Failure to Thrive

FTT Fundamentals - Defining the Dip

• Failure to Thrive (FTT): Inadequate growth in infants & children; a sign, not a diagnosis.
• Key Anthropometric Criteria:
  • Weight for age < 3rd or 5th percentile.
  • Weight for length/height < 3rd or 5th percentile.
  • Weight gain velocity < expected for age.
  • Deceleration: Weight crossing ≥2 major centile lines downwards.
• Classification:
  • Organic: Due to underlying medical illness (e.g., malabsorption, CHD).
  • Non-organic (Psychosocial): Environmental/caregiver factors (e.g., neglect, poor feeding technique).
  • Mixed: Combination of both.

⭐ Weight falling >2 major centile lines on a standard growth chart is a key indicator of FTT.

Root Causes - Why So Small?

Failure to Thrive (FTT) signifies chronically insufficient usable calories. Key mechanisms:

• Feeding problems (technique, supply)
• Absorption (celiac, CF)
• Increased losses (GERD, diarrhea)
• Low intake (neglect, poverty)
• Utilization (metabolic, renal)
• Requirements ↑ (CHD, infection)
• Environmental/Endocrine

⭐ In India, infections (like TB, recurrent diarrhea) and inadequate calorie intake due to poverty or improper feeding practices are major contributors to organic and non-organic FTT respectively.

Detective Work - Spotting FTT

• Core Principle: Identify ↓ growth velocity or crossing 2 major percentile lines on growth charts.
• History Taking - The Foundation:
  • Dietary: Detailed 3-day diet recall (type, quantity, frequency, feeding difficulties, mealtime environment).
  • Medical: Prenatal, birth, postnatal illnesses, developmental milestones, medications.
  • Social & Family: Psychosocial stressors, caregiver-child interaction, family support, economic factors.
• Clinical Examination - The Clues:
  • Anthropometry: Accurate weight, height/length, head circumference (HC). Plot on WHO/IAP charts.
    • Weight-for-age < 3rd or < 5th percentile.
    • Weight-for-length/height < 3rd or < 5th percentile.
    • ↓ growth velocity: Crossing ≥2 major percentile lines.
  • Systemic exam: Signs of malnutrition (e.g., muscle wasting, ↓ subcutaneous fat, hair/skin changes), dysmorphism, or underlying organic disease.
• Initial Investigations (Guided by History & Physical - H&P):
  • CBC, ESR
  • Urine analysis & culture
  • Stool for ova, parasites, occult blood, reducing substances
  • Serum electrolytes, renal function tests (RFT), liver function tests (LFT) (if indicated)

⭐ A 3-day diet recall is a crucial first step in evaluating caloric intake for a child with suspected FTT.

Fixing FTT - Growth Boosters

• Goal: Achieve catch-up growth; target weight gain 20-30 g/day (infants), 10-15 g/day (older children).
• Nutritional Rehabilitation:
  • Calorie intake: $120-150 \text{ kcal/kg/day}$ (can go up to $200 \text{ kcal/kg/day}$ in severe cases).
  • Protein: $2-3 \text{ g/kg/day}$.
  • High-calorie diet: Fortified foods, energy-dense formulas.
  • Micronutrients: Iron, Zinc, Vitamin A, Vitamin D supplementation as needed.
• Feeding Strategies:
  • Structured, frequent meals & snacks.
  • Positive feeding environment; avoid force-feeding.
  • Parental education & counseling.
• Address Underlying Cause: Treat infections, malabsorption, psychosocial issues.
• Monitoring: Regular weight, height, head circumference checks.

⭐ Initial nutritional rehabilitation for severe FTT often requires 120-150 kcal/kg/day and 2-3 g protein/kg/day for catch-up growth.

• Hospitalization if: Severe malnutrition, dehydration, suspected abuse/neglect, failed outpatient management, or complex medical needs requiring multidisciplinary care (e.g., feeding tube).

High-Yield Points - ⚡ Biggest Takeaways

• Definition: Weight < 3rd-5th percentile or crossing 2 major centiles downwards on growth charts.
• Most common cause: Inadequate caloric intake, often psychosocial (non-organic FTT).
• Organic FTT: Caused by underlying medical conditions like malabsorption or chronic illness.
• Sequence of growth failure: Weight affected first, then length/height, lastly head circumference.
• Key investigation: Detailed dietary history and observation of feeding.
• Management: Focus on nutritional rehabilitation and treating any underlying organic cause.