Failure to thrive

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Updated by: Dr. Praveen Goday
Updated on: 3/9/2017

Diagnosis/symptom

Signs and symptoms

• Weight-for-length (or BMI) < 3rd percentile (CDC growth chart) or 2nd percentile (WHO growth chart)
• Poor or no weight gain
  • Over a period of time that varies according to the age of the child. In general, the younger the child, the shorter the interval where there is little or no weight gain
• Significant downtrend in weight percentiles
• These should be done along with:
  • Assessment of parental size / growth
  • Correction for prematurity (where applicable)

Causes

Most commonly is due to inadequate calorie intake; Other causes: malabsorption, etc. account for <5% of FTT cases.

Referring provider's initial evaluation and management:

Diagnosis:

*See gestational age chart and guide to high-calorie beverages below

Initial interventions in a child with failure to thrive

• Establish Mealtime Routine
• Meals and snacks offered every 3 hourly
• Ideally, all meals and snacks should be offered in a high chair/at the table
• Minimize distractions
• Avoid force feeding
• Grazing in between meal and snack times should be eliminated
• NO JUICE
• Limit meals to 30 minutes

*Additional resources below

When to initiate referral/ consider refer to GI Clinic:

• ↓ weight, ↓ height - Malnutrition
• Normal weight, ↓ height - Endocrine
• Normal weight, ↓ height, dysmorphism - Genetics/Endocrine
• SGA patients without catch-up growth can be referred to endocrine clinic for possible growth hormone treatment
• Nutrition Clinic: Contact Dr Praveen Goday at pgoday@mcw.edu for FTT patients who are not progressing according to plan.

What can referring provider send to GI Clinic?

1. Using Epic

• Please complete the external referral order

In order to help triage our patients and maximize the visit, the following information would be helpful include with your referral order:

• Urgency of the referral
• What is the key question you would like answered?

Note: Our office will call to schedule the appointment with the patient.

2. Not using Epic external referral order:

• In order to help triage our patients maximize the visit time, please fax the above information to (414) 607-5288
• It would also be helpful to include:
• Chief complaint, onset, frequency
• Recent progress notes
• Labs and imaging results
• Other Diagnoses
• Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient's problems.

Specialist's workup will likely include:

After referral to GI Clinic:
*Most children with FTT do not need labs

Labs:

• Significant FTT
• FTT not due to inadequate calorie intake

Common labs

• :CBC, ESR
• Metabolic panel, electrolytes
• Anti-TTG IgA, serum IgA level
• Fecal elastase
• Urinalysis

If a child is <10th percentile for gestational age then child is SGA

Guide to high-calorie beverages

Fortifying breast milk

• 24-26 calorie/ounce breast milk:
  • Add 1 tsp infant formula + 2.5 oz expressed breast milk
  • (Calorie level varies with type of formula used)

Fortifying infant formulas

• 24 calorie/ounce recipe:
  • *For infant formulas EXCEPT premature formulas (Neosure, Enfacare), Neocate, and Neocate Jr.
  • 3 scoops powder + 5 ounces water (Add water to bottle first, and then add powder)
• 27 calorie/ounce recipe:
  • *For infant formulas EXCEPT premature formulas (Neosure, Enfacare), Neocate, and Neocate Jr.
  • 5 scoops powder + 7 ounces water (Add water to bottle first, and then add powder)
• 30 calorie/ounce recipe:
  • *For infant formulas EXCEPT premature formulas (Neosure, Enfacare), Neocate, and Neocate Jr.
  • 4 scoops powder + 5 ounces water (Add water to bottle first, and then add powder)

Toddler beverages

• Pediasure ®, Boost ®, Nutren Jr. ®
  • 30 calories/ounce
• Carnation Instant Breakfast ® w/ whole milk
  • 30 calories/ounce
  • Cheaper than Pediasure ($0.50 / packet)
• 7 oz Whole milk with 1 oz heavy whipping cream
  • 30 calories/ounce and cheapest