The document discusses 'failure to thrive' in children, identifying it as a pattern of slow growth compared to expected values for age and gender, and outlines criteria for diagnosis and clinical features. It emphasizes the importance of comprehensive assessments to identify underlying causes and describes management strategies, including dietary interventions and potential hospitalization. The document also highlights the long-term effects of weight faltering and the need for ongoing monitoring and support for affected children.

1. Failure to thrive
By Dr. Haitham Nabeel
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Failure to thrive

3. Failure to thrive
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4. Clinical pearl!
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A single
observation of weight is difficult to
interpret unless markedly discrepant
from the head circumference or
length.

5. Failure to thrive
• The normal
• Healthy children’s weight will fluctuate, but it will usually
progress within one centile space (the distance between two
major centile lines on the growth chart).
• However, size at birth is determined not only by genes but
also by the intrauterine environment.
• Over the first few weeks, infants who are large at birth will
often cross down centiles (catch-down growth), whereas
small babies will move up centiles (catch-up growth) to find
their genetic centile growth lines.
• Infants who become acutely ill will often lose weight, but will
regain their weight centile within 2 weeks to 3 weeks.
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6. Failure to thrive
• Growth faltering
• A pattern of slow growth in children compared to the predicted values for their age and
sex
• Commonly used criteria include:
• Weight-for-age, length-for-age, BMI-for-age, or weight-for-length < 5th percentile
• A decrease across 2 major percentile lines from an already established growth velocity
• Childhood wasting
• Low body weight as a result of acute malnutrition, rapid weight loss, or insufficient weight
gain
• Characterized by a z score below 2 standard deviations in BMI-for-age charts or weight-for-
length charts
• Growth stunting
• Reduced height as a result of chronic malnutrition
• Characterized by a z score below 2 standard deviations in height-for-age charts; weight may
be proportional for height
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7. Failure to thrive
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8. Failure to thrive
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9. Failure to thrive
• Clinical features
• Features of malnutrition
• Failure to gain weight
• Clinical features of protein-energy malnutrition, e.g.,
• Wasted muscle mass
• Minimal adiposity
• Growth stunting
• Dermatologic signs
• Thin, weak hair
• Pale, dry skin
• Features of micronutrient deficiencies, such as:
• Acral dermatitis or change to hair color/texture in zinc deficiency
• Pallor in iron deficiency anemia
• Developmental delay
• Recurrent infections
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10. Clinical pearl!
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Persistent severe malnutrition affects
growth parameters sequentially; the first
affected is weight, then length, and finally
head circumference

11. Failure to thrive
• Clinical features
• Features of underlying conditions
• Suspicious contusions or fractures; abnormal language, social, or psychological
development in children who experience abuse
• In psychosocial FTT there may be signs of neglect e.g. diaper rash, unwashed skin,
untreated impetigo, uncut and dirty fingernails, or unwashed clothing.
• signs suggestive of malabsorption (distended abdomen, thin buttocks, misery)
• Recurrent vomiting and diarrhea in gastrointestinal diseases
• Signs suggestive of chronic respiratory disease
• Atopic dermatitis in food allergies
• Heart murmur in congenital cardiac disease
• Dysmorphic features in genetic abnormalities
• Edema in renal or liver failure
• Signs of heart failure and evidence of nutritional deficiencies (koilonychia, angular
stomatitis).
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12. Clinical pearl!
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In psychosocial FTT there may be signs of
neglect e.g., diaper rash, unwashed skin,
untreated impetigo, uncut and dirty
fingernails, or unwashed clothing

13. Failure to thrive
• Diagnostic approach
• Obtain growth measurements and plot them on growth charts
appropriate to age and any underlying conditions.
• Confirm growth faltering by identifying either:
• Single point measurements in low percentiles
• OR significant delays in linear growth
• Perform a comprehensive clinical assessment to identify the etiology of
growth faltering.
• Consider diagnostic studies in patients with:
• Suspected micronutrient deficiencies
• Severe clinical features (e.g., weight gain velocity < 25% of expected)
• No response to initial management
• Concurrently assess for abnormal pediatric development.
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14. Failure to thrive
• Clinical assessment
• Comprehensive pediatric history and physical examination
including family history and prenatal/birth history
• Feeding and nutrition history
• Number and frequency of feeds
• Food refusal
• Observation of a feed
• Social history: identify risk factors such as food insecurity,
lower socioeconomic status
• Identify features suggestive of an underlying etiology
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15. Failure to thrive
• If weight faltering is confirmed, a dietary history
should be taken to include:
• history of milk feeding
• age at weaning
• range and type of foods now taken
• mealtime routine and eating and feeding behaviours
• a 3-day food diary will provide a more detailed and
accurate picture of intake
• if possible, observe a meal being taken.
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16. Failure to thrive
• Consider also:
• was the child born preterm or had intrauterine growth
restriction?
• is the child well with lots of energy or does the child have
other symptoms such as diarrhoea, vomiting, cough, or
lethargy?
• the growth of other family members and any illnesses in the
family
• is the child’s development normal?
• are there psychosocial problems at home?
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17. Clinical pearl!
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CBP & GUE are good initial tests. Other
tests should be judicious &
relevant to the findings in hx or exam.

18. Failure to thrive
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19. Failure to thrive
• Management
• The management of most weight faltering is carried out in primary care.
• Using mealtime observations and food diaries, health visitors can assess
and support families to improve feeding and increase calorie intake.
• Access to specialist support may be required.
• A paediatric dietician is helpful in assessing the quantity and composition
of food intake, recommending strategies for increasing energy intake and
a speech and language therapist has specialist skills with feeding disorders.
Input from a clinical psychologist and from social services may also be
needed.
• Nursery placement can be helpful in alleviating stress at home and
assisting with feeding. The key outcome measure is a rise up the weight
centiles; this usually begins 4 weeks to 8 weeks after intervention.
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20. Failure to thrive
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21. Failure to thrive
• Management
• In children under 6 months of age with severe weight faltering,
hospital admission may occasionally be necessary for active
refeeding and multidisciplinary team involvement. While being on a
children’s ward may offer the opportunity to observe and improve
the parent’s method and skill in feeding, this rarely transfers back to
home.
• As children’s wards are busy and focused on acute illness, admission
is unlikely to be helpful unless there is a clear and agreed
preadmission plan.
• Indications of hospitalization for patients with FTT include:-
• For further investigations, severe malnutrition, failure of home
management & to evaluate the parent-child feeding interaction
(especially when psychosocial FTT is suspected).
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22. Failure to thrive
• Outcome
• Weight faltering appears to have a long-term effect on
growth, with children remaining on a low centile.
• However, a randomized controlled trial of primary care
intervention has shown that, at 4 years of age, children
who received intervention were heavier and taller than
untreated controls.
• Weight faltering also appears to have an adverse effect on
cognition, although this is small.
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23. Failure to thrive
• Prognosis
• FTT in the 1st yr of life (regardless of cause) is ominous, because
maximal postnatal brain growth occurs in the 1st 6 mo of life as
well as brain grows as much in 1st yr as in the rest of the child's life.
• Thus all patient with FTT require frequent monitoring & assessment.
• Prognosis of patients with organic FTT is variable, whereas ≈ 30% of
children with psychosocial FTT may develop developmental delay
with social and emotional problems.
• Early FTT may be associated with ↑ risk factors for cardiovascular
disease e.g. dyslipidemia, HT, and glucose intolerance as an adult.
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24. Failure to thrive
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25. Do you have any questions?
THANK YOU!