Pediatricians often see the condition of poor growth due to inadequate nutrition – long called failure to thrive but poorly defined. This presentation from pediatric gastroenterologist Arathi Lakhole, MD, MPH, delivers a clearer understanding of this wide-ranging disorder and its many causes, enabling care providers to make more valuable evaluations that lead to better outcomes. Lakhole discusses useful terms and assessment tools, and clarifies categories of undernourishment, questions to ask parents, physical exam features, and appropriate interventions.
uh, it's a topic that we all encounter multiple times a day in our practice. So I thought and and I am sure you guys are exports. But I think I can give you some more points and just go over this as a review. Um, so, uh, the objectives of my talk today are to define and classify poor weight gain and infants and Children to discuss nutritional evaluation of a child with poor weight gain, to identify causes of poor weight gain and to describe a multidisciplinary approach to management of a child with poor weight gain. So the growth is an important indicator of child's well being, as we all know, and any deviations from the curve close to the presence of underlying possible pathological processes. Um, only identification of this problem helps in planning interventions. And although some studies have shown outcomes which are questionable and um whether affecting their future potential remains unclear, it is still generally agreed that assessment and evaluation of poor growth remains central in our routine practice. So the prevalence in the usa 5-10% of Children in primary care setting are diagnosed with failure to thrive. About 1 to 5% of them are referred to tertiary care centers of pediatric hospitalist hospitals or sub specialists. Um And 3 to 5% of the hospital admissions are due to growth concerns Uh due to inconsistencies in definition of under nutrition. Um it creates challenges in assessing the real prevalence of this problem. Um so these numbers might actually be different. Um so the term failure to thrive or cease to thrive actually appeared in 1930s when there was a high burden of infection and socio economic disadvantage in its broadest sense, failure to thrive refers to poor growth in infants and Children. There's actually no consistent definition of failure to thrive. Um It is rather considered a symptom representing a final common pathway of medical psychosocial and environmental processes and growth. Faltering or wait. Faltering is now a preferred term because failure to thrive has a little bit of negative connotation. So the definition, according to aspen, which is american society of parental and central nutrition has defined it as an imbalance between nutrient requirements and intake, resulting in cumulative deficits of energy, protein or micro nutrients that may negatively affect growth, development and other relevant outcomes. Um We all have used one of these anthropology metric criterias and have learned to use these to identify um um identify patients who are faltering to grow. Um And the most commonly used ones are body mass index for chronological age less than third percentile. Um Wait for chronological age less than third percentile um or the length less than third percentile. And um another common one is um deceleration of wait crossing two major percentile lines from birth. So um in a Danish cohort study of 6000 Children where one or more of these criteria were included, 27% of infants um uh were diagnosed with failure to thrive. Now if only one criteria was used then the concurrence among different criteria was generally poor. And the positive productive predictive value of different criterias had very wide range from 1 to 58%. And most single criteria identified either less than half of the cases of significant under nutrition or included. Far too many does having a low positive predictive value. So few other considerations when we just include um consider weight for age less than 30%. um is weight alone enough. Um we usually need multiple data points and comparison over a period of time or a trend to consider how the weight is proportionately small. Children are often not failing to thrive. They may be growing um smaller on their high chart as well. So Bmi or weight for length, less than 3rd%ile might be a better marker in such situations. Um When weight when we see wait crossing over to major percentile lines. Um There's a study done by A my Z. Um at all. Um and they looked at um uh they found that 6-39% of infants crossed. Um two major percentiles either up and up or down between board and two years of age. For both weight and height for age. Um looking at the weight for height Co of 62% of Children between both and six months And up to 27% of Children between six and 24 months had crossed two major percentiles. Um so um and so basically using clinical judgment and not solely relying on these mathematical definitions is important. Um so which growth charts are to be used for 0-24 months? We used the charts irrespective of type of feeding For 2-20 years. You CDC Charts and other charges that are available for specific syndromes, such as Down stoners, Williams syndrome, Noonan syndrome for premature babies as well. Um Using Z score. Um So lately we have been using Z score in our practice. Um as you know, um Z score is basically a uh our number of standard deviations about or below the mean in a normal distribution of values. Percentile charts are not good and good for extreme values. So these core allows for more precision in describing anthropology trick status compared to percentiles, especially for kids who don't lie um in the curve and they are at the extreme values either about 97 percentile or below the third percentile, which is where our failure to thrive kids lie. Now these schools are also used to identify malnutrition and and it's used in its classification as well. It also allows for comparisons across age and sex. Um And it's good for assessing longitudinal changes most significantly, like I mentioned before, The scores helped to identify Children with extreme values and monitoring their progress, such as the kids who lie below third percentile way below the line. Um You can monitor their progress by scoring improvement by looking at the Z score and saying He went from -4.25 to -3.25, which is an improvement. So classification of malnutrition um is uh based on whether there is a single data point available. Um We can use B. M. I. For Hc score and uh and the Z score uh wherever it lies can be described as mild, moderate or severe. When two or more data points are available, you could again use a decline in C. Score and classified as mild moderate or severe nutrition. So this is an example of how to use the score. When for example in this chart this child went down from a Z score of minus 1.56 to minus 2.63. So there was a decline in the score of 1.07 points. And that would be classified as mild malnutrition. Um Another example where only one point is available and um So here this child is way below the 5th%ile. So um in the Z score is -2.82 and according to the classification would lie as a moderate mild nutrition. Mhm. Some of the normal variants who usually do not fit very well in the definitions are patients who are born large for gestational age often present with catch down growth. They initially fall in the weights and then follow a percentile and then follow their own percentile. And then uh some of them should catch up growth, such as premature infant, who need to be corrected for their gestational age using the premature growth charge. Are you g are babies who have rapid growth initially but usually end up being shorter and lighter than their peers during childhood And a small for gestational age, babies who exhibit catch up growth in the first 6 to 24 months, And then a 10% of them will still remain shorter two years of age, who usually we end up seeing in our clinics. Um Other normal variants are where the height is on a lower percentile because of genetics, shorts, teacher or familiar short stature, their parents are short. Um The kids are also showered on low percentiles, but they usually don't cross the percentiles. Um for such kids, it's important to assess the mid parental height um using this formula and that would be their average height and um adding 8.5 cm above and below, would give them the two standard deviations above and below, and that would be their actual curve where they lie for kids with constitutional delays. Um Usually they drop initial percentiles, but at the around puberty they'll achieve their final height and would be normal at their target. Hide these kids have positive family history of delays and growth. Um And the bone age assessment will also show a delay which would actually correlate with the growth curve rather than their chronological age. Um So just to show it on graph, this darker uh line is showing constitutional delay where the kid is growing below the second standard deviation, But as puberty hits, he is going towards his um predicted height, whereas in familial short stature, the kid continues to grow on a lower percentile growth, but often their parents also lie there. So, coming to the theologies, um like any other problem um under nutrition or malnutrition doesn't exist in isolation, and there are there is often an interplay of various um um problems at various levels at individual, societal and governmental levels, which contribute to an under or two under nutrition and kids. Um On a more individual level, you could divide the causes as inadequate intake of calories, loss of calories or increased metabolic demands. Um It could also be classified as organic versus non organic causes, or um acute illness related versus chronic causes for most purposes. We go with the classification um on the top, which is inadequate intake versus loss of calories versus increased metabolic demands. Um So when you look at inadequate intake, it could be a problem with either the person who's feeding the child or the the child himself. So if it's a breast feeding or bottle feeding infant, uh could have a large suck problem or a bottle aversion, too much dilution of formula, inappropriate knowledge of infant feeding of caregivers. I don't know the frequency then how offering some other fluids other than milk, inadequate breast milk supply, poor bonding with infant or mental mental health issues and parents. Another stage where we see this problem come up is when there is a transition from formula or milk to solid or table food and there is often an imbalance of amount of milk even and amount of solids offered or vice versa. There is often cultural or food beliefs which come in the way such as um too much sugar is not good or high. Carbs are not good and could lead to inadequate intake. Um And of course the child not taking enough because of problems, mechanical problems or cleft lip palate, hypo Tony a developmental delay, kid having a behavioral issue, picky eating or any other medical condition leading to loss of appetite, um loss of calories. So this list is not extensive, I must say, but try to put in as much as I can. Uh But just to give you an idea, it's basically um uh causes related to either warm knitting or diarrhea. Um And these are some things that we often encounter in our G. I. Practice um and increased metabolic demands is where um the child is getting less than what his body requires or the body is requiring more um because of the pathological processes. So some examples of when there is chronic infections such as TB HIV torch infections, inflammatory disorders, cardiac respiratory renal conditions in Ukraine conditions, malignancies or any um genetic chromosomal syndromes and metabolic syndrome such as invulnerable as of metabolic isM. So evaluation of such Children. Um So starting from the very beginning um birth history. So we want to identify kids who were born small for gestational age um or who have interest. You try and growth retardation. Um You want to understand the early neonatal history whether they were in the nicu for too long had a prolonged N. G. Tube. Which leads to oral aversions. Um babies with genetic syndromes, cleft lip palate or um hypoxic ischemic injury. Um Medical history. You want to go through um all their symptoms. Whether they exhibit any vomiting, diarrhea allergies, examine any difficulty swallowing and pointing towards particular gi conditions such as you easily at IBD. So finding mouth also joint pain, rashes, any frequent infections, tiredness, fatigue, abdominal pain, constipation, diarrhea, rectal bleeding, um feeding history is where I would spend most of my time for these kids and try to really understand um how what goes into their feeding. Um So for an infant, for example, you want to understand how many times the baby breast feeds, How long for how much formula for feed or if the baby is taking formula, then you want to know how much formula or total formula intake. Um questions to assess breast milk supply for the mom, whether she's producing enough as she pumping, um And who prepares the formula? Is it being too diluted? Um And often we find one or two reasons here of not adequate intake um assessing their hydration status. Oftentimes when parents know that the child is not feeding. I mean the child is not gaining weight well, they would resort to force feeding, which leads to bottle aversion. Um Most parents and infants are small, they are tired and tend to sleep. Or like babies who sleep through the night but might not be a good time for when babies need to um continue to grow. So assessing whether they wake up at night to feed um who takes care of the baby? How many caretakers and then of course, understanding maternal well being, Is that enough family support? Is mom returning back to work and stress us related to that. Um For older child or a toddler, you want to understand that food and take um in terms of 24 r. Recall or a three day record to be more detailed. Um So you would go through their qualitative and quantitative food assessment. Um So going through questions like what does the child eat, what's described a typical day for him? Does he sell feed independently feed or someone feeds him? How long does the mealtime last? Are there any distractions? Are there too many fluids being offered during meal times? Such as um uh juice or water? Um juice or milk? Um Food beliefs of parents like we talked about earlier looking for excessive juice and take excessive milk can take and grazing. Um And then oftentimes this is where parents describe feeding difficulty or picky eating in a child and I asked them to describe it to me in more detail, You would kind of understand or gauge a little bit. Is it a problem with the child or the parent and then able to guide them accordingly? Um You want to know the developmental and behavioral history for this child whether this child is capable of showing hunger or asking food. Is he able to sit in a high chair or a table for adequate length of time? Does he have any sensory issues with texture, temperature, consistency? Does he show any aversive behaviors such as screaming, crying, gagging or hitting during meals or you know, turning away head from turning his or head away from food, inducing nemesis, pocketing food in the mouth for long periods of time. Um and then also assessing parents behavior around mealtimes. So um it needs to be asked more diplomatically um to avoid any defensive reactions. So, um what do you do when the child does not finish meals? Trying to assess um parents, frustration, anger, things like that. Um Social history Oftentimes, um when you look at the growth chart, you can see that the child was growing really well up until a certain time and then the steady decline started. Um And then I go back and ask what happened around this time. Was there any life stressors such as divorce, parental separation, addition of a sibling, um, Death or transition to a new school, new place, new caretaker and all of that contributes to their um feeding behaviors. Um I want to understand their financial resources and um family structure, the cultural religious beliefs and their expectations about child development and growth. Um Of course, any red flags for neglect and abuse should be considered. Um And then families perception of the problem, whether they are overly anxious or under worried about this. Um, physical exam. Um We go through, um, The parameters for anthropology metric measurements as you know, weight for age length for age, B. M. I. And weight for length for less than 24 months old and B. M. I. For 2 to 20 years old. Um head circumference up until 36 months of age. And in special um kids or circumstances you want to use the mid upper arm circumference and calculating the mid parental height. So we perform what is called a nutrition focused physical exam where in addition to or assessing all the other systems that we routinely do, We want to look more carefully at their skin nails. Hair, oral cavity, which is where most of the micronutrient deficiencies would be um exhibited. You want to assess whether they are dehydrated, whether they are swollen, have eaten Mattis appearance, um feel their muscle and fat their texture symmetry size. So this is just a table showing different nutrition related deficiencies and abnormal findings on hair, eyes, lips, tongues, skin nails. Um So um and these days with telehealth, it's become more important to do more like a visual exam since we don't have uh much luxury of feeling the child. Um So this and the camera always adds extra pounds, so it's become a little bit more challenging. Um But this guide is helpful, so when you look at the child, a normal child would have um rounded cheeks. Um And with mild to moderate malnutrition, you would see um signs of sunken eyes or some under eye dark circles, some temporal muscle wasting or prominence of the temporal bone. And that would just be more prominent in severe malnutrition. Similarly for adolescent kids, when you look go down and look at their chest and upper arm. Um For my mild to moderate malnutrition, you would be seeing some mild re prominence is and when you lift up their arm they're a cranial process would be a little bit more prominent. Um um And then more pronounced for severe malnutrition as you can see here. Okay? Um And also the clavicle, when you look at the back again, for a normal child will have a good amount of sub cute fat. So for mild to moderate malnutrition you would see prominence of the scapula and the appearance of the rib cage. And that would just be more pronounced for severely malnourished child. Um When you look at the under their ribs under the actually. Um So for a mild to moderate uh malnourished child, you would see more prominence under their eggs lay of replicate as well. And that's again more pronounced for severe malnutrition. Um And then for babies, I'm sorry for that ties are lower extremities. Um And for their ties um Here it's more well rounded. Can see a lot of creases that's just less pronounced in mild to moderate malnutrition. Then you would see more severe bony prominence is in severe malnutrition. And looking at their gluteal cleft are fat pads uh Again more uh skin is more wrinkled in appearance and no evident fat in severe malnutrition versus um slightly curved but not as round as the normal child. So just using this visual cues might also give us an idea in addition to the charts. Um mid upper arm circumference is um used specifically for Children who who's weights are not as reliable because of edema, organic omega Leora societies. And as this is not really affected as much by the fluid shifts going on in the body. It's also more reflective for diseases such as myopathy, uh than the reference standard. Um Regular reference standards. Um and it's shown to be more sensitive prognostic indicator. And there are also these scores available for calculating these and the way it's done is measuring your length from a criminal process to the elbow joint, then finding a midpoint and finding your circumference around there. So a lab evaluation um there are various studies that have shown that very few Children actually have um um organic causes of failure to thrive. Uh and those can usually be identified or are strongly suggested by just history and physical exam. And in that study it also showed that only 1% of lap tests were actually of assistance when diagnosing these conditions. Um So but usually like to get some basic labs um such as Cbc SRC RP CMp, thyroid celiac panel iron studies led screen um and additional tests as necessary depending upon their history. Getting stool tests, I often find getting an elasticity and cal protecting for gi related conditions is useful um And um screening for infections such as uh giardia or parasites. Stool culture is also useful um and then sweat chloride tv screen HIV if you're considering infections bone it's chest X ray video salo or the imaging studies. Upper and lower endoscopy is as uh pediatric gi's like to do um testing for metabolic syndromes with urine organic acid serum amino acids. Sorry I should have elongated this A. N. O. A. And um genetic tests and carry a types. Um I cannot stress the importance of a multidisciplinary evaluation in um helping Children with failure to thrive. So um there's a huge role played by our dietitians, social workers, feeding therapists of course pediatricians and therapists or psychologists, other caretakers and all the team members should work with the strength of the family to encourage the development for nurturing environment and determine which potential interventions are most feasible and acceptable As um not one size fits all as a therapy for the kids. So in terms of management these are just some average growth goals. Just gives a reference of what we're looking at and what we should aim for. Um So starting with behavioral interventions, avoiding distractions during mealtimes, avoiding television, cell phones. It's important for parents to maintain a neutral attitude throughout meals, avoiding punishments, timeouts, things like that. Um I often find that kids who have some textural or prefer a certain type of meal, just adding different textures and colors in that same category helps them in a stepwise fashion to increase their report royal Um limiting meal durations to no longer than 30 minutes. Um trying aiming for 4-6 meals including two snacks a day. Um age appropriate foods and you know also offering um not overwhelming amounts of foods to kids. Uh just fewer bytes and then offering seconds if necessary. Um introducing new foods. So a lot of times parents would say my child doesn't like this and not into it, but you want to ask them, have you offered them at least it 10 times before considering that he doesn't like it, encouraging self feeding. And I put this picture because this is this amount of mess is age appropriate and should be tolerated. Um feeding is also parenting. And I found this interesting picture on the google. And so there's a concept of division of responsibility where parent determines where then and what the child is fed and the child determines how much to eat. So in this way both have enough choice and control. So on this chart you can see if the child is given enough choice and there is adequate parental control, there is your area of success, but if there is too much parental control and there is no um, choice for the child, that is an authoritarian feeding style, which just doesn't work well. Similarly, when there is, the child has too much choice, but there is very little parental control. It's called permissive parenting, where again, not shown to be successful, and of course, when there is too little control from either side, it's neglectful and obviously not good. Um, picky eating is something which presents are together with under nutrition. And I just wanted to address that just with a few words and oftentimes it's a misperception, like we said that often it's a normal behavior at the end of first year of life. And we hear that my Um parents say that my baby was a good feeder until Virginia and then something happened um the first year of life and peaks at around 18-21 months. Um And then so basically setting reasonable expectations that exposing child to new foods without pressure. Um and at different times, different occasions is what would be helpful. Oftentimes certain Children show mild selectivity where they would consume fewer foods and repeated exposure doesn't really result in acceptance in those situations, interventions such as hiding pureed vegetables into sources or using some different dips to enhance flavors, um modeling, eating uh in front of them or presenting an attractive designs. Um often helps And uh and there are other kids who are highly selective. There are only 10-15 choices or even less that they would eat. Such can often tend to have sensory issues that are autistic and need a more structured, systematic approach. Reference to feeding therapy and sometimes they end up with alternate routes of feeding um such as youtube, nutritional interventions include Excuse me First. Um For kids who are breastfed babies who are breast feeding uh if they are um the mom is very um um encouraged to do so then uh arranging with a proper lactation consultant if available and ideas to increasing mom supply by adequate hydration, lactation supplements. Some medications such as medical, provide hubs, bumping and adequate emptying, or some ways that she can increase her supply um and knowledge about appropriate storage of freezing is also important. The breast milk or formula could be fortified to 22 or 24 calories. Um and um just some recipes here um and they can start doing that this way. The child doesn't have to increase volume, but just um the calories increase anyway. Um For toddlers. Um few nutritional interventions such as avoiding juice because it's no calories, no proteins. I mean it has empty calories, no proteins. Um avoiding excess milk consumption because it leads to iron deficiency likely kills your appetite and also constipation and avoiding food grazing. Um And then these are the Children who can be offered high calorie beverages such as period. Sure. But the question is who should we give them to? I usually tend to offer it to families who are low motivated um or if the child is at risk of failure um and avoiding it as a replacement rather than rather give it as a supplement after feeds are done or at night time is a better intervention. So they don't feel full during the day when they are taking period. Sure, and still can continue eating regular food. Um So we do have pretty azure ensure. Of course they are expensive. So the cheaper versions are either adding instant carnation breakfast powder Which gives up to 200 calories. About similar. Um to pd assure ensure. Or other way is to um just adding heavy whipping cream or half and half to the regular milk which also gives equal and calories without the added micronutrients. High calorie food advice. I think we all know this um adding oils, butter, cream cheese as appropriate um um um Or high calorie drinks such as smoothies offering that with peanut butter. And you can see just by edition of those calories you can go up Almost double The calories from 1700 to 30 500. Um Some kids may end up needing and G. Feeds or G. Tube feeds especially who are unable to maintain their nutrition needs orally. Um But we do have to consider that when they started on N. G. Fits especially kids who are otherwise normal do lose their appetite on whatever is left. Um They do show an increase in orally. Aversive behaviors and um there are problems such as proper placement and the tube getting misplaced or nasal irritation. There's a small chance of aspiration of formula. And these decisions are complex because not all families agreed to G. Tube or N. G. Two. And detailed discussion about the risk and benefit and understanding families preferences is important medications so you could use and there's shown proven benefit of using multivitamins, vitamin D. Zinc or iron supplements. Um As most kids tend to be deficient once uh malnutrition is um um is identified and using appetite stimulants. Um So again as a project in is what we use. Um And I tend to use it more for Children who are motivated but to eat but for whatever reason um is not having enough appetite or rather families who are motivated to feed the child. So um or kids who have a. D. H. D. Or autism who are not really able to um understand their hunger cues. So having said that don't um don't tend to use it for kids who may have underlying conditions such as IBD or Cronin Celia because you want to fix that before starting an appetite stimulant. Um So usually user once a day bedtime dosing since there are drowsiness as one of the biggest side effects and you use it um on a cycle either three weeks on one week off or two weeks on two weeks off whatever works. Um So that the medication works appropriately as it tends to lose its effect after prolonged use. Hospitalization is reserved for severe cases of malnutrition or dehydration, where there is any inter current illness um or any psycho social neglect abuse um type situation and when they failed to respond to several months of occupation management and also kids who we want to consider a feeding syndrome um outcomes. Um So uh there's been a few studies looking at what are the outcomes long term outcomes of such Children who have failure to thrive in their infancy or childhood. and one meta analysis by Corbett and drew it suggested that um poor nutrition and young Children, especially infants, may result in long term cognitive developmental problems. And on contrast, another meth analysis found that failure to thrive was only associated with three points lower I. Q. Than expected. So it was of questionable significance. Having considered that it's still an overall trend shows that meaningful number of Children still have persistent intellectual behavioral deficits um although they are not uh possible to predict accurately who will develop it and who will be fine. Um So addressing this problem is important. Um And um there's also definitely a um factor of social psychosocial and micronutrient deficiencies which may contribute to the cognitive outcomes, non cognitive outcomes. So there's another study where They studied a group of 12 year old Children who had failure to thrive as infants. And they saw that they were shorter, lighter and had lobby um ice. And they reported having less lesser appetites. But they were satisfied with their body shapes and did not differ from the controls on measured measures related to anxiety, depression or slow self esteem. So the authors concluded that failure to thrive in infancy is not associated with adverse emotional development and childhood. Um Are there any harms of overfeeding? So the study um lately have shown there are several studies which have proposed that Children who experience a U. G. R. May actually develop insulin resistance as a defense mechanism to protect against post natal hypoglycemia. And according to this line of thought, vigorous nutritional intervention in such infants who have failure to thrive may exacerbate their insulin resistance and eventually drive them into frank metabolic syndrome. So for such patients nutrition therapy and overcorrection should be cautiously chosen. Summary um infants and young Children up to two years of age make crossbows and tiles on growth curves during a normal course of growth. Falling off a growth chart itself is not conclusive of FTT. Um Use your clinical judgment to diagnose FTT and not rely just on mathematical definitions and extensive lab screening is of little utility in evaluation of FTT and adopting a multidisciplinary approach for intervention is more effective. Thank you so much for listening to me and uh that's just how do you refer to us