Failure to Thrive: Taking the Failure out of FTT

As a pediatric gastroenterologist, I often see infants and children who are not gaining weight. This diagnosis, regardless of the etiology, is usually coined failure to thrive. Parents are often frustrated with the name of this diagnosis as it sometimes seems that they or their child has ‘failed’ at something and that their child is not ‘thriving’. Since FTT, as it is often abbreviated, is a common reason for referral to a pediatric gastroenterologist, I wanted to further discuss and shed some light on this topic.

What is failure to thrive?

This is a term used by pediatricians to describe a child that is not gaining weight as expected for his or her age. Typically, it is defined as a child whose weight is at less than then 5 percentile for his or her age OR if a child has crossed two percentiles. An example would be if your child was growing at the 75 percentile and has dropped to the 25 percentile for weight for age. There are many reasons why a child may not be gaining weight so it is necessary for your child’s pediatrician to assess nutritional intake and take a history to decide what further testing would be needed.

What growth chart should I use?

The current recommendations for which growth chart to use depends on the age of your child. From birth to 2 years, the World Health Organization (WHO) growth charts are now recommended while the Center for Disease Control (CDC) growth charts are still used from 2 to 18 years. Many pediatric offices and hospitals are still using the CDC growth charts from birth since it may be part of their electronic medical record but in 2010 the CDC addressed this issue and recommended the use of the WHO growth chart from birth to 2 years. The WHO growth charts are based on studies with breast fed infants, and the sample size for young infants was larger and better represents how infants should grow under ideal conditions.

What are the reasons for failure to thrive?

The causes of FTT are from a variety of reasons. The most common is a child who is a picky eater that may lead to insufficient caloric intake. The other two main causes are increased caloric need that is often seen in children with congenital heart disease, and increased caloric losses as is seen in children with chronic vomiting and diarrhea, such as in children with celiac disease. Food allergies may also present with poor weight gain since these children may have feeding issues or may have difficulty ingesting enough calories since they are on such a limited diet.

What tests may need to be done?

The tests that may be done to evaluate for medical reasons for poor weight gain will vary dependent on your child’s age and any other symptoms that may be present. In general, your doctor will usually check for celiac disease (as long as they have been exposed to gluten), and assess for anemia, liver, thyroid and kidney disease by performing blood work. In addition, if your child has diarrhea, your doctor may check their stool for protein, fat and sugar to check whether your child is adequately absorbing the food that they eat. Your pediatrician may refer your child to a nutritionist who will perform a 3-day calorie count to see if your child is getting enough calories. A referral to a gastroenterologist also could be suggested, especially if a child is vomiting, has diarrhea, gags with feeds or has abdominal pain.

What is the treatment for failure to thrive?

The treatment for FTT varies depending on the underlying cause. If FTT is related to insufficient calories, meals should be fortified with high caloric foods such as avocado, whole milk, heavy cream and natural oils. Coconut oil is full of good fats, tastes great and can be added to your child’s milk or pureed foods. Each tablespoon of coconut oil has 125 calories! There are also many fortified nutritional supplements available in the form of milk, juices and powdered supplements. The initial goal should be to add an additional 75-100 calories per day. Working with a health care professional and nutritionist is essential to ensure that your child is getting adequate calories so that they grow and develop appropriately.

Anthony F. Porto, MD, MPH is a board certified pediatric gastroenterologist working at Yale University School of Medicine. He is the associate clinical chief in the section of gastroenterology/hepatology as well as director of pediatric gastroenterology at Greenwich Hospital. He received his medical and master of public health degrees from Tufts University School of Medicine. He completed his residency training at the Children’s Hospital at Montefiore Medical Center, Bronx, NY, and his fellowship in pediatric gastroenterology and hepatology at Columbia University. He was named both physician and teacher of the year at Columbia in 2005 and 2006, respectively. He writes public education materials for the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition website and is on the medical advisory board of the Crohn’s Colitis Foundation of America.
He has a strong interest in nutrition especially in celiac disease and gluten-related disorders, food allergies, obesity and ensuring proper growth in children with feeding problems.

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