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Failure To Thrive
Nutrition and Metabolic Disease Division Department of Pediatrics University of Sumatera Utara

Introduction
Failure to thrive (FTT) is a term used to describe inadequate growth or the inability to maintain growth. There is no concensus on which specific criteria should be used to define FTT. A combination of anthropometric criteria, rather than one criterion, should be used to more accurately identify children at risk of FTT.

Am Fam Physician. 2011;83(7): 829-34

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Am Fam Physician. 2011;83(7): 829-34

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Suggested definition
Weight for age less than 3rd percentile Dont be obsessed by the 3rd centile Dont wait untill the 3rd centile is crossed before calling it FTT Infants can be failing to thrive with severe deceleration of weight gain, well before they cross the 3rd centile Excluding small but proportionate children avoids mislabelling normal children Downward crossing of weight for age > 2 major percentile lines More appropriate term are : weight faltering weight loss slow weight gain
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Definition of growth faltering

Age 0 4 mo : Gains of < 0.5 kg per month ( N : 20-25 g/kg/day) Age 6 15 mo : Three horizontal or failing monthly weights, even within the road to health area (usually from -2SD to median) Age 16 60 mo : Three horizontal or failing monthly values, below the road to health area; Any loss of> 1 kg in a month Any value > 2 kg below road to health area
Steveny, 1982
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Weight faltering (Fail to thrive) : kurva BB naik tetapi tidak sejajar garis (hitam) Flat growth : kurva BB mendatar (merah) Downward growth :kurva BB menurun (biru)

Prevalence
Approximately 80% of children with FTT presents before 18 months of age In the US : 5 10% in primary care settings 3 5% in hospital settings

Am Fam Physician. 2011;83(7): 829-34

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Etiology
FTT may result from a variety of organic and nonorganic. There is increasing recognition that in many children the cause is multifactorial : biologic, psycosocial and environmental contributors
Korean J Pediatr. 2011;57(7): 277-81

A practical way to categorize FTT is according to calories, including inadequate caloric intake, inadequate caloric absorption, or excessive caloric expenditure
Am Fam Physician. 2011;83(7): 829-34
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..Etiology
Inadequate caloric intake Infants < 8 wks : Problems with feeding : poor sucking and swallowing. Breastfeeding difficulties Older infants : Difficulty transitioning to solid foods Insufficient breast milk or formula consumption Excessive juice consumption Parental avoidance of high calorie foods Any age : family factors, poverty, child neglect/abuse Inadequate absorption : disorders causing frequent emesis or malabsorption Excessive caloric expenditure : chronic condition first 8 wks of life
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Clinical Presentation

Dtsch Arztebl. 2011;108(38): 642-9

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Diagnostic Evaluation
1. History Childs eating habits Caloric intake Parent-child interaction/Psycosocial history 2. Physical Examination Anthropometry examination Signs of physical abuse Red flag signs 3. Further Evaluation Routine laboratory testing is not generally recommended, but may be indicated
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Management
The Primary goal of management FTT is improved nutritional status through provision of adequate nutrient intake for catch-up growth Other goal : enhance the nurturing ability of the caretakers (they must be involved in the treatment plan) May require Changes to : The diet Feeding schedule Feeding environment
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Initial Management
Depends on nutritional status : Mild Without underlying medical disorder outpatient setting With underlying medical disorder multidisciplinary management Moderate Interdisciplinary team Severe Hospitalization Interdisciplinary team
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Hospitalization in FTT
Indication : Severe malnutrition Significant dehydration Serious illness/medical problems Failure to respond to outpatient management Precise documentation of energy intake Psychosocial circumstances Practically of distance Objective : Safe implementation of feeding regime catch up growth Enhance the nurturing ability of caretakes
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Hospitalization in FTT
Intervention : Recorded daily consumption Estimated energy intake Nutritional therapy Other interventions
Discharge criteria : Safe home environment + demonstration by the caretakers Provision of necessary support and follow up
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Nutritional Therapy
Requirements Energy and protein Common regimen : 50% greater than DRI Other method for caloric requirements (kkcal/kg) : average RDA for age x median weight actual weight Protein (g/kg) : 2.2 gr x median weight actual weight Vitamins and minerals Multivitamin include zinc and iron
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Recommended dietary allowances (RDA), 1989

Age 0 6 month 6 12 month 1 3 yr 4 6 yr Kkcal/kg 108 98 102 90 Protein 2.2 2.2 2.2 2.2

7- 10 yr 11 14 yr
15 18 yr

70

2.2 2.2
2.2 2.2 2.2

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47 45 40

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Example
A 3-month-old boy, weight of 3.6 kg, length of 57 cm weight-for-age z-score, -2.50; and weight-for-height zscore, -2.11. Waterlow classification: moderate malnutrition (weight for height 74%) RDA for calories: 108 kcal/kg/day, protein: 2.2 g/kg/day Ideal weight for length : 4.8 kg Caloric requirement for catch up growth (108 x 4.8)/3.6 = 144 cal/kg/day Protein requirement for catch up growth (2.2 x 4.8)/3.6 = 2.9 g/kg/day
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Increasing intake
For infants Human milk adding term formula powder/concentrate Infant formula

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 Older children Increasing caloric density : use of soils, sour cream, heavy cream, butter, peanut butter and cheese as dietary additives is helpful Limited juice consumption : 4 to 8 ounces per day Avoid giving liquids before solid food Feeding schedule Feeding environment

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Other Intervention
Medical Developmental and behavioral Psycosocial

Adequate response
Age 0 3 mo 3 6 mo Expected weight gain, g/day 26 31 17 18

6 9 mo
9 12 mo 1 3 yr

12 13
9 79
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Prognosis
Determined by a variety of factors, including: - genetic potential - the timing of malnutrition - the severity of malnutrition - the presence of underlying medical problems Prognosis to weight gain and growth is good, they are at risk for : Cognitive deficits Behaviour problems Learning difficulties
Pediatrics. 2007;120:59 27

Prevention
Increased awareness of the medical and psychosocial factors that may predispose to growth failure Classify such patients along the anthropometric guidelines Recognize the benefits of multidisciplinary approach to difficult management situations

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