Failure to Thrive Management

Aka: Failure to Thrive Management, Growth Faltering Management

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II. Approach

  1. See Growth Faltering Diagnosis
  2. Mild Malnutrition (Anthropometric Z Score -1 to -2 or Z-Score drops by 1 over time)
    1. Estimate and Correct caloric deficits and follow-up in 2 to 4 weeks
    2. If worsening, obtain 24 hour diet diary and consider lab testing and multidisciplinary consults
  3. Moderate Malnutrition (Anthropometric Z Score -2 to -3 or Z-Score drops by 2 over time)
    1. Estimate and Correct caloric deficits and follow-up in 1 to 2 weeks
    2. If worsening, obtain lab testing, multidisciplinary consults and consider hospitalization
    3. Continue with regularly scheduled follow-up until Z-Score in mild range or less
  4. Severe Malnutrition (Anthropometric Z Score <-3 or Z-Score drops by 2 over time)
    1. Estimate and Correct caloric deficits and follow-up in 1 week
    2. Obtain lab testing and multidisciplinary consults
    3. Hospitalization for Abnormal Vital Signs, toxic appearance, untreated comorbidity or worsening
  5. Resources
    1. Z-Score for ages 0 to 2 years (WHO)
      1. https://peditools.org/growthwho/
    2. Z-Score for ages 2 to 20 years (CDC)
      1. https://peditools.org/growthpedi/

III. Management: Calories required for catch-up

  1. Children with FTT require 150% of RDA of calories
  2. Schedule: Replacement calories needed per day
    1. Kg based on expected weight
    2. Age 2-4 weeks: 120 KCal/kg/day
    3. Age 1-2 months: 115 KCal/kg/day
    4. Age 2-3 months: 105 KCal/kg/day
    5. Age 3-6 months: 95 KCal/kg/day
    6. Age 6 months to 5 years: 90 KCal/kg/day
  3. Formula: Replacement calories needed per day
    1. KCals/kg = (120 kcal/kg x (Normal kg)) / (current kg)

IV. Management: Dietary

  1. Dietician Consultation
  2. General
    1. Stop solids less in calories/ounce than formula, milk
    2. Limit fruit juice to <8 ounces per day
    3. Consider Nutritional Supplement
    4. Take daily Multivitamin
  3. Breast-fed infants
    1. See Breast Feeding Technique
    2. See Breast Feeding Problems for the Infant
    3. See Breast Feeding Problems for the Mother
    4. Consider lactation Consultation
  4. Bottle fed infants
    1. See Infant Feeding
    2. See Catch-Up Formula Preparation for Growth Faltering Children
    3. Use 22 calorie per ounce formula (and prepare as energy dense formula with less water)
  5. Toddlers and younger children
    1. Add rice cereal, cheese, and peanut butter to foods to increase calorie intake
  6. Older children
    1. Add gravies, sauces, butter to foods to increase calorie intake

V. Management: Behavioral

  1. Consider home nurse Consultation
  2. Consider WIC referral
  3. Involve parents actively in evaluation and management
    1. Helps with frustration and guilt of Failure to Thrive
  4. Restore adequate caretaking
    1. Establish scheduled regular, balanced meals with adequate nutrition
  5. Modify maladaptive learned feeding responses
    1. Behavioral and Family Treatment
  6. Address interactional difficulties with parents
  7. Consider Psychiatric and Social Services
  8. Developmental Stimulation
    1. Community infant-stimulation programs
  9. Correct underlying conditions
    1. Treat Dental Caries

VI. Monitoring

  1. Close, weekly pediatric follow-up
  2. Hospitalization indicated in severe or refractory cases

VII. References

  1. Bauchner in Behrman (2000) Nelson Pediatrics, p. 120-1
  2. Goodwin (2023) Am Fam Physician 107(6): 597-603 [PubMed]
  3. Homan (2016) Am Fam Physician 94(4): 295-9 [PubMed]
  4. Krugman (2003) Am Fam Physician 68(5)?879-886 [PubMed]
  5. Maggioni (1995) Pediatr Clin North Am 42(4):791-810 [PubMed]

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