Failure to Thrive: Rethinking Our Treatment Goals Darren Fiore, MD 2013 Advances & Controversies in Clinical Pediatrics Tips and Reference Sheet Various Definitions of FTT: Weight < 5th percentile for age Note: Use special growth charts when indicated (prematurity, Down, Turner Syndromes) Weight for length < 5th percentile for age A rate of weight gain that is exhibited by a decrease in 2 major percentiles (90th, 75th, 50th, 25th, 10th, 5th % percentiles) over time Lack of height growth due to poor weight gain over time that cannot be attributed to an identifiable organic cause Lack of appropriate growth in head circumference following previous decrease in height growth rate and poor weight gain that cannot be attributed to an identifiable organic cause Diagnostic Classification of Causes and Selected Examples of Failure to Thrive Inadequate Nutritional Intake o Not enough food offered Food insecurity Poor knowledge of child s needs Poor transition to table food Avoidance of high calorie foods Formula dilution Excessive juice Breastfeeding difficulties Neglect o Child not taking enough food Oromotor dysfunction Developmental delay Behavioral feeding problem Altered oromotor sensitivity Pain and conditioned aversion o Emesis Gastroesophageal reflux Malrotation with intermittent volvulus Increased intracranial pressure Malabsorption o Cystic fibrosis o Celiac disease o Food protein insensitivity or intolerance Increased Metabolic Demand 1
o Insulin resistance (e.g., intrauterine growth restriction) o Congenital infections (e.g., human immunodeficiency virus, TORCH) o Syndromes (e.g., Russell Silver, Turner, Down) o Chronic disease (e.g., cardiac, renal, endocrine) Some Points to Consider When Taking FTT History Feeding History Diet History Social History When, where, and with whom the child eats. Feeding/breastfeeding position. Does infant make eye contact while feeding? Distractions during feeding (TV, toys, siblings). Duration of each feeding, tiring out. Does patient seem hungry at feeding time? Does the infant or child resist eating? How does caretaker know when child is hungry/full? Are there struggles over feeding? Spit up or vomiting associated with feeds? Details of everything the child eats. Be specific, keep a detailed food log. Assess if formula is prepared properly. Quantify caloric intake (diet log). History of excessive juice, soda, cow s milk. Vegetarian or unusual diet. How does the child interact with the family? Parental description of patient s temperament. Financial stressors, difficulty buying food. Identify all caregivers who feed the patient. Parental history of depression or mental illness. Indicators of substance abuse in the family. Indicators of domestic violence. History of CPS involvement with the family. Recommendations A consistent, multidisciplinary group of healthcare providers (including, but not limited to, social workers, occupational/speech therapists, nutritionists/dietitians, nurses, advanced practice nurses, and pediatricians) should be involved in the management of children with FTT (Hobbs 1996). Standardized admission to an inpatient unit is not necessary for all children with FTT. Note: While studies have shown that children with FTT do have improved catch up growth when admitted to an inpatient unit, these studies lack long term follow up of growth following discharge and assessment of developmental outcomes (Fryer 1988). 2
An institution or practice might consider the establishment of an organized, multidisciplinary team of health care providers to form a Grow Team in order to improve the ease of access to services for families with children who carry the diagnosis of FTT. There is insufficient evidence and lack of consensus to make a recommendation for routine or standardized inpatient management of FTT, including criteria for when discharge is appropriate. There is no evidence that a panel of standardized or routine laboratory screening tests for FTT is indicated in the absence of guiding evidence from the history and physical. When the physician feels that laboratory studies are warranted, even when there are no specific clinical indications, a reasonable selection might include a CBC with red cell indices (to evaluate for anemia and iron deficiency), a complete chemistry panel (including tests for renal and hepatic function), celiac screening, stool examination for fats and reducing substances, and a sweat chloride test for cystic fibrosis. Screening for hypothyroidism or growth hormone deficiency should be considered only if the child s length has decelerated and is below the 50th percentile on the length for age chart. Children diagnosed with failure to thrive need to receive about 150 percent of the recommended daily caloric intake for their expected, not actual, weight for age: Age Daily Recommended Intake Needed in FTT for catch up 0 6 mo 108 kcal/kg/d 158 kcal/kg/d 6 12 mo 98 kcal/kg/d 147 kcal/kg/d 12 36 mo 102 kcal/kg/d 153 kcal/kg/d Discussion/summary of evidence FTT in the pediatric population has traditionally been a challenging diagnosis for health care providers to evaluate and treat in both the inpatient and outpatient setting. Treatment protocols for FTT vary immensely between healthcare providers. There is insufficient evidence in the literature to support a specific protocol for management of FTT that would result in improvement in the sustained growth of children with FTT. In 1988, Fryer published a meta analysis that compiled the evidence from eight trials that studied the efficacy of inpatient admission for FTT (Fryer 1988). This study concluded that hospitalization favorably influenced the growth of children with FTT, stating that hospitalization approximately doubled their probability of catch up growth. In contrast, psychosocial development only moderately improved with inpatient admission. The author was careful to note, however, that none of the studies in the meta analysis evaluated long term growth and developmental outcomes in children admitted for FTT. Therefore, while inpatient admission may result in short term improvements in growth, the long term efficacy of inpatient admission for FTT is unknown. While 3
inpatient admission may be undeniably necessary in severe cases (i.e. dehydration, electrolyte abnormalities, or monitoring for re feeding syndrome) or in complicated social situations, the cost to the healthcare system for inpatient admission may outweigh the long term benefits. Five identified studies focused on various intensive outpatient management protocols and their effect on growth and psychosocial development of children with FTT. A summary of the studies is compiled below. Study Intervention Outcome (Black 1995) (Hutcheson 1997) (Raynor 1999) (Wright 1998) Evaluated the efficacy of a one year home intervention protocol in children with FTT. (Randomized Controlled Trial) Evaluated effects of risk status on the impact of home interventions in children with FTT. After receiving home intervention for three years children were followed for a total of eight years. (Randomized Controlled Trial) Evaluated the effectiveness of home intervention with a trained health visitor in children with FTT. (Randomized Control Trial) Evaluated the efficacy of a home intervention specialist in children with FTT. Randomized Controlled Trial 1 year following intervention, no significant improvement in weight for age, height for age, or weight for height was noted in intervention group as compared to the control group. Children with FTT in home intervention group also experienced less of a decline in cognitive development and receptive language, and were noted to have higher interactive competence, were living in more child centered homes, and parents were more in control of parent child interactions over time than those in the control group. Among families with a lower socioeconomic status that had children with FTT, home intervention was most useful in among mothers with a low negative affectivity. Both children in the intervention and control groups exhibited improved wt gain, developmental scores, and energy intake. Children in control group had significantly more dietary referrals, social service involvement, hospital admissions, and less compliance with physician appointments. In children under the age of two, 76% of those children who received a home intervention specialist had recovered from their diagnosis of FTT at the time of follow up, while only 55% of those in the control group had recovered. 4
References Review Articles Krugman, S.D., & Dubowitz, H. (2003). Failure to thrive. American Family Physician, 68(5), 879. Jaffe, A.C. (2011). Failure to thrive: current clinical concepts. Pediatrics in Review, 32(3), 100 108. Other References Sills, R.H. (1978). Failure to thrive: the role of clinical and laboratory evaluation. Archives of Pediatrics & Adolescent Medicine, 132(10), 967 Berwick, D.M., Levy, J.C., & Kleinerman, R. (1982). Failure to thrive: diagnostic yield of hospitalisation. Archives of Disease in Childhood, 57(5), 347 351. Black, M. M., Dubowitz, H., Hutcheson, J., Berenson Howard, J., & Starr, R. H. (1995). A randomized clinical trial of home intervention for children with failure to thrive. Pediatrics, 95(6), 807 814. Black, M. M., Dubowitz, H., Krishnakumar, A., & Starr Jr, R. H. (2007). Early intervention and recovery among children with failure to thrive: follow up at age 8. Pediatrics, 120(1), 59 69. Fryer Jr, G. E. (1988). The efficacy of hospitalization of nonorganic failure to thrive children: a metaanalysis. Child abuse & neglect, 12(3), 375 381. Hobbs, C., & Hanks, H. G. I. (1996). A multidisciplinary approach for the treatment of children with failure to thrive. Child: care, health and development,22(4), 273 284. Raynor, P., Rudolf, M. C., Cooper, K., Marchant, P., & Cottrell, D. (1999). A randomised controlled trial of specialist health visitor intervention for failure to thrive. Archives of disease in childhood, 80(6), 500 506. Wright, C. M., Callum, J., Birks, E., & Jarvis, S. (1998). Effect of community based management in failure to thrive: randomised controlled trial. BMJ: British Medical Journal, 317(7158), 571. Wood, J. et al. (2009). Cincinnati Children s Best Evidence Statement. Failure to Thrive Treatment Protocol. 5