BNU2363 Paediatric Nursing: Failure To Thrive (FTT)

Definition and Overview of Failure to Thrive (FTT)

• Conceptual Definition: Failure to Thrive (FTT) is characterized by a child's failure to gain weight and the presentation of signs denoting delayed development. It is often referred to by synonymous terms such as "weight faltering," "faltering growth," or "growth deficit."

• Classification as a Symptom: It is critical to note that FTT is a symptom of an underlying condition rather than a standalone diagnosis.

• Clinical Criteria and Thresholds: FTT is defined by specific anthropometric measurements and growth chart data:

  • Weight falling below the $3rd$ or $5th$ percentile on an appropriate growth chart on more than $1$ consecutive occasion.

  • Weight is less than $80\%$ of the ideal weight for the child's age (Weight < 80\% \text{ of ideal weight}).

• Severity: FTT is regarded as a potentially life-threatening disorder.

• Primary Physiological Mechanisms: The condition results from one or a combination of the following three factors:

  1. Inadequate intake of calories.

  2. Inadequate absorption of calories.

  3. Excessive expenditure of calories.

Malnutrition Z-Scores and Anthropometric Definitions

According to the consensus statement from the American Society for Parenteral and Enteral Nutrition, FTT is defined by the following malnutrition Z-scores and measurements:

• Weight-for-height/BMI Z-score:

  • Mild Malnutrition: $-1$ to $-1.9$

  • Moderate Malnutrition: $-2$ to $-2.9$

  • Severe Malnutrition: $\le -3$

• Length/height Z-score:

  • Severe Malnutrition: $\le -3$

• Mid-upper arm circumference (MUAC) Z-score:

  • Mild Malnutrition: $-1$ to $-1.9$

  • Moderate Malnutrition: $-2$ to $-2.9$

  • Severe Malnutrition: $\le -3$

• Weight gain velocity (for children < 2 years):

  • Mild Malnutrition: < 75\% of expected

  • Moderate Malnutrition: < 50\% of expected

  • Severe Malnutrition: < 25\% of expected

• Weight loss (for children ≥ 2 years):

  • Mild Malnutrition: $5\%$ body weight

  • Moderate Malnutrition: $7.5\%$ body weight

  • Severe Malnutrition: $10\%$ body weight

• Deceleration of weight-for-length Z-score:

  • Mild Malnutrition: $-1$ Z-score

  • Moderate Malnutrition: $-2$ Z-scores

  • Severe Malnutrition: $-3$ Z-scores

Pathophysiological Classification and Investigative Pathways

The assessment of FTT involves identifying if the child was Small for Gestational Age (SGA) or experienced Intrauterine Growth Restriction (IUGR):

• Symmetric FTT: In this presentation, everything is proportionally small, including weight, length, and head circumference ($Low \, BW$, $Low \, LT$, $Low \, HC$).

  • Implications: Suggests genetic or chromosomal causes, TORCH infections, Fetal Alcohol Syndrome, or maternal Phenylketonuria (PKU).

• Asymmetric FTT: In this presentation, the weight drops first, while length and head circumference are relatively preserved.

  • Implications: This suggests nutritional problems, placental insufficiency, or late pregnancy problems.

• Investigative Branches:

  • IUGR or SGA present: Investigate prenatal history. If maternal/placental or fetal factors are known, or prematurity is present, evaluate accordingly. If unknown, look for TORCH infections or chromosomal abnormalities.

  • No IUGR or SGA (Normal size at birth):

    • If weight faltering occurs first, investigate inadequate calorie intake, feeding difficulties, neglect, or malabsorption.

    • If head circumference faltering occurs first, investigate cerebral malformations, congenital infections, or brain growth issues.

    • If length faltering occurs first, investigate endocrine disorders, chronic illness, or genetic conditions.

Etiology of Failure to Thrive

Calorie-Related Factors

• Increased Caloric Expenditure: Conditions such as hyperthyroidism, congenital heart disease, and chronic pulmonary disease cause the body to use calories faster than they are consumed.

• Increased Loss of Calories: Caloric loss can occur through persistent vomiting, Gastroesophageal Reflux Disease (GERD), Gastrointestinal (GI) obstruction, Renal Tubular Acidosis, Diabetes Mellitus (DM), or other metabolic disorders.

• Reduced Calorie Absorption: Inadequate absorption is linked to conditions like cystic fibrosis, celiac disease, hepatic disease, and various vitamin deficiencies.

• Reduced Intake of Calories: This is the most common cause of FTT. It may be due to a physical inability to suck, chew, or swallow.

Dietary Factors

• Breastfeeding difficulties.

• Improper mixing of infant formula.

• Poor transition from milk/formula to solid foods.

• Excessive consumption of juice.

• Avoidance of high-calorie foods.

Family and Social Conditions

• Lack of knowledge regarding nutrition and childcare.

• Maternal or parental mental health issues.

• Family chaos or instability.

• Child neglect.

• Financial constraints/poverty.

Altered Growth Potential or Regulation

• Chromosomal abnormalities.

• Endocrinopathies.

Types of Failure to Thrive

• Organic FTT: Caused by a physical defect or medical condition. Examples include:

  • Premature birth.

  • Maternal smoking, alcohol consumption, or drug use during pregnancy.

  • Mechanical problems (e.g., swallowing or GI issues).

  • Metabolic abnormalities.

  • Malabsorption syndromes.

• Inorganic FTT: Caused by non-medical or psychosocial factors. Primary examples include:

  • Poor feeding skills or lack of parenting preparation.

  • Dysfunctional family interactions or difficult parent-child interactions.

  • Lack of social support.

  • Family dysfunction (e.g., abuse, divorce).

  • Child neglect and emotional deprivation.

Clinical Manifestations

• Physical Growth: Height, weight, and head circumference measurements do not align with standard growth charts. Weight is consistently found to be below the $3rd$ percentile. Growth may slow significantly or stop entirely.

• Developmental Delays:

  • Decrease in physical skills (e.g., rolling over, sitting, standing, and walking).

  • Decrease in mental and social skill development.

  • Delayed secondary sexual characteristics in adolescents.

• Physical and Behavioral Signs:

  • Constipation.

  • Excessive crying and irritability.

  • Lethargy and unresponsiveness.

  • Minimal smiling and avoidance of eye contact.

Diagnosis and Evaluation

History Taking

• Prenatal History: Maternal health and exposures during pregnancy.

• Birth History: Labour, delivery, and neonatal history.

• Medical History: Identifying underlying organic diseases.

• Social History: Assessing family dynamics and socioeconomic status.

• Nutritional History: Detailed assessment of intake and feeding habits.

Clinical and Laboratory Assessment

• Physical Examination: Specifically looking for signs of malnutrition.

• Denver Developmental Screening Test (DDST): A standardized tool used to assess four domains of development:

  1. Personal-Social: Items like "Hands Together" and "Follow Past Midline."

  2. Fine Motor-Adaptive: Items like "Grasp Rattle."

  3. Language: Assessing word counts ($1$, $2$, or $3$ words), naming pictures, and combining words.

  4. Gross Motor: Milestones like "Head Up $45$ degrees," "Sit-No Support," "Pull to Stand," "Walk Well,"/"Kick Ball Forward," and "Balance Each Foot."

• Growth Charts: Regular plotting of anthropometric data.

• Blood Investigations: Complete Blood Count (CBC), electrolytes, and hormone studies (especially thyroid function).

• Urinalysis: To screen for metabolic or renal issues.

• X-ray: Used to determine bone age to assess physiological maturity.

Management and Treatment

• Nutritional Education: Providing caregivers with the knowledge to meet the child's caloric needs.

• Feeding Intervention: Implementing structured feeding schedules or techniques.

• Monitoring: Continuous tracking of weight gain, physical growth, and developmental milestones.

• Treating Underlying Conditions: Addressing organic causes (e.g., heart disease or metabolic disorders).

• Hospitalization: Necessary if the child presents with severe dehydration or electrolyte imbalances.

Nursing Management and Care Plan

Primary Nursing Diagnoses

1. Imbalanced nutrition: less than body requirements related to insufficient intake of calories.

2. Risk for delayed development related to inadequate stimulation.

Nursing Aims

• Provide adequate nutrition to support catch-up growth.

• Promote normal growth and development through appropriate interventions.

• Assist caregivers in developing the necessary skills to nurture their infant effectively.

Summary of Findings and Potential Causes

• Dysmorphic appearance: Potential for genetic abnormalities or undiagnosed syndromes.

• Edema: Potential renal or liver disease.

• Hair color/texture change: Potential zinc deficiency.

• Heart murmur: Potential anatomic cardiac defect.

• Hepatomegaly: Potential infection, chronic illness, or severe malnutrition.

• Mental status change: Potential Cerebral Palsy (CP) or poor social bonding.

• Poor parent-child interaction: Potential depression or social stress.

• Rash, skin changes, or bruising: Potential HIV infection, cow's milk allergy, or child abuse.

• Respiratory compromise: Potential cystic fibrosis.

• Wasting: Potential for cancer or Cerebral Palsy (CP).