Children

(414) 266-2000

Failure to thrive

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Updated on: 3/9/2017
Updated by: Dr. Praveen Goday

Diagnosis/symptom

Signs and symptoms

  • Weight-for-length (or BMI) < 3rd percentile (CDC growth chart) or 2nd percentile (WHO growth chart)
  • Poor or no weight gain
    • Over a period of time that varies according to the age of the child. In general, the younger the child, the shorter the interval where there is little or no weight gain 
  • Significant downtrend in weight percentiles
  • These should be done along with:
    • Assessment of parental size / growth
    • Correction for prematurity (where applicable)

Causes

Most commonly is due to inadequate calorie intake; Other causes: malabsorption, etc. account for <5% of FTT cases.

Referring provider’s initial evaluation and management:

Diagnosis:

*See gestational age chart and guide to high-calorie beverages below

Initial interventions in a child with failure to thrive

  • Establish Mealtime Routine
  • Meals and snacks offered every 3 hourly
  • Ideally, all meals and snacks should be offered in a high chair/at the table
  • Minimize distractions
  • Avoid force feeding
  • Grazing in between meal and snack times should be eliminated
  • NO JUICE
  • Limit meals to 30 minutes

*Additional resources below

When to initiate referral/ consider refer to GI Clinic:

  • ↓ weight, ↓ height - Malnutrition
  • Normal weight, ↓ height - Endocrine
  • Normal weight, ↓ height, dysmorphism - Genetics/Endocrine
  • SGA patients without catch-up growth can be referred to endocrine clinic for possible growth hormone treatment
  • Nutrition Clinic: Contact Dr Praveen Goday at pgoday@mcw.edu for FTT patients who are not progressing according to plan.

What can referring provider send to GI Clinic?

  • Using Epic
    • Please complete the external referral order
      In order to help triage our patients and maximize the visit, the following information would be helpful include with your referral order:
    • Urgency of the referral
    • What is the key question you would like answered?
      Note: Our office will call to schedule the appointment with the patient.
  •   Not using Epic external referral order: 
    • In order to help triage our patients maximize the visit time, please fax the above information to (414-607-5288)
    • It would also be helpful to include:
      • Chief complaint, onset, frequency
      • Recent progress notes
      • Labs and imaging results
      • Other Diagnoses
      • Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient’s problems.

Specialist’s workup will likely include:

After referral to GI Clinic:
Labs

Most children with FTT do not need labs

Labs

  • Significant FTT
  • FTT not due to inadequate calorie intake

Common labs

  • CBC, ESR
  • Metabolic panel, electrolytes
  • Anti-TTG IgA, serum IgA level
  • Fecal elastase
  • Urinalysis

Overall Algorithm

 

If a child is <10th percentile for gestational age then child is SGA

Female   10th %ile  Male  10th %ile
GA Grams Pounds/ounces GA Grams Pounds/ounces
23  477 1 lb 0.8 oz  23 

509

1 lb 2.0 oz 
24  524 1 lb 2.5 oz 24  561  1 lb 3.8 oz
25  584 1 lb 4.6 oz  25  626 1 lb 6.1 oz
26  645 1 lb 6.8 oz 26  704 1 lb 8.8 oz
27  719 1 lb 9.4 oz 27  789 1 lb 11.8 oz
28  807 1 lb 12.5 oz 28  884  1 lb 15.2 oz
29  915 2 lb 0.3 oz  29  988 2 lb 2.9 oz
30  1052 2 lb 5.1 oz 30  1114 2 lb 7.3 oz
31  1196 2 lb 10.2 oz 31  1267 2 lb 12.7 oz
32  1352 2 lb 15.7 oz 32  1433 3 lb 2.5 oz
33  1545 3 lb 6.5 oz  33  1625 3 lb 9.3 oz
34  1730 3 lb 13 oz  34  1810 3 lb 15.8 oz
35  1869 4 lb 1.9 oz  35  1980 4 lb 5.8 oz
36  2028 4 lb 7.5 oz  36  2170  4 lb. 12.5 oz
37  2260 4 lb 15.7 oz 37  2401 5 lb 4.7 oz
38 2526 5 lb 9.1 oz 38  2652 5 lb 13.5 oz
39  2724 6 lb 0.1 oz 39  2833 6 lb 3.9 oz
40  2855 6 lb 4.7 oz 40  2950 6 lb 8.1 oz
41 2933 6 lb 7.5 oz 41  3039 6 lb 11.2 oz

 

 Mid-parental height

  •  To the average of the parents’ heights
    • Add 2.5” if male
    • Subtract 2.5” if female
  • This is the median height expected for that child
    •  8.5 cm on either side of the median will give you 5-95%iles for that child

Guide to high-calorie beverages

Fortifying Breast Milk

  •  24-26 calorie/ounce breast milk:
    • Add 1 tsp infant formula + 2.5 oz expressed breast milk
    • (Calorie level varies with type of formula used)

Fortifying infant Formulas

  •  24 calorie/ounce recipe:
    • *For infant formulas EXCEPT premature formulas (Neosure, Enfacare), Neocate and Neocate Jr.
    • 3 scoops powder + 5 ounces water (Add water to bottle first, and then add powder)
  • 27 calorie/ounce recipe:
    • *For infant formulas EXCEPT premature formulas (Neosure, Enfacare), Neocate and Neocate Jr.
    • 5 scoops powder + 7 ounces water (Add water to bottle first, and then add powder)
  • 30 calorie/ounce recipe:
    • *For infant formulas EXCEPT premature formulas (Neosure, Enfacare), Neocate and Neocate Jr.
    • 4 scoops powder + 5 ounces water (Add water to bottle first, and then add powder)

Toddler beverages

  •  Pediasure ®, Boost ®, Nutren Jr. ®
    • 30 calories/ounce
  • Carnation Instant Breakfast ® w/ whole milk
    • 30 calories/ounce
    • Cheaper than Pediasure ($0.50 / packet)
  • 7 oz Whole milk with 1 oz heavy whipping cream
    • 30 calories/ounce and cheapest
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