Failure to thrive (FTT) is a common paediatric problem that often warrants referral to the outpatient clinic and sometimes the acute admission unit. (2)
2. OUTLINE
● Introduction
● Data and Statistics
● Causes of Failure to Thrive
● Signs and Symptoms
● Diagnostic Criteria
● Evaluation
● Treatment
● Problems associated with FTT
● Prevention and Control
● Conclusion
1
3. INTRODUCTION
● CASE STUDY
● Josh presents at 11 months of age with a history of poor weight gain over the past 4-5 months and a
fall in weight over the past 2 weeks. He was born at term by spontaneous vagina delivery following an
uncomplicated pregnancy with a normal birth weight of 3.4kg and length of 49cm.
● He was breastfed until 7 months of age and solid was introduced at 5 months of age. At 3 months he
had mild bronchiolitis for 1 week and at 8 months he had a 4-day history of diarrhea, which resolved
spontaneously.
2
4. ● At the time of presentation, he had no physical symptoms and a clinical review showed normal
examination except for a slight reduction in muscle bulk in his buttocks. Investigation revealed normal
urine and stool culture test, normal renal, liver, and thyroid function, normal calcium, full blood
examination, and ESR. However, his Coeliac screen showed an abnormal anti-endomysial antibody level
and elevated anti-gliadin antibodies. A diagnosis of Coeliac disease was confirmed via endoscopy and
following the institution of a gluten-free diet, his weight started to increase again.
Case study: Adapted from a scientific article on “An approach to failure to thrive. (1)
3
5. OBJECTIVES
This study is aimed at facilitating an in-depth understanding of Failure to thrive in children and bridging
any possible knowledge gap on the subject matter in relation to:
● Early recognition of the condition in affected children
● Thorough evaluation and
● Proper management of the disease condition
4
6. DEFINITION
● Failure to thrive (FTT) is a common paediatric problem that often warrants referral to the outpatient
clinic and sometimes the acute admission unit. (2)
● It is a term that is widely used to describe a child whose current weight and height fall below the
expected for age, sex, and ethnicity (3)
● Failure to Thrive is not a definitive diagnosis and the more acceptable term is Weight Faltering
which is generally used to refer to a slower rate or an abnormal pattern of weight gain than expected for
age and sex that is usually due to insufficient usable nutrition and reported as an inadequate weight gain
over time. (4,5)
5
7. DEFINITION OF TERMS
● Underweight: It is defined as the proportion of children whose weight in relation to their age is
less than 2 standard deviation of the median on a standard growth chart. An underweight child can
either be stunted, wasted or both.
● Wasting: It is defined as low-weight-for-height and indicates a recent weight loss.
● Stunting: It is defined as low-height-for-age and indicates long-term or chronic undernutrition in
children.
● Malnutrition: According to WHO, it is defined as deficiencies in nutrient intake, imbalance of
essential nutrients or impaired nutrient utilization.
6
8. DATA AND STATISTICS ON FTT
• The 2023 edition of the UNICEF-WHO-World Bank Group report on
childhood malnutrition revealed that we are still far from a world free
of malnutrition because over one in five i.e., 148.1 million children
under 5 were stunted in 2022.
• In the same year, 45 million children under five were wasted of which
13.7 million were severely wasted globally which translates to a
prevalence of 6.8 percent. More than half of all children affected by
wasting lived in South Asia and nearly one quarter in sub-Saharan
Africa. (6)
7
9. DATA AND STATISTICS ON FTT
● According to UNICEF Malnutrition Rate
among Under 5 Children in Nigeria, 37% or 6
million children are stunted with half of them
being severely stunted
● 18% of children are wasted and up to half are
severely wasted.
● 29% of children are underweight and almost
half of them are severely underweight
● Nigeria is ranked among the top 10 countries
in the world with the highest prevalence of
stunting and wasting among under 5 children.
37% STUNTED
18% WASTED
29% UNDERWEIGHT
8
14. SIGNS AND SYMPTOMS
● Symptoms of Failure to thrive include:
● Hair depigmentation and dryness
● Weight loss
● Voracious appetite
● Poor dentition
● Bruising
● Anorexia
Vomiting
Diarrhea
Skeletal deformities (Rickets)
Dermatitis, which may indicate micronutrient
deficiencies such as zinc and niacin (8)
13
15. SIGNS AND SYMPTOMS
● Clinic signs that may be present are:
Ocular signs of vitamin A deficiency in
children, such as Xerosis or Bigots spots
A palpable goiter, which may indicate iodine
deficiency
A low-grade cardiac flow-murmur e.g.,
congenital heart disease
Dysmorphic Features e.g., Turner’s disease
Abdominal distensions
Signs or symptoms of heart failure, such as
third or fourth heart sounds, cardiomegaly,
shortness of breath, cough, or edema (9)
●
14
16. DIAGNOSTIC CRITERIA
If birth weight was below the 9th Centile, a fall across 1 or more weight-centile space
If birth weight was between the 9th and 91st Centiles, a fall across 2 or more weight centile spaces
If birth weight was above the 91st centile, a fall across 3 or more weight centile spaces
Whatever birth weight, when current weight is below the 2nd centile for age. (3,10,11)
● Whilst using the diagnostic criteria, it is important to note that it is common for neonates to lose
some weight during the early days of life. (3,11)
15
17. EVALUATION
● Clinical evaluation of a child with suspected
Failure to thrive should include a detailed history
and physical examination. (12)
● The most important part of outpatient
evaluation in Failure to Thrive is obtaining an
accurate account of a child's eating habits and
calorie intake. (13)
16
18. HISTORY TAKING
● A detailed history should elucidate all aspects of a paediatric history from start to finish with a clear
emphasis on the patient’s dietary history.
● Every section of the clinical history provides the clinician with a broad overview of the child’s
current and past health status which is very important in arriving at a diagnosis of Failure to thrive.
● BIODATA: This section of history is very important in evaluating a child with failure to thrive
because it provides the clinician with an overview of the child’s geographical location, and religious and
ethnic background.
17
19. HISTORY TAKING
● PRESENTING COMPLAINT: This is the patient’s symptom or health concern that gives the
clinician an idea of a diagnosis. While evaluating for failure to thrive, it is important to note that the
complaint might be unrelated to the patient’s actual symptom and in some instance, the diagnosis of
failure to thrive could be based on an incidental finding.
● HISTORY OF PRESENTING COMPLAINT: This is a vital part of history because relevant
information about the patient’s condition ranging from the Complaints, Cause, Course, Care, and
Complication should be explored to aid in having a proper understanding of the patient’s condition.
18
20. HISTORY TAKING
● BIRTH HISTORY: The birth history can give an insight into birth insults that may cause growth
retardation e.g., intrauterine growth restriction, perinatal asphyxia, prematurity, and neonatal jaundice (3)
NUTRITION HISTORY: Diet history should be detailed and consist of:
● Feeding schedules
● Composition of meals
● Frequencies of feeding
● Duration of breast-feeding
● Introduction of Complementary feeds
● Techniques for feeding and preparation of meals. (3)
19
21. HISTORY TAKING
● DEVELOPMENTAL HISTORY: The section on history taking gives the physician an idea of the child’s
developmental pattern from birth.
● FAMILY HISTORY: Information in this history section should include familial growth patterns in parents and
siblings and inherent genetic conditions in the family such as Cystic fibrosis. (3,9)
● PAST MEDICAL HISTORY: Medical conditions that can cause a long-term growth impairment should also be
explored e.g. Tuberculosis, HIV, Congenital heart diseases (3)
● IMMUNIZATION AND DRUG HISTORY: History of medication, immunization, and allergies are equally
important (4)
● SOCIAL HISTORY: Attention should also be placed on retrieving information about the family composition and
socioeconomic status of the parent (3)
20
22. PHYSICAL EXAMINATION/EVALUATION
● A physical examination is conducted in suspected cases of FTT to carry out a thorough evaluation of
the patient. The clinician should conduct a general assessment and Anthropometric measurement of the
child.
● During clinical assessment, dysmorphic features that predict an underlying chromosomal
abnormality and are associated with poor weight gain such as Russel- Silver syndrome, Trisomy-21, and
Turner’s syndrome should be looked out for. (2)
● The mid-parental height should also be assessed in order the explore the option of a familial cause of
small stature. (4)
21
23. ANTHROPOMETRY MEASUREMENTS
● Anthropometric measurements are noninvasive
quantitative measurements of the body.
According to the Centers for Disease Control
and Prevention (CDC), it provides a valuable
assessment of nutritional status in children and
adults. (5)
22
24. ANTHROPOMETRY INDICES
Recommended anthropometric indices used to characterize failure to thrive include:
• Weight-for-Height (to assess wasting)
• Height-for-Age (to assess stunting)
• Weight-for-Age (to assess underweight)
23
25. The weight and height of every child presenting to the clinic should be charted on the immunization
record to monitor their growth trend.
If a child who is less than 2 years fulfills the diagnostic criteria of FTT, plot their weight and length
on the WHO growth chart to assess their weight change and linear growth over time (10)
If the child is over 2 years of age use the BMI centile chart by calculating the BMI (weight in
kg/Height in m2) and plotting your result on the BMI centile chart. [(5,10,14)
For preterm born before 37 weeks use the Neonatal and Infant Close Monitoring Chart to correct
for gestational age, until 12 months if delivered between 32-37 weeks, and 24 months if delivered
before 32 weeks. (8)
24
26. ● WHO growth chart
Fig 1.0 The WHO growth chart
25
28. LABORATORY EVALUATION
● First line tests:
Complete blood count
Urinalysis for protein, nitrites, blood
Blood gas
Stool culture and sensitivity, microscopy of ova, cysts, and parasites.
Blood film (for signs of Iron deficiency), ESR, ferritin level
Biochemical profile including U&E, liver and bone profile, CRP, creatinine, bicarbonate, calcium
and albumin
27
29. LABORATORY EVALUATION
● Further tests:
B12, folate,vit A, D, E, trace metals
Coeliac screen (anti-Ttg and Ig A)- useful after weaning a child off breastmilk, Sweat test, fecal
elastase
Chest x-ray, abdominal uss, endoscopy
Bone scan
Genetic testing
28
30. TREATMENT OF FAILURE TO THRIVE
● Optimal management of FTT will require the involvement of the general pediatrician, dietician, and
other health care professionals.
● Treatment is solely routed to identifying and addressing the underlying cause of growth failure.
● Explore factors and address contributory factors to FTT such as ineffective suckling and bottle
feeding, feeding aversion, feeding environment, patient/carer-infant interaction, and child neglect (5,10)
29
31. TREATMENT OF FTT AS A RESULT OF
INADEQUATE CALORIE INTAKE
Parents and caregivers should be offered advice on ideal feeding practices, such as (10,11):
● Appropriate food choices in terms of type, quantity, and constituent in accordance to the child’s developmental age.
● Implementing regular feeding schedules
Informing parents to keep a dietary record
Calorie-dense dietary products should be recommended to the parents and caregivers. It is important to also pay
attention to the calorie needs according to age group.
● Consider a trial of an oral nutritional supplement for children with continuing FTT despite other interventions.
● Every child whose Failure to thrive is due to inadequate calorie intake should be referred to a Paediatric
dietician for proper nutritional rehabilitation
30
32. TREATMENT OF FTT AS A RESULT OF
INADEQUATE CALORIE ABSORPTION
● A common cause of Failure to thrive due to Inadequate absorption in the paediatric outpatient
clinic is Chronic diarrhea which is defined as diarrhea of “infective cause” that often last for
more than 14 days.
● It can be caused by underlying conditions such as Lactose intolerance, Coeliac disease or
Inflammatory bowel disease
● Treatment is usually supportive and includes, dietary restrictions e.g. restricting gluten-containing
products in Coeliac disease or lactose containing products such as milk and other dairy products in
the case of Lactose intolerance
● In the case of Failure to thrive due to excessive calorie use, which occurs when energy is rapidly
broken down more than the daily requirement for growth and development it is important to treat
the underlying of calorie expenditure.
31
33. TREATMENT OF FTT AS A RESULT OF
PSYCHOSOCIAL FACTORS
● A high index of suspicion is required to make a diagnosis of FTT as a result of psychosocial
factors.
● When a diagnosis of Failure to thrive is made due to any psychosocial factors such as child neglect
and child abuse the hospital’s social support team should be informed.
Food aversion defined as a repulsive feeling toward various types of food is best managed by:
● Slowly exposing a child to new foods
● Creatively presenting new food, like placing food in the shape of a smiley face on their plate.
● Introducing new food on the same plate as familiar food they like.
● Eating any new food with them
● Avoid punishing them for not eating.
● Managing portion size of new food and do not force a child to eat more if he or she is full.
32
34. REASONS FOR ADMITTING A CHILD WITH FTT
● Serious concerns about the child’s weight
● Acutely unwell child
● An appropriate multidisciplinary specialist assessment has been conducted for possible causes and
other interventions have been tried without any improvement.
● Safeguarding concerns in the case of suspected child neglect or abuse (5,10,11)
33
35. FOLLOW-UP CARE
● Growth monitoring should be instituted for every patient with FTT (5,7,10)
● Height/ Length should be measured every three months
Two to three times weekly
< 1 month
Weekly
1-6 months old
Fortnightly
6-12 months
Monthly
> 1 year
FOLLOW-UP
CARE
34
36. PROBLEMS ASSOCIATED WITH FTT
• Long-term Failure to thrive is associated with:
• Delayed development
• Increased incidence of behavioral and psychological disturbances
• Severe malnutrition
• Increased risk of infection
35
37. Start
PREVENTION OF FTT
Primary
prevention
Primordial
prevention
Secondary
prevention
This mode of prevention involves
preventing the development risk factors
before they occur:
A. Health promotion and advocacy
programs
B. Encouraging adherence to routine
immunization schedules
These are actions taken before the
occurence of a disease in an individual
who has already developed risk factors :
A. Routine patient assessment
B. Reinforcing dietary and lifestyle
improvement
Tertiary
prevention
This is usually a rehabilitation phase or
follow-up phase where further
complications are prevented
A. Growth monitoring
B. Nutritional rehabilitation
This step represents the actions carried
out when the condition has been
established to prevent complications
A. Early diagnosis
B. Prompt evaluation and treatment
End
36
38. CONCLUSION
● Failure to thrive (FTT) is a common paediatric problem that often warrants referral to the
outpatient clinic and sometimes the acute admission unit. (2) Thus, it is recommended that every
child presenting to the paediatric outpatient unit should have his or her complete anthropometric
measurement taken and documented on the immunization card to promptly identify children who
are at risk of Failure to thrive.
37
39. REFERENCES
● 1. 200509bergman.
● 2. Matthai S. Faltering Growth / Failure to Thrive.
● 3. Christopher Raab BP. MEDICAL TOPICS RESOURCES NEWS PROFESSIONAL / PEDIATRICS /
MISCELLANEOUS DISORDERS IN INFANTS AND CHILDREN / FAILURE TO THRIVE (FTT) IN CHILDREN
ABOUT DISCLAIMER COOKIE PREFERENCES Failure to Thrive (FTT) in Children. 2023.
● 4. Homan GJ. Failure to Thrive: A Practical Guide. Am Fam Physician. 2016 Aug 15;94(4):295–9.
● 5. Pande S, Muhammad N. LRI Children’s Hospital Faltering Growth: Recognition and Management of
Faltering Growth in Children.
38
40. REFERENCES
● 6. Isanaka S, Andersen CT, Cousens S, Myatt M, Briend A, Krasevec J, et al. Improving estimates of the burden of severe
wasting: Analysis of secondary prevalence and incidence data from 352 sites. BMJ Glob Health. 2021 Mar 2;6(3).
● 7. RobinsLazner M. Paediatric Clinical Practice Guideline Faltering growth.
● 8. GUIDELINES on A, FOR EVALUATION OF THE NUTRITIONAL STATUS AND GROWTH IN REFUGEE
CHILDREN DURING THE DOMESTIC MEDICAL SCREENING EXAMINATION Division of Global Migration and Quarantine
[Internet]. 2013. Available from: www.cdc.gov/healthyyouth/obesity/facts.htm.
● 9. Paediatric Guidelines 2018-20 Bedside Clinical Guidelines Partnership In association with FOI ref 507-2122 UHNM
version [Internet]. Available from: http://www.partnersinpaediatrics.org
● 10. Faltering growth: recognition and management of faltering growth in children NICE guideline [Internet]. 2017.
Available from: www.nice.org.uk/guidance/ng75
39
41. REFERENCES
● 11. Trust Guideline for Management of Faltering Growth (Failure to Thrive) in Babies and Young Children.
● 12. CLINICAL INQUIRIES From the Family Physicians Inquiries Network [Internet]. Available from:
www.cdc.gov/nchs/
● 13. Cole SZ, Lanham JS. Failure to thrive: an update. Am Fam Physician. 2011 Apr 1;83(7):829–34.
● 14. A Health Professional’s Guide for using the WHO GROWTH CHARTS FOR CANADA [Internet].
Available from: www.whogrowthcharts.ca.
● 15. https://my.clevelandclinic.org/health/diseases/22948-food-aversion
● https://www.researchgate.net/publication/327598095_Burden_of_Malnutrition_in_Children_Under_5_Years_in_Ni
geria_Problem_Definition_Ethical_Justification_and_Recommendations
40
42. CREDITS: This presentation template was created by
Slidesgo, including icons by Flaticon and infographics &
images by Freepik
Do you have any questions?
youremail@freepik.com
+91 620 421 838
yourwebsite.com
Thanks
Please keep this slide for attribution
41
