Failure to Thrive Evaluation

Aka: Failure to Thrive Evaluation, Growth Faltering Evaluation

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II. Evaluation: Step 1 - Review Growth Patterns

  1. See Growth Assessment
  2. See Height Measurement in Children
  3. See Weight Measurement in Children
  4. Head Circumference (age <2 years)
  5. Expected Weight gain (g/day)
    1. Age 0 to 3 months: 26-31 grams weight gained per day (requires 110 kcals/kg/day)
    2. Age 3 to 9 months: 13-18 grams weight gained per day (requires 80 kcals/kg/day)
    3. Age 9 to 14 months: 10-11 grams weight per day (requires 80 kcals/kg/day)
    4. Age 15 to 24 months: 7-9 grams weight per day (requires 80 kcals/kg/day)
  6. Plot weight, height and Head Circumference
    1. Correct Premature InfantGestational age (<24 months)
    2. Of Small for Gestational Age infants, 35% are <5% at age 4 years

III. Evaluation: Step 2- Determine if Failure to Thrive is present and to what degree

  1. See Failure to Thrive Diagnosis
  2. See Failure to Thrive Red Flags
  3. Evaluation below is in light of distinguishing Failure to Thrive Causes

IV. History: Nutrition in Infants

  1. Ensure formula or Lactation have persisted as primary nutrition source in first 12 months
    1. Despite solid food introduction at 5-6 months
  2. Feeding difficulties
    1. Coughing, back arching or gagging
    2. Aspiration, Fatigue or Dysphagia
  3. Nursing or Breast Feeding history
    1. Infequent brief feedings
    2. Maternal ingestion of milk suppressant
      1. Alcohol
      2. Diuretics
    3. Inadequate milk supply
    4. Nipple problems
    5. Inadequate milk let down
    6. Poor suck
    7. Maternal Malnutrition
    8. Maternal exhaustion or Major Depression
    9. Discuss food preparation (e.g. formula too dilute)
  4. Other foods
    1. At what age was whole milk introduced
    2. At what age were solids introduced

V. History: Nutrition in Children

  1. Past history
  2. Dietary intake
    1. Consider detailed 24 hour food diary of intake
    2. Quality and Quantity of food
      1. What is a typical meal?
      2. What is a typical snack?
    3. Does the child feed themself (e.g. spoon, cup)
    4. Psychosocial events around feeding time
      1. Is the child distracted (e.g. Screen Time)?
      2. Is the child not supervised while eating?
      3. Are there food battles or food refusal?
      4. Are there specific food preferences or aversions (e.g. food textures, selectivity)?
    5. Beverages
      1. Milk amounts (excessive?)
      2. Nonnutritive drinks such as juice soda
  3. Symptoms after eating
    1. Vomiting or Spitting Up
    2. Abdominal Pain
    3. Diarrhea
  4. Stool habits (e.g. frequency and consistency)
  5. Consider dietary or nutrition Consultation
  6. Pica history

VI. History: Social

  1. Interference with adequate caretaking
  2. Risk factors
    1. Economic stress
    2. Disorganized family
    3. Social isolation
    4. Parental depression
    5. History of parent loss
    6. Overworked parent
    7. Parental Alcohol Abuse or Drug Abuse
    8. Intimate Partner Violence or other abuse
    9. Eating Disorders (e.g. Anorexia Nervosa)
    10. Consider physical, psychological or marital problems
    11. Restricted home diet due to health, cultural, religious or nutritional beliefs
    12. Food insecurity
      1. Is the family making use of SNAP, WIC or TANF?
      2. Does the family having Running water and electricity?

VII. History: Past Medical

  1. Birth
    1. Gestational age <37 weeks
    2. Low birth weight (<2500 g or <5 lb 8 oz)
    3. Complications
  2. Congenital anomalies
    1. Autism
    2. Developmental Delay
    3. Cerebral Palsy
    4. Trisomy 21
  3. Chronic medical conditions
    1. Anemia
    2. Asthma
    3. Gastroesophageal Reflux disease
    4. Poor Oral Health or Dentition
  4. Acute illness
    1. Otitis Media
    2. Gastroenteritis

VIII. History: Family

  1. Short Stature
  2. Failure to Thrive in siblings
  3. Mental illness

IX. Exam: Observe interaction between parent and child

  1. Feeding and non-feeding times
  2. Decreased, inconsistent, or nonmutual interactions
  3. Maladaptive parent-child feeding interactions
  4. Consider observation in hospital with multispecialty evaluation

X. Exam: Assess for Developmental Delay

  1. Gross Motor function from neuromuscular weakness
  2. Social skills and Expressive Language
    1. Gaze avoidance
    2. Minimal smiling
    3. Non-responsive to people
    4. Inappropriately friendly to strangers
    5. Bizarre behavior
    6. Apathy
    7. Poor hygiene

XI. Exam

  1. Perform Complete Physical Exam including Vital Signs
  2. Findings of Malnutrition
    1. Decreased skin fold thickness
    2. Decreased Subcutaneous fat
    3. Decreased Muscle mass
    4. Hair thinning
    5. Midarm circumference correlates with fat deposition (and may be plotted on standardized curves from CDC, WHO)
  3. Identify findings suggestive of Nonaccidental Trauma (physical abuse) or neglect
    1. Observe for parent-child interactions
  4. Focus on evaluation for Failure to Thrive Red Flags
    1. Dysmorphic features in Congenital Disorders
    2. Cacchexia
      1. Malignancy
      2. Type I Diabetes
    3. Cognitive deficits (or other neurologic findings)
      1. Developmental Delay
    4. Heart Murmur
      1. Congenital Heart Disease
    5. Hepatomegaly
      1. Chronic illness, infection or Malnutrition
    6. Edema
      1. Renal or hepatic disease

XII. Labs

  1. Indications
    1. Failure to Thrive Red Flags are present OR
    2. Refractory course despite adequate caloric replacement
  2. Efficacy
    1. Normal in 98% of Failure to Thrive
      1. Consider obtaining only if no improvement
      2. Sills (1978) Am J Dis Child 132:967-9 [PubMed]
  3. Initial labs
    1. Urinalysis and Urine Culture
    2. Serum Comprehensive Metabolic Panel (Electrolytes, Renal Function tests, Liver Function Tests)
    3. Complete Blood Count
    4. Thyroid Function Tests
    5. Erythrocyte Sedimentation Rate (ESR) or C-Reactive Protein (C-RP)
    6. Iron Studies (Serum Iron, TIBC, Serum Ferritin)
    7. Lead Level
    8. IgA Tissue Transglutaminase (TTG) and Total IgA for Celiac Sprue
  4. Specific Labs if indicated by history and physical
    1. Stool for fat content
    2. Stool for Ova and Parasites
    3. Serum complement levels
    4. Immunoglobulin levels
    5. Serum Calcium
    6. Seum Phosphate
    7. Serum Albumin
    8. Beta Carotene
    9. Echocardiogram
    10. HIV Test
    11. Hepatitis B Surface Antigen
    12. PPD or Tb Quantiferon
    13. Cystic Fibrosis testing (if not done with Newborn Screen)

XIII. Imaging

  1. Consider Skeletal XRay of hands and wrist for Bone Age

XIV. References

  1. Goodwin (2023) Am Fam Physician 107(6): 597-603 [PubMed]
  2. Homan (2016) Am Fam Physician 94(4): 295-9 [PubMed]

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