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FAILURE TO THRIVE

Nilesh Baxi

Family Physician, Tardeo, Mumbai 400 007.

What is Failure to Thrive?

Failure to Thrive is the term used for children who for some reason, do not gain weight corresponding to their age and nutrition. In severe cases height and head circumference may also be affected. In our country, most commonly affected children are between ages of 3 months and 5 years.

All children are different. Some are small and some are big, some are thin and some are fat. It is far more important that the child should be active, playful, full of energy and free from lassitude. Mothers are often worried about the normal slowing down of weight gain in the second half of the first year. This is associated with less appetite which may result in food forcing and so food refusal. A well child’s poor appetite is almost always due to food forcing.

Common Causes of Failure to Thrive

When an apparently well child is unusually small for his age, one must consider the following factors.

1.Genetics - When a parent is of unusually small build, the child may be small too. One must also pay attention to the familial pattern of growth such as slower growth in earlier months.

2.Low Birth Weight - Growth in utero is some indication of his later growth potential. If a child was small at birth, particularly if small for dates, he is likely to be small even later. Conversely the larger he is at birth, the larger he is likely to be in later years.

3.Socio-economic factors - together with genetic factors and low birth weight explain the great majority of cases of slow physical growth. This fact should be considered before ordering detailed investigations.

4.Defective physical growth from previous diseases now cured.

Presenting features

Most common presentation is mother comparing the growth of another child in relation, with her own child, and finding slow growth and rushing to the doctor. In some cases several people may have commented about lack of growth or dullness of the child prompting the mother to seek medical aid. A small percentage of cases may be picked up by the physicians while treating recurrent infections. Complaints may range from no appetite, fussy child, low appetite or eating normally and still not putting on weight or simply child falling sick too often. In severe cases mile stones may be delayed. It must be kept in mind that many cases may be of normal weight, it may just be an anxious or neurotic mother.

Examination Findings

*According to the percentile charts for height, weight and head circumference, failure to progress normally.

* Physical milestones may be delayed - e.g. sitting, standing, walking, talking, self feeding and toilet training.

* Signs of recurrent infections.

Predisposing factors

* Poverty

* Malnutrition

* A negative emotional environment (neglect or rejection).

* Chronic disease (e.g. Koch’s, chronic infection, Malabsorption or HIV).

* Genetic disorders, such as Down syndrome.

* Endocrine diseases, including disorders of the thyroid, pituitary, adrenal and pancreas.

* Premature or sick newborn.

* Infant with physical deformity.

* Parental inexperience

* Parents who were raised in a negative emotional environment or are poorly educated.

* Crowded or unsanitary living conditions.

* Worm infestations

Diagnosis

Once it has been accepted that a particular child does fall in the category of failure to thrive, going through the following list mentally will be of great help in narrowing down the problem.

Defective Intake

Breast feeding - insufficiency of milk

Artificial feeding - inadequate quantity for pre-term baby

- fear of over feeding

- Incorrectly prepared food

Emotional deprivation: prolonged crying : non accidental injury

Vitamin deficiency on synthetic diets

Chronic infection e.g. Koch’s, urinary tract infection

Protein calorie malnutrition

Defective absorption

Fat, carbohydrate, protein

Hirschsprung’s disease

Allergy to cow’s milk

Increased loss

Excessive perspiration - overclothing, inadequate fluid intake

Diarrhoea, vomiting

Organ diseases

Involving heart, brain, kidney, chest, pancreas etc.

Mental deficiency, subdural haematoma

Congenital heart disease, severe asthma, juvenile diabetes

Miscellaneous

Chromosome abnormalities

A clinic must be equipped with Growth charts for height, weight, and head circumference. Detailed history including birth, diet, immunization and family history is a must. Number of siblings, socio-economic status and health status of parents should provide a guidance to the most likely cause of failure to thrive. Baseline certain routine investigations e.g. CBC, ESR, urine, stool (for malabsorption of fat), MT, X-ray chest PA view will have to be carried out. In today’s times HIV may also be included in a sick child. In certain cases X-rays of wrist may have to be asked for to assess bone age.

Details of all investigations is out of purview of this article, they have to be based on merits of individual case.

Management

Management of a case of failure to thrive largely depends on advising an adequate, well-balanced diet. If malnutrition is causing failure to thrive, a special diet may be required. Commonest malnutrition in our country is Marasmus/Kwashiorkar, poverty being the cause behind. Diet advice should be such to incorporate low-cost food stuff available round the year.

Medication

None routinely.

If an underlying disorder is causing failure to thrive, medication to treat the condition may be prescribed.

Activity

No restrictions to be imposed.

Possible Complications

Permanent mental, emotional or physical disability.

Child remains small and developmentally slow.

Recurrent infections.

Prognosis

* If failure to thrive is caused by parental inexperience or psychological problems, recovery is possible with education and counseling for the parents.

* If failure to thrive is caused by an underlying physical illness or disorder, including malnutrition, recovery depends on whether the condition can be corrected.

Prevention

Family physician has to be involved in regular guidance to the parents of the newborn especially during weaning period.



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