Case Numbr 3: Faltering Growth / Failure To Thrive

Case Numbr 3
Faltering Growth / Failure to Thrive

Faltering growth is not a diagnosis; rather it
is a symptom of other underlying organic
or non-organic problems.
Definition
• as a significant interruption in the expected rate of growth compared
to other children of similar age and sex during early childhood. It is a
persistent, gradually evolving phenomenon which can frequently and
relatively easily go undetected, particularly in children who do not
frequently access healthcare.
• Causes tend to be multifactorial and often involve problems with diet
and feeding behaviour that usually respond to simple targeted advice
How to approach a child with
failure to Thrive
SCREENING
• History:
• Should include both medical and social factors.
• Pay particular attention to the feeding history - record amounts taken at
each feed.
• Ask about mealtime routine and eating and feeding behaviour.
• Ask about associated symptoms e.g. vomiting, diarrhoea, food refusal,
respiratory infections, urinary symptoms and should cover all system
specific symptoms.
• History of consanguinity is important in Asian children who present with
vomiting to rule out metabolic conditions.
Examination
• Dysmorphic features – signs of TORCH infection, Russel-Silver, Turner’s

syndrome
• Distended abdomen, gluteal muscle wasting, – signs of Malabsorption
• Examine all systems to make sure there is no underlying pathology -
example neurological examination in a child with feeding difficulty
Growth measurements
• Plot on growth chart. Serial measurements of growth will help

determine growth velocity and need for investigation (remember to
make allowance for prematurity (<37weeks), until 2 years old).
• An early request for a 3 day dietary assessment may save fruitless
investigations!
Diagnostic criteria
• Combination of the following:
• 1) Children with weight crossing 1 centile space where birthweight or
previous weight was below the 9th centile; or weight crossing 2
centile spaces where weight was between 9th -91st centiles; or
weight crossing 3 centile spaces where weight was above the 91st
centile.
• 2) Growth persistently below 2nd centile (weight and/or height)
• 3) Asymmetrical weight and head circumference measurements (e.g.
weight on 5thcentile, head circumference on 50th centile.)
CAUSES
Inadequate intake
• Is the most common cause. The child does not consume enough
calories to support adequate growth. Contributary factors may
include
• poor appetite - chronic infections, chronic fever, anaemia

• feeding problems - gastro-oesophageal reflux, cerebral palsy, cleft
lip/palate
• Social/family factors - chaotic family, parental mental health, lack of
knowledge, neglect
Increased calorie demand and expenditure
• Chronic infections with fever

• Surgery
• Chronic illness such as GI disorders (cystic fibrosis, inflammatory
bowel disease), respiratory disorders (cystic fibrosis, severe asthma),
congenital heart disease, endocrine disorders (diabetes mellitus,
hyperthyroidism), renal failure
Inefficient utilisation of calories or loss of calories
• GI disorders - coeliac disease, chronic diarrhoea, chronic vomiting

• Endocrine/metabolice disorders - diabetes mellitus, hyperthyroidism,
inborn errors of metabolism
• Burns, GI problems or other chronic illnesses
Some children may have chromosomal abnormalities
associated with poor weight gain (e.g Russel-Silver
syndrome, Trisomy 21, Turner’s Syndrome) ormay poor
weight gain due to perinatal causes (e.g. TORCH infection,
fetal alcohol syndrome)
INVESTIGATIONS TO CONSIDER
• FBC
• ZPP
• Blood Gas – In infants where vomiting is the presentation and when
consanguinity exists to rule out metabolic problems
• U&Es - renal tubular acidosis, electrolyte abnormalities which
indicate endocrine problems for example pseudohypoaldosteronism
• Bone profile
• LFT
• TFT
• Mid-stream urine - urinary tract infection
Consider more investigations when history is suggestive
• IgA TTG and IgA EMA - coeliac disease (also request

immunoglobulins)
• CXR and Sweat test - history of respiratory infections
• Vitamin D levels - rickets
Management
WHO 10 Steps
Inpatient treatment takes between 2 to

6 weeks. However, if the necessary
community support is available close
to where the child lives, they may be
discharged early (at step 8) to continue
recovery at home.
These steps are accomplished in two
phases: an initial stabilization phase
where acute medical conditions are
managed, and a longer rehabilitation
phase. This is summarized in the table
below.
The decision of whether to allow a child to be discharged with
close follow up while a trial of:
• feeding takes place will take into account:
• 1.) Severity of the faltering growth and overall physical condition of the child.
• 2.) How likely an alternative diagnosis is felt to be?

• 3.) Safeguarding concerns – e.g. neglect.
• 4.) Logistic implications – e.g. availability of patient transport for follow ups,
availability of inpatient beds.
References
• Matthai, S. (n.d.). Faltering Growth / Failure to Thrive
• 200509bergman. (n.d.).
• World Health Organization. (n.d.). Guideline.
• Trust Guideline for Management of Faltering Growth (Failure to
Thrive) in Babies and Young Children. (n.d.).
• Shields, B., Wacogne, I., and Wright, C.M. (2012) Weight faltering and
failure to thrive in infancy and early childhood. British Medical
Journal, 345. e5931.BMJ Best Practice. Failure to thrive

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Case Numbr 3

Faltering Growth / Failure to Thrive

• Dysmorphic features – signs of TORCH infection, Russel-Silver, Turner’s

• Plot on growth chart. Serial measurements of growth will help

• poor appetite - chronic infections, chronic fever, anaemia

• Chronic infections with fever

• GI disorders - coeliac disease, chronic diarrhoea, chronic vomiting

• IgA TTG and IgA EMA - coeliac disease (also request

Inpatient treatment takes between 2 to

• feeding takes place will take into account:

• 2.) How likely an alternative diagnosis is felt to be?

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