most appropriate management of a child with Poor Growth?

Answer 17

Consider admission if child has signs of illness or dehydration. Find a definitive cause for the Poor Growth and manage according to that. Sometime there is no reason for Poor Growth and the child is otherwise healthy and neurodevelopmentally sound. There is no reason to worry in these cases other than reassurance and discussion about feeiding and whatnot.

If there is a child that you are worried about child abuse/neglect, poor parental understanding or psychosocial concerns then more thought needs to be take in the assessment of this child.

Make sure that any child with Poor Growth is followed up either with a Maternal and Child Health Nurse or with the GP. The frequency of this follow up obviously depends on the circumstances and how old the child is but it is critical in all situations.