Assessment
Most children with failure to thrive (FTT) can be assessed by a general pediatrician with the help of professionals in other disciplines. The clinical evaluation for FTT should include a comprehensive history, physical examination, feeding observation, and a home visit by an appropriate health professional. For breastfed infants, an observation of feeding should include an evaluation of the mother's breastfeeding technique and the infant's response to feeding and be conducted by a professional specifically trained in lactation counseling and assessment. Laboratory and radiologic studies are frequently unnecessary. A multidisciplinary approach involving nursing, social services, and dietetics personnel is essential when children with FTT fail to recover and sustain normal growth velocity after treatment interventions.
History
A thorough review of the child's family history should include genetic conditions, growth histories, endocrine disorders, caregivers' knowledge of normal growth and development, family function, eating patterns, types of food available in the home, and family stressors. The child's parents should be queried about personal history of abuse, eating disorders, psychopathology, alcohol use, drug use, domestic violence, and stress; their social skills, nutritional beliefs, and positive assets also should be considered in the evaluation.
The child's medical history should include a general review of systems, current medications, allergy history, feeding history, 72-hour dietary record, gastrointestinal symptoms, travel history, feeding routines, feeding skills, time required to feed, behavior during feedings, sleep patterns, developmental history, daily routine, gestational and prenatal history, and history of organic disease. Information obtained from all child care providers should include a history of eating patterns, interactions, social skills, responses to the providers, and family concerns.
Physical Examination
The physical examination should include documentation of past and present growth parameters, including head circumference, using appropriate growth charts. General examination should include a search for major and minor anomalies, careful neurologic examination, assessment of suck-swallow coordination, and observation of the child's developmental skills and responses and interactive behaviors with parents and examiners.
Feeding Observation
A feeding observation can be performed in the office but is enhanced as part of a home visit. Feeding behavior, the child's oral interest or aversion, and parent-child interactions before, during, and after feeding should be observed and recorded.
Laboratory Testing
When history, comprehensive physical examination, feeding observations, and home visitation do not reveal an obvious cause of FTT, laboratory testing may be performed to rule out organic disease and ascertain nutritional deficits. Testing should be performed if there are concerns arising from the history or physical examination; however, the yield of positive laboratory data are <1%.
Recognition of FTT Secondary to Neglect or Abuse
The risk factors that should alert the pediatrician to the possibility of neglect as the cause of FTT include:
- Parental depression, stress, marital strife, divorce
- Parental history of abuse as a child
- Mental retardation and psychological abnormalities in the parent(s)
- Young and single mothers without social supports
- Domestic violence
- Alcohol or other substance abuse
- Previous child abuse in the family
- Social isolation and/or poverty
- Parents with inadequate adaptive and social skills
- Parents who are overly focused on career and/or activities away from home
- Failure to adhere to medical regimens
- Lack of knowledge of normal growth and development
- Infant with low birth weight or prolonged hospitalization
Moreover, concerns of abuse or neglect should be raised during the course of intervention and monitored if the following become evident:
- Intentional withholding of food from the child
- Strong beliefs in health and/or nutrition regimens that jeopardize a child's well-being
- Family that is resistant to recommended interventions despite multidisciplinary team approach
Treatment and Management
FTT in the young infant and toddler must be considered a medical emergency if the growth curve documents weight <70% of the predicted weight-for-length. Guidelines on management of less severe cases of FTT are listed in the Pediatric Nutrition Handbook from the American Academy of Pediatrics. Because early malnutrition can have severe deleterious effects on early brain development, prompt recognition of severe cases is essential. After resolution of urgent, life-threatening medical conditions, the priority in an evaluation of FTT is a period of observation of at least several weeks to monitor intake, output, growth, feeding style, interactions, and infant/child characteristics. Historically, this has taken place in a hospital but may be better situated in a home environment, possibly including a foster home, until the cause of the FTT is determined.
Despite current economic and managed care constraints, inpatient care is justified for a child with severe FTT and/or if abuse or neglect is suspected. In contrast to other children, a child with FTT secondary to neglect may eagerly eat in the protective and predictable hospital environment. Liberal intake and above-average weight gain observed in the hospital support a diagnosis of neglect as an underlying cause of the FTT. When appropriate, pediatricians should advocate for inpatient care with managed care plan personnel, because hospitalization has been shown to significantly improve outcome in some cases. However, FTT needs to be considered a chronic process, and interventions need to be long-term.
Severely malnourished children may be anorectic and weak. The institution of adequate caloric intake may be difficult. Moreover, institution of increased feedings may initiate significant metabolic problems, known as refeeding syndrome. Guidelines for diagnosis and management of this condition are available elsewhere. Nutritional guidance and occupational and/or oral-motor evaluation by a speech therapist regarding effective feeding techniques are invaluable. Parents should be involved in all aspects of the treatment program and should be provided with support and education, empowering them to fulfill the care plan.
Suspicion of child maltreatment must lead to a report to the appropriate child protective services agency. The pediatrician must adequately document interventions that have been attempted, specific instructions to parents, evidence of parental understanding of the instructions, evidence of parental understanding of the potential adverse consequences to the child, and evidence of parental failure to adhere to nutritional and feeding recommendations. Intervention by child protective services agencies may increase parental compliance or allow for additional support services such as child care, counseling, and home visitation. If aggressive interdisciplinary intervention fails to correct the weight to safe levels (>80% of predicted weight-for-length) and maintain weight gain, then placement in foster care may be the only alternative. Education and training of foster parents regarding feeding and the importance of close social interaction are mandatory. The involvement of the pediatrician during all phases of protective service intervention is essential.
Guidance for the Pediatrician
- Pediatricians are encouraged to recognize that child neglect is among the many causes of FTT.
- Pediatricians are strongly encouraged to consider child abuse and neglect and to report cases of FTT that do not resolve with appropriate interventions.
Conclusions
FTT usually can be evaluated by the office-based pediatrician with minimal laboratory tests and medical interventions. However, for infants with FTT who are suspected to be victims of abuse and neglect, aggressive multidisciplinary intervention is required in either an inpatient or outpatient setting. Close follow-up from a multidisciplinary team and home visitors who are respectful and supportive of the family are important components of assessment and treatment. FTT as a consequence of abuse or neglect must be considered in families with profiles indicating a high risk of abuse and in families that consistently fail to adhere to the recommended interventions or are unable to maintain a safe environment for their child.
