Introduction:

Failure to thrive (FTT) is a chronic, potentially life-threatening disorder of infants and children who fail to
gain and may even lose weight. Children are considered as failing to thrive when their rate of growth does
not meet the expected growth rate for a child of their age. More specifically, the term characterized those
whose weight is below the 3rd percentile on an appropriate growth chart.
The deviation from a normal growth channel is actually more descriptive of what is happening to an
individual than a decrease in the actual amount of weight. Any infant or child at the fifth percentile should
alert the caregiver that a problem exists. If the condition progresses, the undernourished child may become
irritable and/or apathetic and may not reach typical developmental markers such as sitting up, walking, and
talking at the usual ages.

Background:
Failure to thrive (FTT) is a common problem of children from poor socioeconomic group. This term was
mentioned as early as 1915. Afterwards it was termed as 'Emotional deprivation and as 'Maternal
deprivation syndrome' by Bowlby, in 1969.

Definition:
FTT is a term used to describe inadequate growth or the inability to maintain growth in childhood.

Failure to thrive can be defined as a chronic potentially life-threatening disorder of infant and children who
fail to gain weight and even lose weight. The children with FTT show failure of expected growth and
noticeable lack of well-being. It indicates psychosomatic growth failure.
Concept:
The physiologic concepts of FTT are based on inadequate parent-child relationship leading to disturbances
of neuro-endocrine functions. The hyperactivity of adrenal cortex of the emotionally disturbed children may
suppress the growth. Secretion of pituitary growth hormone may be inhibited due to abnormal sleep pattern
and deprivation of food of the disturbed child.

Attained growth:

• Weight<3rd percentile on standard growth chart.

• Weight for height<5th percentile on standard growth chart.

• Weight 20% or more below ideal weight for height.

Rate of growth:

• Less than 20g/day from birth to 3 months of age.

• Less than 15g/day from 3 months to 6 months of age.

• Fall off from previously established growth curve.

• Downward crossing of >2 major percentiles.

Classification:

Causes of failure to thrive can be grouped into three categories:

1. Organic FTT:
It is usually associated with all serious paediatric illnesses like congenital heart diseases, malabsorption
syndrome, intestinal parasitosis, tuberculosis, juvenile diabetes mellitus, cystic fibrosis, liver abscess,
congenital pyloric stenosis, gastroesophageal reflux, etc.

Occurs when there is underlying medical cause like:

 Premature birth.

 Maternal smoking, alcohol use or illicit drugs during pregnancy.

 Mechanical problems present.

 Unexplained poor appetites that are unrelated to mechanical problems. Inadequate intake also can
result from metabolic abnormalities.

 Poor absorption of food, inability of the body to use absorbed nutrients or increased loss of nutrients.

2. Nonorganic FTT:
It is a psychosocial problem due to disturbed parent child relationship leading to emotional deprivation,
poverty, illiteracy, ignorance, faulty food habit and conflict in the family resulting social deprivation. All
these lead to poor nutritional intake, feeding problems and failure of growth.
 Poor feeding skills on the part of the parent
 Dysfunctional family interactions
 Difficult parent-child interactions
 Lack of social support
 Lack of parenting preparation
 Family dysfunction, such as abuse or divorce
 Child neglect
 Emotional deprivation

3. Mixed FTT:
It is combined effect of both organic and non-organic causes.

Causes of FTT:
 Inadequate caloric intake
 Inadequate absorption
 Increased caloric requirement
 Excessive loss of calories
 Altered growth potential or regulation

1.Inadequate caloric intake

 Incorrect formula preparation

 Neglect
 Excessive juice consumption
 Poverty
  Behavioral problem affecting eating
 Non-availability of food
 Misperceptions about diet and feeding practices
 Errors in formula reconstitution
 Dysfunctional parent-child interaction, child abuse and neglect
 Behavioral feeding problem
 Mechanical problems with sucking, swallowing and feeding
 Primary neurological diseases
 Chronic systemic disease resulting in anorexia, food refusal and neurological problems

2. Inadequate absorption:

 Cystic fibrosis
 Celiac disease
 Vitamin deficiencies
 Hepatic diseases

3.Increased caloric requirement

 Hyperthyroidism
 Congenital heart disease
 Chronic immunodeficiency
 Chronic respiratory disease
 Neoplasm
 Chronic or recurrent infection

4. Excessive loss of calories

 Persistent vomiting
 Gastro oesophageal reflux disease
 Gastrointestinal obstruction
 Increased intracranial pressure
 Renal losses - renal tubular acidosis
 Diabetes mellitus
 Inborn errors of metabolism

5.Altered growth potential regulation

 Chromosomal abnormalities
 Endocrinopathies

Clinical features:

 Height, weight, and head circumference do not match standard growth charts
 Weight is lower than 3rd percentile
 Growth may have slowed or stopped after a previously established growth curve
 Physical skills such as rolling over, sitting, standing and walking decreased
 Mental and social skills decreased
 Secondary sexual characteristics delayed in adolescents.
 Constipation
 Excessive crying
 Excessive sleepiness (lethargy)
 Irritability
  Minimal smiling
 Avoidance of eye contact
 Unresponsive

History taking:
 Prenatal
 (intranatal) labour, delivery, and neonatal events
 Medical history of child
 Social history
 Nutritional history
Examination and Tests:
 Physical examination
 Denver Developmental Screening Test
 A growth chart outlining all types of growth
 Complete blood count (CBC)
 Electrolyte balance
 Hemoglobin electrophoresis
 Hormone studies, including thyroid function tests
 X-rays to determine bone age
 Urinalysis

Assessment of degree of FTT:

Degree of FTT
Growth Mild Moderate Severe
Parameter
Weight 75-90% 60-74% <60%
Height 90-95% 85-89% <60%
Wt/Ht Ratio 81-90% 81-90% <70%

Management:

 Management of a child with FTT needs physical, social and emotional approach in home and
hospital on immediate and long-term basis.
 Initial assessment of child's physical and mental health status including the assessment of family
condition and socio- cultural influence are very important for the management of the child with FTT.
 Detailed collection of family history is the prime responsibility of the paediatric nurse.
 Thorough physical examination and laboratory investigations (stool, urine, blood) should be done to
detect the organic cause.
 Growth chart also helps in diagnosis that should be followed, if maintained previously.
 Hospitalization may be necessary to confirm the diagnosis and to treat the cause and complications.
 Children with FTT require 50% of Recommended Dietary Allowance (RDA) of calories for catch up
growth.
 Correction of any underlying disease
 Improvement in care-giver skills.
 Regular and effective follow up
 Treatment may also involve improving the family relationships and living conditions.
Nursing management:
Nursing management should emphasize on supervision of optimum food intake, warm emotional care
with love and affection from parent and family members with psychological stimulation to the child.
Parental involvement in treatment plan and care is vital.
Emotional support to the parents and necessary instructions are essential for improvement of parent-
child relationship and resolution of emotional conflict of the child.
Regular follow-up should be done for effective management. Referring may be planned, whenever
needed, for social support and community assistance to improve socioeconomic status.
Community health nurse should arrange regular home visit for follow-up and further assistance towards
tender loving care of the child

The nursing management to the care of child with FTT and their families includes-

• Optimum nutrition

• A consistent, warm, caring environment

• Organized program of Appropriate Stimulation

• Parental support and education

• Discharge planning

Malnutrition

Definitions:

Malnutrition is defined as any nutritional disorder. It may result from an unbalanced, insufficient, or
excessive diet or from impaired absorption, assimilation, or use of foods

Over-nutrition - a condition of excess nutrient and energy intake over time. Over nutrition may be regarded
as a form of malnutrition when it leads to morbid obesity.
Obesity - an abnormal increase in the proportion of fat cells, mainly in the visceral and subcutaneous tissues
of the body.
Under-nutrition - malnutrition caused by an inadequate food supply or an inability to use the nutrients in
food.

PROTEIN-ENERGY MALNUTRITION
Protein-energy malnutrition (PEM) has been identified as a major public health and nutrition problem in
India. It can be defined as a group of clinical conditions that may result from varying degree of protein
deficiency and energy (calorie) inadequacy. Previously, it was known as protein calorie 1 malnutrition
(PCM)
Causes of malnutrition:

 Food: Inadequate household food security (limited access or availability of food)

 Nutrition: Inadequate access to food coupled with unsanitary environment, inadequate health
services, and lack of knowledgeable care to ensure healthy life.

 Health: Limited access to adequate health services and/or inadequate environmental health
conditions.

 Care: Inadequate social and care environment in the household and local community, especially in
regard to women and children.

Conceptual framework:

Clinical Features of PEM

Clinical features of PEM depend upon severity and duration of nutritional inadequacy, age of the child,
relative lack of different foods and presence or absence of associated infections.
 Kwashiorkor and nutritional marasmus are two extreme forms of PEM. These extreme forms
account for a small proportion of cases of PEM, whereas a much larger number of children suffer
from mild to moderate nutritional deficiency.

 When the dietary intake is inadequate for a short period, the body adjusts its metabolism to
 compensate for the deficiency to some extent. If deficit of food persists for a longer period, the
malnourished children conserve energy by reducing physical activity.

 Moderately malnourished children appear more slow and less energetic. If the nutrition deficit
continues longer, growth of the child is affected. As the nutritional deficiency exaggerates with
infections, the child may become marasmic or may develop kwashiorkor.

Classification by Indian Academy of Pediatrics:

When the child is having weight more than 80 percent of expected weight for age, considered as normal.
The grade of malnutrition is described as follows: Grade I between 71 and 80 percent of expected weight for
the age.

 Grade II between 61 and 70 percent of expected weight for that age.

 Grade III between 51 and 60 percent of expected weight for that age.

 Grade IV 50 percent or less of weight expected for that age. In case of demonstrable oedema in the
child, the letter 'K' is placed in front of the evaluated grade.

Gomez Classification:

According to this classification, PEM is graded with reference to the weight for age as percentage of the
expected weight RI, (Harvard Standard). It is an international classification that takes a weight of more than
90 percent of expected for that age (50th percentile) as normal. The grade of malnutrition are as follows:

 Grade I Weight between 75 and 90 percent of expected for the age.

 Grade II Weight between 61 and 75 percent of expected for the age.

 Grade III Weight less than or equal to 60 percent of expected for the age.

According to WHO:
Under nutrition in children below five years of age in populations is measured by three anthropometric
indices which are based on a comparison of the measured height and weight of the child compared to the
WHO defined reference height and weight of children of the same age and sex.

These three indices-

(i) weight-for-age, (ii) height/ length-for- age, (iii) weight- for-height/ length
They are used to identify underweight, stunting and wasting, respectively.

 Underweight: Underweight can result from either chronic or acute malnutrition or both. An
underweight child has a weight-for-age Z-score at least two standard deviations below the median (-2
SD) for WHO Child Growth Standards.

 Moderate Underweight (MUW) is defined as weight-for-age between -2 and -3 SD as per WHO

growth standard.
 Severe Underweight (SUW) is a condition in which a child has a very low weight in relation to
 age (Z score of < - 3 SD), as per WHO child growth standards.

 Stunting:
Failure to achieve expected height/length as compared to healthy, well- nourished children of the same age
is a sign of stunting. Stunting is an indicator of linear growth retardation.
It is an indicator of chronic growth failure associated with a number of long-term factors including
chronic insufficient nutrient intake, frequent infection and inappropriate feeding practices.
A stunted child has a height-for-age Z-score that is at least two standard deviations (-2 SD) below the
median for the WHO Child Growth Standards.
 Wasting:
Wasting indicates current or acute malnutrition resulting from failure to gain weight or actual weight loss.
Suboptimal Infant and Young child care and feeding practices including inadequate complementary feeding
in older infants and young children from 6 months to 2 years of age, repeated enteric and respiratory tract
infections are some of the factors leading to Severe Acute Malnutrition (SAM) in children.
Wasting in individual children and population groups can change rapidly and shows marked seasonal
variations associated with changes in food availability or disease prevalence to which it is very sensitive. A
wasted child has a weight- for-height Z-score at least two standard deviations (-2 SD) below the median for
the WHO Child Growth Standards.

 Moderate Acute Malnutrition (MAM) defined as weight-for-height between -2 and -3 SD as per

WHO growth standard.
 Severe Acute Malnutrition (SAM) is a condition in which a child has a very low weight in relation
to length/height (Z score of < - 3 SD), as per WHO child growth standards. SAM is a severe form of
wasting.

Kwashiorkor
Kwashiorkor was first described by Dr. Cicely Williams in 1933, but the particular term "Kwashiorkor" was
introduced in 1935, according to local name for the disease in Ghana. The term was said to mean "red boy"
due to characteristic pigmentary changes.

This nutritional deficiency condition is mainly found in preschool children but may occur in any age. The
childhood infections like ARI, diarrhoea, measles, etc. may precipitate the disease.

The presenting features can be divided into two groups, i.e. essential and nonessential features.

Essential features of kwashiorkor:

o Marked growth retardation with low weight and low height gain.
o Muscle wasting with retention of some subcutaneous fat.
o Psychomotor changes characterized by mental apathy with listless, inertness, lack of interest about
the surrounding, lethargy, dullness and loss of appetite.
o Pitting oedema, especially over the pretibial region, due to hypoalbuminemia, and increased capillary
permeability with damage cell membrane.
o These essential features are to be considered as the minimal diagnostic criteria for kwashiorkor.

Nonessential features of kwashiorkor:

These features are variable and may or may not be present in the children.
 o Hair changes: Hair changes are found as light-coloured hair or reddish-brown colour hair which
becomes thin, dry, coarse, silky with easy pluckability. The affected child may have alopecia with
alternate band of light and dark colour hair as 'flag sign' which indicates period of inadequate,
adequate and inadequate nutrition over a prolonged period.
o Skin changes: It is found initially with erythema and hyperpigmented skin patches but later found as
desquamated and hypopigmented patch with the appearance like old paint flaking off the surface of
the wood (flaky-paint dermatosis).
o The child may also have crazy pavement dermatosis, mosaic dermatosis, reticular pigmentation,
pyodermas, scabies and indolent sores and ulcers over the exposed parts or limbs.
o Superadded infections: These children usually suffer from repeated infections of GI tract with
diarrhoea, vomiting, anorexia and dehydration. Respiratory infections (ARI, tuberculosis), skin
infections and septicaemia, are common and difficult to manage in these patients.
o Other usual associated features in these children are manifestations of minerals and vitamin
deficiencies, hepatomegaly, intestinal parasitosis, metabolic disorders, malabsorption syndrome with
stunted growth.

Nutritional Marasmus

Nutritional marasmus is also termed as infantile atrophy or athrepsia. It is common in infants and may found
in toddlers and even in later life.
Dietary history reveals both proteins and calories inadequacy in diet in the recent past with
predominant lack of calories. The child looks like old person with wizened and shrivelled face due to loss of
buccal pad of fat.

The clinical features are subdivided into essential and nonessential features.

Essential features of nutritional marasmus

o Marked growth retardation with less than 60 percent of expected weight for age and subnormal
height/length.

o Gross wasting of muscle and subcutaneous tissue.

o Marked stunting and absence of edema.

o Nonessential features of nutritional marasmus

o Hair changes usually not present or may be hypopigmented.

o Skin looks dry, scaly with prominent loose folds and having reduced mid-upper arm circumference.

o Skin infections and diarrhea with vomiting and abdominal distention usually occur.

o Liver usually shrunk and the child is having craving for food and hunger.

o Psychomotor changes usually present with irritability, apathy and miserable appearance.

o Features of mineral deficiencies (anemia) and vitamin deficiencies are usually found.
 o Grading of nutritional marasmus is done depending upon the areas of loss of fat. Grade I is
considered when there is loss of fat from axilla, grade II for loss of fat from abdominal wall and
gluteal region, grade III for loss of fat from chest and back and grade IV for loss of buccal pad of fat.

Management:

Hospitalization:
Hospitalisation may be needed in advanced cases of PEM with infections and other complications.
 Children weighing less than 60 percent for age with oedema, severe dehydration, severe diarrhoea,
hypothermia, shock, infections, jaundice, bleeding, persistent loss of appetite and age less than one
year should be admitted and managed in the hospital. Children having severe wasting or oedematous
undernutrition also need hospitalization.
 The initial management in the hospital should be done with treatment of complications and metabolic
abnormalities along with correction of specific deficiencies and intensive feeding.
 Feeding should be started as early as possible. If oral feeding is not possible, nasogastric tube feeding
to be given. Frequent small amount feeding according to child's tolerance to be provided initially
with milk-based diet, then semisolid food items are given orally.
Calorie need:
 The diet should provide and contain high protein and high calorie. To begin with a daily intake of 80
to 100 kcal/kg/day for maintenance requirement, which need to be gradually increased to 150
kcal/kg/day of energy and 2 to 3 g/kg/day of proteins.
 Total amount of fluid intake should be within 100 to 125 mL/kg/day. Higher intake of protein is not
necessary, it is safer to obtain 10 to 15 percent of calories from dietary protein.
 Fat should be supplemented to make the food energy dense. Minerals and trace elements to be
supplemented but iron and vitamin 'B' complex are not useful in initial therapy.
 During initial management of one week, a child with kwashiorkor will lose weight and a marasmic
child gains little or nothing because the tissue gains are masked by excess body water loss.
 Emotional and physical stimulation and preparation for discharge along with training of mother for
home care are essential aspects. Recovery may take place in 6 to 8 weeks.

Discharge criteria:
 Discharge from hospital is planned when the child has achieved a weight about 85 to 90 percent of
the normal weight for height and complications are treated effectively.
 Mother should be provided with necessary information regarding continuation of nutritional support
at home along with regular medical check-up to prevent relapse and to promote adequate growth and
development.
 Necessary hygienic measures, immunization coverage and other routine care of the children to be
emphasized to the parents.

Complications and Prognosis of PEM

PEM has acute and long-term complications which influence the outcome.
 The acute complications are systemic or local infections, severe dehydration, shock,
dyselectrolytemia, hypoglycaemia, hypothermia, CCF, bleeding disorders, hepatic dysfunction,
sudden infant death syndrome (SIDS), convulsions etc.

 The long-term complications include cachexia, growth retardation, mental subnormality, visual
and learning disabilities.
Preventive Management of PEM:

There is no simple solution of the problem of PEM. Prevention of PEM needs various approaches from all
levels. Nutrition education is the high priority to prevent this problem. Other preventive measures include
the followings:

 Health Promotion: Improvement of health of prepregnant state, pregnant mother and lactating
women towards healthy mother for healthy child.

 Promotion of exclusive breastfeeding up to 4 to 6 months of age to prepare firm base of child health
and promotes nutritional status.

 Appropriate weaning practices and necessary nutritional supplementations.

 Improvement of family dietary habit with locally available, low-cost food items for balanced diets.

 Nutrition education and nutrition counselling to promote correct feeding practices, food habits, food
hygiene safe water, environmental sanitation and to eliminate misconceptions regarding food and
feedings.

 Improvement of home economics, earnings, income generating activities, adequate dietary budget
and diet planning for family members.

 Birth spacing and regulating family size.

 Promotion of educational status especially women literacy to improve the family health.

 Provision of nutritional supplementation from ICDS centres and schools (Mid-day meal).

 Maintenance of healthy family environment, congenial for physical, social and psychological
development of children.

 Specific Protection: Provision of balanced diet with adequate proteins and energy for all children
according to the age

 Immunization against vaccine preventable diseases

 Promotion and maintenance of hygienic measures (hand- washing, food hygiene)

 Food fortification to enrich the food items.

 Early Diagnosis and Treatment: Periodic health check-up of all children for health supervision and
maintenance of 'growth chart.

 Detection of growth lag or growth failure as early as possible.

  Early diagnosis and management of infections, worm infestations and common childhood illnesses
(ARI, diarrhea, measles, malaria).
 Promotion of early rehydration therapy in the child having diarrhea, without restriction of feeding.
 Implementation of supplementary feeding programs and services.

Roles and responsibilities:

 Regular identification/detection and referrals
 Monthly village health sanitation and nutrition day
 Biannual de- worming day, bi-annual vitamin-A supplementation rounds, etc., may also be utilized
for identification/detection of children with SAM.
 Manage Nutritional requirements of malnourished children at Anganwadi level. Maintain the list of
SAM children detected by her and maintain follow-up records. Ensure immediate referral of the
SAM children to the nearest health facility.
 Share the list of SAM children identified by her with ASHA and ANM within 2 days, to help in
timely medical evaluation and referral by ANM.
 Counsel the parents and caregivers of children.
 Administer vaccines as per immunization schedule according to the child’s age.
 Closely monitored: Number of new admissions each month Number of children referred

Role of Community

1. Panchayats:
The role of Panchayati Raj Institutions is very important for the success of nutritional Interventions. --
Awareness generation on the effects of malnutrition at the Poshan Panchayat platform can be the first
step.
Members of Panchayat Raj Institution (PRI) should be involved to motivate, mobilize community leaders.
Ensure the availability of clean and safe drinking water and toilet to the residents of the Gram Panchayat At
the grassroots level,
2. Buddy Mothers:
Buddy system between mother of a healthy child and mother of a malnourished child may be
introduced, enabling close and joint supervision and exchange of guidance between the buddy mothers
with respect to health of the malnourished child.

Conclusion:
Malnutrition is estimated to contribute to more than one third of all child deaths, although it is rarely listed
as the direct cause. At the global level, a science and technology initiative is required to solve the listed
problems such as increasing food prices, economic recession, increased competition for natural resources
and climate change. Diseases like cancer, HIV/AIDS, oral health and chronic renal failure also breakdown
the nutritional status. Bio fortification, probiotic foods and food processing strategies have shown the
potential to overcome the malnutrition.
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Publishers; 2015.
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