This document defines failure to thrive and outlines its causes and evaluation process. Failure to thrive is defined as weight or growth below major percentiles. Causes include inadequate intake due to issues with appetite, ingestion, or food availability; altered growth regulation from prenatal or genetic factors; calorie wasting from vomiting or malabsorption; and increased caloric needs. Evaluation involves assessing growth data, medical history, nutrition, development, a feeding observation, and labs if indicated. Hospitalization may be needed if abuse is suspected or for severe cases.

1. Hisham Ahmed AlyHisham Ahmed Aly
Prof. of pedeatricsProf. of pedeatrics
Al- Azhar UniversityAl- Azhar University

5. FAILURE TOFAILURE TO
THRIVETHRIVE

6. DefinitionDefinition::
 FTT usually referred to growFTT usually referred to grow
below 3rd or 5th percentilesbelow 3rd or 5th percentiles

8.  Other definitionOther definition
Change of growth that has crossed twoChange of growth that has crossed two
major growth percentiles (i.e. from abovemajor growth percentiles (i.e. from above
the 75th percentile to below the 25th).the 75th percentile to below the 25th).

9.  Attained growthAttained growth
Weight <3rd percentile on NCHS growthWeight <3rd percentile on NCHS growth
chartchart
Weight for height <5th percentile on NCHSWeight for height <5th percentile on NCHS
growth chartgrowth chart
Weight 20% or more below ideal weight forWeight 20% or more below ideal weight for
heightheight
Triceps skinfold thickness < 5 mmTriceps skinfold thickness < 5 mm

10.  Rate of growthRate of growth
Depressed rate of weight gainDepressed rate of weight gain
<20 g/d from 0 to 3 months of age<20 g/d from 0 to 3 months of age
<15 g/d from 3 to 6 months of age<15 g/d from 3 to 6 months of age
 Falloff from previously established growth curveFalloff from previously established growth curve
Downward crossing of >2 major percentiles onDownward crossing of >2 major percentiles on
NCHS growth chartNCHS growth chart
Documented weight lossDocumented weight loss

11.  Organic CausesOrganic Causes
 Non-Organic CausesNon-Organic Causes

12. Patterns of FTTPatterns of FTT
BW, L, H.C.BW, L, H.C.
Pattern 1:Pattern 1:
Pattern 2Pattern 2
Pattern 3Pattern 3

13.  PrimaryPrimary
 SecondarySecondary

14. CAUSES OF INADEQUATECAUSES OF INADEQUATE
WEIGHT GAINWEIGHT GAIN
 Inadequate intakeInadequate intake
 Altered growth potential regulationAltered growth potential regulation
 Calorie wastingCalorie wasting
 Increased caloric requirementsIncreased caloric requirements

15. CAUSES OF INADEQUATECAUSES OF INADEQUATE
WEIGHT GAINWEIGHT GAIN
1) Inadequate intake1) Inadequate intake
a)a)Lack of appetiteLack of appetite
Chronic diseaseChronic disease (eg, CNS pathology, GIT(eg, CNS pathology, GIT
disorders, chronic infections)disorders, chronic infections)
AnemiaAnemia (eg, iron deficiency(eg, iron deficiency
Psychosocial problemsPsychosocial problems (eg, apathy)(eg, apathy)

16. b)b)Difficulty with ingestionDifficulty with ingestion
Feeding disorderFeeding disorder
Psychosocial problemsPsychosocial problems (eg, apathy,(eg, apathy,
rumination)rumination)
Craniofacial anomaliesCraniofacial anomalies (eg, choanal(eg, choanal
atresia, cleft lip and palate, micrognathia)atresia, cleft lip and palate, micrognathia)

17. Dyspnea (eg, congenital heart disease,Dyspnea (eg, congenital heart disease,
pulmonary diseases)pulmonary diseases)
Tracheoesophageal fistulaTracheoesophageal fistula
Neurologic disordersNeurologic disorders (eg, cerebral palsy,(eg, cerebral palsy,
hypertonia, hypotonia, generalized musclehypertonia, hypotonia, generalized muscle
weakness)weakness)

18. c)Unavailability of foodc)Unavailability of food
Inappropriate feeding techniqueInappropriate feeding technique
Insufficient/inadequate volume of foodInsufficient/inadequate volume of food
Inappropriate food for ageInappropriate food for age
Withholding of food (abuse, neglect)Withholding of food (abuse, neglect)

26.  2) Altered growth potential2) Altered growth potential
regulation(Assimilation disorders)regulation(Assimilation disorders)
 Prenatal insultPrenatal insult
 Chromosomal abnormality/geneticChromosomal abnormality/genetic
syndromesyndrome
 EndocrinopathiesEndocrinopathies

27. 3) Calorie wasting3) Calorie wasting
1)1)VomitingVomiting

CNS pathology (increased intracranial pressure)CNS pathology (increased intracranial pressure)
 Intestinal tract obstruction (eg, pyloric stenosis, Intestinal tract obstruction (eg, pyloric stenosis,
malrotation)malrotation)
 Gastrointestinal refluxGastrointestinal reflux
 Metabolic problemsMetabolic problems
 Drugs/toxinsDrugs/toxins

30.  2)Malabsorption2)Malabsorption
Primary gastrointestinal diseases: biliaryPrimary gastrointestinal diseases: biliary
atresia/cirrhosis, celiac diseaseatresia/cirrhosis, celiac disease
Inflammatory bowel disease, enzymatic deficiencies,Inflammatory bowel disease, enzymatic deficiencies,
food (protein) sensitivity/intolerance, Hirschsprungfood (protein) sensitivity/intolerance, Hirschsprung
diseasedisease
Cystic fibrosisCystic fibrosis
Immunologic deficiencyImmunologic deficiency
InfectionsInfections
EndocrinopathiesEndocrinopathies
Drugs/toxins

32.  3)Renal losses3)Renal losses
 Renal tubular acidosisRenal tubular acidosis
 DiabetesDiabetes

33. CAUSES OF INADEQUATECAUSES OF INADEQUATE
WEIGHT GAINWEIGHT GAIN
 Inadequate intakeInadequate intake
 Altered growth potential regulationAltered growth potential regulation
 Calorie wastingCalorie wasting
 Increased caloric requirementsIncreased caloric requirements

34. COMPONENTS OF EVALUATIONCOMPONENTS OF EVALUATION
 Growth dataGrowth data
 HistoryHistory: : Problem contextProblem context , , MedicalMedical , ,
NutritionalNutritional , , PsychosocialPsychosocial , ,
Developmental/behavioralDevelopmental/behavioral
 Physical examinationPhysical examination
 Developmental/behavioral assessmentDevelopmental/behavioral assessment
 Observation of a feedingObservation of a feeding
 Laboratory studiesLaboratory studies
 HospitalizationHospitalization

35.  Growth dataGrowth data
Current growth parametersCurrent growth parameters
Growth curves over timeGrowth curves over time
Relationship of growth parameters to eachRelationship of growth parameters to each
otherother

36.  HistoryHistory
Problem contextProblem context
When growth problem first became a When growth problem first became a
concernconcern
Previous interventions attemptedPrevious interventions attempted

37.  Medical historyMedical history
Prenatal care and complications (infection, Prenatal care and complications (infection,
maternal nutrition, drug exposure)maternal nutrition, drug exposure)
Gestational age and growth parameters at birth Gestational age and growth parameters at birth
(SGA, prematurity)(SGA, prematurity)
Perinatal complications (infections, CNS Perinatal complications (infections, CNS
insults, anomalies)insults, anomalies)

38. Previous hospitalizations, illnesses, and surgeryPrevious hospitalizations, illnesses, and surgery
Current medications Current medications
Review of systems (vomiting, stooling patterns, Review of systems (vomiting, stooling patterns,
mechanics of feeding/swallowing, anorexia, mechanics of feeding/swallowing, anorexia,
distress/tiring with feeds) distress/tiring with feeds)

39. Nutritional historyNutritional history

Caloric intakeCaloric intake
Breast-fed: schedule and length of feeds; maternal Breast-fed: schedule and length of feeds; maternal
cues to prefeeding engorgement, milk let-down, and cues to prefeeding engorgement, milk let-down, and
drainage postfeeding; maternal diet, rest, stress, and drainage postfeeding; maternal diet, rest, stress, and
medicationsmedications
Formula fed: type, method of preparation; feeding Formula fed: type, method of preparation; feeding
schedule; amount offered and consumedschedule; amount offered and consumed
Mixed diet: 3-day diet history (food/beverage type, Mixed diet: 3-day diet history (food/beverage type,
method of preparation, quantity consumed)method of preparation, quantity consumed)

40.  Schedule and length of feedingsSchedule and length of feedings
Daily feeding/mealtime environmentDaily feeding/mealtime environment
Location/positioning during feedingsLocation/positioning during feedings
Perceptions of suck, swallow, and grasp of nipplePerceptions of suck, swallow, and grasp of nipple
Caregivers involved with feedingsCaregivers involved with feedings

41. Amount and type of mealtimeAmount and type of mealtime
supervisionsupervision
Behavior during feedingBehavior during feeding
History of progression to solid/table foods History of progression to solid/table foods
Favorite/disliked foods Favorite/disliked foods
Parental knowledge/beliefs regarding Parental knowledge/beliefs regarding
child/infant feedingchild/infant feeding
Family eating practices and beliefs Family eating practices and beliefs
Financial constraints affecting food Financial constraints affecting food

42. PsychosocialPsychosocial
Caregiving environmentCaregiving environment
Family support systemsFamily support systems
Family financesFamily finances
Stability of parents and their relationshipStability of parents and their relationship
Family/household compositionFamily/household composition

43.  Parent and child relationshipParent and child relationship
Attitudes toward parentingAttitudes toward parenting
Content/structure of typical day for childContent/structure of typical day for child
Parents' perceptions of child's needsParents' perceptions of child's needs

44.  Developmental / behavioralDevelopmental / behavioral
Age-related behavior problems (eg, attachment, Age-related behavior problems (eg, attachment,
autonomy)autonomy)
Developmental milestones: gross/fine motor, Developmental milestones: gross/fine motor,
language, social/emotional, cognitionlanguage, social/emotional, cognition
Parents' perception of child's Parents' perception of child's
temperament/behavior temperament/behavior

45.  Physical examinationPhysical examination
Physician and child interactionPhysician and child interaction
Skinfold measurementsSkinfold measurements
Complete physical examinationComplete physical examination

46.  Observation of a feedingObservation of a feeding
Feeding environment (home observation)Feeding environment (home observation)
Type and amount of food offeredType and amount of food offered
Duration of feedingDuration of feeding
Child's oromotor and fine motor skillsChild's oromotor and fine motor skills

47. Laboratory studiesLaboratory studies
Diagnostic tests directed by positive findings Diagnostic tests directed by positive findings
on history, physical, and review of growth on history, physical, and review of growth
datedate
@complete blood count, @complete blood count,
@serum electrolytes, @serum electrolytes,
@serum creatinine, urinalysis (± culture), @serum creatinine, urinalysis (± culture),
total protein/albumin, bone age (if height total protein/albumin, bone age (if height
growth also poor)growth also poor)

48.  Hospitalize if:Hospitalize if:
Evidence of physical abuse and/or severe Evidence of physical abuse and/or severe
neglectneglect
High risk for abuse and neglect, very disturbed High risk for abuse and neglect, very disturbed
parent & child interaction, poor parent functioning, parent & child interaction, poor parent functioning,
and/or an extremely stressful environmentand/or an extremely stressful environment
Severe malnutrition and/or medically unstableSevere malnutrition and/or medically unstable
Outpatient management failure Outpatient management failure