The clinical evaluation of failure to thrive (FTT) includes a thorough history and physical examination; observation of parent-child interactions; observation and documentation of the child's feeding patterns; and a home visit by an appropriately trained health care professional (Strength of Recommendation [SOR]: C). Further diagnostic testing should be performed as indicated by positive findings from the history and physical exam or if the child's weight has not improved at follow-up (SOR: C)

Gentry, Barry C.

Kendall, Susan K.

Michener, Mike D.

Stephens, Mark B.

University of Missouri: MOspace

CLINICAL INQUIRIES From the Family Physicians Inquiries Network264 VOL 57, NO 4 / APRIL 2008  THE JOURNAL OF FAMILY PRACTICE  What is the clinical workup for failure to thrive?The clinical evaluation of failure to thrive (FTT) includes a thorough history and physical examination; observation of parent–child interactions; observation and documentation of the child’s feeding patterns; and a home visit by an appropriately trained health care professional (Strength of Recommendation [SOR]: C). Further diagnostic testing should be performed as indicated by positive fi ndings from the history and physical exam or if the child’s weight has not improved at follow-up (SOR: C).A complex problem that requires a team approach We admit several infants with FTT to the hospital each month from a large population of young families at Fort Bragg, NC, and manage many more in our outpatient practice. Our experience confi rms that FTT is a complex problem with many potential causes.  Laboratory and other evaluation beyond history, physical examination, and observation rarely help establish the diagnosis or prognosis. Incidental abnormalities occasionally change management, but more often result in false positives.  Close follow-up and a multidisciplinary team approach generally uncover the cause and lead to successful treatment. Children who don’t respond to treatment or have a suspected “organic” cause of FTT always warrant further laboratory investigation to identify the 1% of cases that result from a diagnosable disease. FTT can also be the sole indication of neglect or nonaccidental trauma, with devastating consequences.  Early identifi cation of an infant or child approaching the diagnostic criteria for FTT is critical. Diagnosis and intervention may be delayed by inaccurate growth curve points, loss of a growth chart in a busy practice, or lack of well-child visits. Our experience with early detection and a multidisciplinary team treatment approach has been highly successful. Robert Gauer, MDFamily Medicine Residency Clinic Faculty, Womack Army Medical Center, Fort Bragg, NCMark B. Stephens, MD, Barry C. Gentry, MD, and Mike D. Michener, MD Uniformed Services University, Bethesda, MdSusan K. Kendall, PhD, MS(LIS)Michigan State University Libraries, East Lansing❚ Evidence summaryFTT is a generic term used to describe a child whose current weight (or trajectory of weight gain) does not equal that of other children of similar age, gender, and ethnicity. No single accepted anthropo-metric measure can be used to diagnose the condition.1 FTT has been variously defi ned in children who: •  drop more than 2 standard per-centile lines on standardized FAST TRACKAs many as 10% of children seen in primary care show signs of failure to thrive Evidence-based answerClinical commentary264_JFP0408   264 3/19/08   9:33:35 AMCopyright® Dowden Health Media  For personal use onlyFor mass reproduction, content licensing and permissions contact Dowden Health Media.FAST TRACKgrowth charts,2 •  are below the third percentile for weight,•  have weight-for-length <80% of ideal weight,3 •  have height-for-weight less than the third percentile,4 •  have weight-for-height less than the 10th percentile, or have weight-for-age less than 2 standard deviations below the mean for age. Recent updates of standardized growth charts for children are available from the Centers for Disease Control and Prevention at www.cdc.gov/nchs/about/major/nhanes/growthcharts/clini-cal_charts.htm. A complex diagnosisFTT occurs when nutritive intake is in-suffi cient to meet demands for growth (TABLE). It is usually manifested by fail-ure to gain weight. In more severe cases, height and head circumference are af-fected. FTT is also associated with lower developmental testing scores,5 persistent poor growth, increased susceptibility to infections, and an increased prevalence of behavioral disorders and neurologic disability.4 As many as 10% of children seen in primary-care settings show signs of FTT.2 Children with FTT are most often identifi ed when parents raise concerns about the child’s feeding or growth pat-terns or when a physician notes a de-crease in the child’s growth on physical examination. The terms “organic” and “inorganic” or “nonorganic” FTT, of-ten used to guide diagnostic thinking, are outdated because most cases of FTT are infl uenced by many variables.6 FTT represents the fi nal common pathway of disruptions in the complex system of bio-logical, psychosocial, and environmental factors contributing to a child’s growth and development. FTT has 3 basic causes 1. Inadequate caloric intake. More than 80% of children with poor growth do not have an underlying medical dis-order.7 The initial workup, therefore, should include a thorough dietary and psychosocial history. Find out exactly what the child eats, how often he eats, and what behaviors he exhibits at meal-times. A detailed prenatal history (including birth weight and pregnancy complications) and medical history for both the child and parents can identify underlying metabolic, endocrine, or familial disorders. It is al-ways important to look for signs of child abuse, because children with FTT are more likely to be victims of abuse than normal-weight peers.3 That said, other factors are responsible for poor nutritional intake in as many as 80% of cases.82. Inadequate caloric absorption (mal-absorption). This usually results from per-sistent emesis or malabsorption. Emesis can be caused by refl ux, obstruction, med-ication, food sensitivities, or underlying metabolic disease. Malabsorption most often arises from chronic diarrhea, celiac disease, protein-losing enteropathy, food sensitivities, or excessive juice intake. 3. Excessive caloric expenditure. Such expenditure is associated with underly-ing medical conditions such as congenital heart disease, chronic hypoxia (pulmo-nary disease), hyperthyroidism, metabolic disease (diabetes, renal tubular acidosis), chronic immunodefi ciency, recurrent in-fection, or malignancy.FTT accounts for between 1% and 5% of all pediatric hospitalizations.9 Children who continue to exhibit poor growth despite adequate outpatient eval-uation should be admitted to the hospi-tal. Admission is also indicated if abuse is suspected.  RecommendationsThe American Academy of Pediatrics rec-ommends that physicians consider child neglect as a cause of FTT, particularly in cases that do not resolve with appropri-ate medical intervention.3 The American Gastroenterological Association10 and World Gastroenterol-More than 80% of children with poor growth do not have an underlying medical disorder VOL 57, NO 4 / APRIL 2008 265www.jfponline.comFailure to thrive265_JFP0408   265 3/19/08   9:33:39 AMFAST TRACKCLINICAL INQUIRIES266 VOL 57, NO 4 / APRIL 2008  THE JOURNAL OF FAMILY PRACTICEogy Organization11 recommend that phy-sicians consider celiac sprue in children presenting with FTT. Interestingly, the Co-chrane Database of Systematic Reviews suggests that there is little systematic evi-dence to support routine growth monitor-ing in children.12 ■References 1.  Olsen EM. Failure to thrive: still a problem of defi ni-tion. Clin Pediatr. 2006;45(1):1-6.  2.  Wright CM. Identifi cation and management of fail-ure to thrive: a community perspective. Arch Dis Child. 2000;82(1):5-9. 3.  Block RW, Krebs NF. Failure to thrive as a manifes-tation of child neglect. Pediatrics. 2005;116:1234-1237. 4.  Perrin EC, Cole CH, Frank DA, et al. Criteria for determining disability in infants and children: fail-ure to thrive. Evid Rep Technol Assess (Summ). 2003;(72):1-5.  5.  Rudolf MC, Logan S. What is the long-term out-come for children who fail to thrive? A systematic review. Arch Dis Child. 2005;90:925-931.  6.  Gahagan S, Holmes R. A stepwise approach to evaluation of undernutrition and failure to thrive. Pediatr Clin North Am. 1998;45:169-187. 7.  Gahagan S. Failure to thrive: a consequence of un-dernutrition. Pediatr Rev. 2006;27:e1-11. 8.  Skuse DH, Gill D, Reilly S, Wolke D, et al. Failure to thrive and the risk of child abuse: a prospective population survey. J Med Screen. 1995;2:145-149. 9.  Shah MD. Failure to thrive in children. J Clin Gas-troenterol. 2002;35:371-374. 10.  American Gastroenterological Association. Ameri-can Gastroenterological Association medical po-sition statement: celiac sprue. Gastroenterology. 2001;120:1522-1525. 11.  WGO-OMGE practice guideline: celiac disease. 2005. Available at: www.worldgastroenterology.org/globalguidelines/guide13/guideline13.htm. Ac-cessed September 30, 2007. 12.  Panpanich R, Garner P. Growth monitoring in children. Cochrane Database Syst Rev. 1999;(4):CD001443.  13.  Bergman P, Graham J. An approach to “failure to thrive.” Aust Fam Physician. 2005; 34:725-729. 14.  Krugman SD, Dubowitz H. Failure to thrive. Am Fam Physician. 2003;68:879-884. Consider child neglect when medical intervention doesn’t resolve the failure to thriveFailure to thrive: Causes and physical ﬁ ndingsGENERIC  CAUSE ASSOCIATED CONDITIONS PHYSICAL FINDINGS*DIAGNOSTIC EVALUATIONInadequate caloric intakePoor food intake  Chronic illness  Inappropriate type/volume     of feedingFood not available  Parental withholding  Neglect  PovertySigns of neglect   or abuseMinimal subcutaneous   fatProtuberant abdomenComplete dietary history  and psychosocial   evaluation Complete blood count   (CBC)Basic metabolic profi le Lead screeningInadequate caloric absorptionGastrointestinal causes  Malabsorption  Chronic vomiting  Pancreatic insuffi ciency  Celiac disease  Chronic refl ux  Infl ammatory bowel   disease  Chronic renal diseaseCystic ﬁ brosisDysmorphism suggestive   of chronic diseaseOrganomegalySkin/mucosal changesStool pathogens Stool fatCystic fi brosis screeningCBC/erythrocyte sedi-  mentation rate (ESR)Basic metabolic profi leUrinalysis (U/A)Excessive caloric expenditureHyperthyroidismChronic disease (cardiac,   renal, endocrine, hepatic)MalignancyDysmporphismSkin dysmorphologyCardiac fi ndingsTSH CBC/ESRBasic metabolic profi leLiver function tests*Abnormal weight is observed in all cases.Modifi ed from Skuse DH et al.,8 Bergman P et al.,13 Krugman SD et al. 14TABLE266_JFP0408   266 3/19/08   9:33:43 AM

What is the clinical workup for failure to thrive?

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