Failure to Thrive (FTT): A Comprehensive Guide for Nurses

Failure to Thrive (FTT) is a condition in which a child’s growth and development are significantly below expected standards for their age and gender. It may result from a variety of medical, nutritional, or psychosocial factors and requires a comprehensive approach for diagnosis and management. Nurses are essential in identifying, assessing, and managing children with FTT, as well as supporting families in addressing underlying causes.

Definition

FTT is not a diagnosis but a descriptive term that indicates inadequate growth or the inability to maintain appropriate weight and height for age.

Criteria for FTT:

• Weight-for-age or weight-for-length below the 5th percentile.
• A downward crossing of at least two major growth percentiles on a growth chart over time.
• Weight less than 80% of ideal weight-for-age.

Types of Failure to Thrive

Organic FTT:

Caused by an underlying medical condition.

• Examples: congenital heart disease, cystic fibrosis, gastrointestinal disorders (e.g., celiac disease), or chronic infections.

Non-Organic FTT:

Caused by environmental, psychosocial, or economic factors.

• Examples: neglect, poverty, or improper feeding practices.

Mixed FTT:

A combination of organic and non-organic causes.

Causes of FTT

1. Medical Causes (Organic):

Gastrointestinal Disorders:

• Gastroesophageal reflux disease (GERD).
• Malabsorption syndromes (e.g., celiac disease, lactose intolerance).

Endocrine Disorders:

• Hypothyroidism, growth hormone deficiency.

Chronic Illnesses:

• Congenital heart disease, cystic fibrosis, chronic kidney disease.

Neurological Conditions:

• Cerebral palsy, developmental delays affecting feeding.

2. Environmental and Psychosocial Causes (Non-Organic):

• Inadequate caloric intake (e.g., improper formula preparation, restrictive diets).
• Poverty or food insecurity.
• Parental mental health issues (e.g., depression, anxiety).
• Lack of knowledge about proper feeding practices.

3. Mixed Causes:

• Poor feeding practices in a child with a chronic medical condition.

Clinical Presentation

Symptoms:

• Poor weight gain or weight loss.
• Delayed milestones (e.g., motor, social, or cognitive development).
• Persistent hunger or lack of interest in feeding.
• Frequent illnesses or infections.
• Irritability, lethargy, or low energy levels.

Physical Findings:

• Thin or wasted appearance.
• Loose skin due to loss of subcutaneous fat.
• Hair thinning or sparse hair growth.
• Delayed dentition (late eruption of teeth).

Diagnosis

1. History:

Medical History:

• Chronic illnesses, infections, prenatal or birth complications.

Dietary History:

• Feeding practices, types of food, formula preparation.

Family History:

• Growth patterns, genetic disorders.

Social and Environmental History:

• Socioeconomic status, parental knowledge, family dynamics.

2. Physical Examination:

• Growth chart analysis: Compare weight, height, and head circumference to age and gender norms.
• Assess for signs of malnutrition or systemic illness.

3. Laboratory and Imaging Studies:

Nutritional Deficiencies:

• Complete blood count (CBC) for anemia.
• Serum albumin, vitamin levels.

Endocrine Tests:

• Thyroid function tests, growth hormone levels.

Gastrointestinal Tests:

• Stool studies for malabsorption.
• Celiac serology.

Imaging:

• Bone age radiographs to evaluate growth delays.

Management of Failure to Thrive

Goals of Treatment:

• Address the underlying cause (medical, psychosocial, or both).
• Improve nutritional status.
• Support normal growth and development.
• Educate and empower caregivers.

1. Nutritional Management:

Caloric Optimization:

• Provide high-calorie foods or formula.
• Consider nutritional supplements (e.g., Pediasure, fortified milk).

Feeding Schedule:

• Offer small, frequent meals.
• Avoid excessive liquids that displace caloric intake (e.g., juice, water).

Dietary Interventions:

• Work with a dietitian to develop a tailored feeding plan.

2. Medical Interventions:

• Treat underlying medical conditions (e.g., reflux, infections, malabsorption).
• Address nutrient deficiencies with supplements (e.g., iron, calcium, vitamins).

3. Behavioral and Psychosocial Support:

• Educate parents or caregivers on proper feeding techniques.
• Address parental anxiety or misconceptions about feeding.
• Provide mental health support for caregivers if needed.

4. Hospitalization:

• Indicated for severe FTT with complications such as dehydration, severe malnutrition, or need for close monitoring.

Nursing Interventions

1. Assessment and Monitoring:

• Regularly measure and chart weight, height, and head circumference.
• Monitor intake and output, including feeding patterns and stool characteristics.
• Observe parent-child interactions during feeding.

2. Education:

• Teach caregivers about appropriate nutrition for the child’s age and condition.
• Provide guidance on formula preparation or breastfeeding support.
• Address misconceptions about food allergies or restrictive diets.

3. Supportive Care:

• Create a positive feeding environment (e.g., minimize distractions).
• Encourage responsive feeding, allowing the child to express hunger and fullness cues.
• Advocate for social services if food insecurity or neglect is suspected.

4. Documentation:

• Record feeding patterns, growth data, and parent education efforts.
• Document interactions with multidisciplinary team members (e.g., dietitians, social workers).

Complications of FTT

• Developmental Delays: Cognitive, motor, and social impairments.
• Infections: Increased susceptibility due to weakened immunity.
• Chronic Malnutrition: Stunted growth and delayed puberty.
• Emotional and Behavioral Issues: Anxiety, attachment disorders, or feeding aversions.

Prevention of FTT

1. Early Screening and Intervention:

• Regular growth monitoring during well-child visits.
• Early identification of growth faltering.

2. Parental Education:

• Teach caregivers about age-appropriate nutrition and feeding techniques.

3. Support for At-Risk Families:

• Provide resources for low-income families (e.g., WIC, food banks).

4. Early Treatment of Medical Conditions:

• Manage chronic illnesses and address feeding difficulties promptly.

Conclusion

Failure to thrive is a complex condition requiring a multidisciplinary approach to address its multifactorial causes. Nurses play a pivotal role in the early detection, management, and prevention of FTT through regular monitoring, caregiver education, and advocating for necessary resources. By providing holistic and evidence-based care, nurses can significantly improve outcomes for children and their families.