Dr. Adolfo Molina (Pediatric Hospitalist at UAB) joins The Cribsiders for a deep dive on all things Failure to Thrive! From the 3 broad buckets of the FTT differential, the red flags to keep an eye on, and how a lab-heavy hospital workup is almost never needed!
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Expert opinion: There is no one universally accepted definition of FTT. Dr. Molina simply defines FTT as a “young child recently out of the neonate phase that is having trouble growing” (Jaffe 2011). He relies most on weight/time (age) as a metric. Weight/age that is crossing two z-scores is a good indicator of malnutrition. Weight for length and mid-upper arm circumference is advocated for by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the American Society for Parenteral and Enteral Nutrition (ASPEN) as good metrics, however, these measurements can often be unreliable if the measurer and/or data interpreter are untrained (Becker 2015; Beer 2015).
It is important to remember though that growth charts are a bell curve and that someone has to be at the bottom statistically. Some kids may be low on the percentiles and just ride that percentile their whole life and it is not a problem. That is why time is such a key factor to put into gauging a child’s growth.
More often than not, it’s talking about infants (<1 y of age). When patients are older, malnutrition is used more. However, an infant who is “failure to thrive” is also considered mild, moderate, or severely malnourished, as “Failure to thrive” is not technically a diagnosis (nor is it a diagnostic code that can be billed for).
When evaluating a growth chart we should always be evaluating if the growth is symmetric or asymmetric. Our bodies are made to preferentially feed calories to the brain. Therefore, if the head circumference is not being spared in malnutrition that is a red flag for an underlying disease process. Examples of such include an underlying syndrome, metabolic disorder, TORCH infection, antenatal ischemic insult/stroke, or neuroanatomic abnormality. Additionally, if height is preserved, this makes an underlying endocrinological problem much less likely (Bennett 2014; Mei 2004).
Weight → Height → Head Circumference is the order in which things should drop off!
There’s no clear answer for this, but it is clear that the majority of FTT care can be done in the ambulatory setting. Especially as many studies have shown that a large laboratory/imaging workup for FTT is not needed most of the time (Khan 2021). The important question to ask is “what can we do during a hospitalization to really help?” The most common indications for admission are
The differential for FTT can be broken up into the same broad reasons anyone loses weight (Schwartz 2000):
Listeners will master the overarching differential for failure to thrive, recognize red flag symptoms for underlying organic causes, and value the importance of a thorough history and physical.
After listening to this episode listeners will…
Dr Molina reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures.
Snellgrove S, Molina A, Lee N, Masur S, Chiu C, Berk J. “#39: Failure to Thrive – Growing into Focused Management”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ Nov 24, 2021
The Cribsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit cribsiders.vcuhealth.org and search for this episode to claim credit.
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