FAILURE TO THRIVE
What do we mean by ‘thrive’?
Old Norse thrïfask ~to grasp for oneself
Dictionary ~ to be successful, to grow strongly
In our context ~ implies acceptable size for age ,
rate of growth and activity
How to recognise failure to thrive?
Evidence of growth failure
Weight and height for age…Simplest way to assess?
Reduced growth velocity…How can you estimate
this?
Other evidence of failure to thrive?... Play, affect,
possibly developmental delay
Centiles, percentages, & SD score
applied to weight for age
Mean
SDS=0.0
SDS= - 2.0 SDS = +2.0
50th centile
3rd centile 97th centile
Reference mean ~
Wt // age ~ 80% of ‘standard’ or 100 % Wt // age ~ 120% of
reference mean reference mean
Child health record: the under-fives or road to health
clinic card ( permits study of growth faltering)
weight chart for children (sexes combined) up to 36 months showing trends
for 100%, 80% & 60% of reference weight for age
16
15
14
13
12
11
10
wei8ght in kg
9
8
7
6
5
4
3
2
1
0
0 3 6 9 12 15 18 21 24 27 30 33 36 mean
80%
age in months 60%
Road to Health chart
Continuous record allows
assessment of faltering in weight
gain, even when actual weight
is within ‘normal’ range
Causes of failure to thrive
Organic causes:-
Systemic disease which might result in:-
Nutritional deficiency which might result in:-
Infection recurrent or severe +/- immune deficit ~
HIV
Non organic causes :-
Psychosocial ; may be associated with some form of
neglect or abuse. ( see literature or local example: orphans in care
homes or unaccepted by extended family )
Failure to thrive ~ failure of nutrient
intake to meet metabolic requirements
1. Deficiency of supply of macro- or micro-nutrients
2. Inefficient digestion /absorption
3. Increased metabolic demands due to infection
4. Increased metabolic demands due to e.g. inefficient
work of a diseased heart or lungs or disruption due
to other organ disease e.g. of kidneys, CNS,
5. Disruption of metabolism due to inborn metabolic
error, chromosomal abnormality etc.
6. Non-organic ( f to t) ~ undernutrition ~
psychosocial problem
Characteristics of Systemic diseases
associated with failure to thrive
Long standing , often gradual onset or present
from birth.
Obvious cause ; a condition interfering with
nutritional intake OR affecting metabolism in a
major way, or increasing the work needed for
normal activities?
Occult cause e.g. a condition affecting growth &
metabolism , which remains relatively ‘silent’ or
symptom free ?
Examples
Chronic gut parasitosis (from giardia L, to tape worm ) , or
gut allergy e.g. to gluten ( in susceptibles in wheat eating
populations or to cow milk protein ; identified in some
DCs)
Congenital ( acyanotic) heart disease
Chronic renal insufficiency; may ~ polyuria (+/- raised
urea or other abnormal biochemistry in blood or urine)
Lung disease e.g. poorly controlled asthma, or cystic
fibrosis
Gut : anatomical problem e.g. reflux, Hirschsprung’s etc.
Endocrine or Degenerative CNS disease: in latter child may
progress OK until storage affects neurological & cognitive
development.
Failure to thrive ~ underfeeding i.e. is due to
& PEM +/- micronutrient deficiency
Diagnosis is usually accessible via history
NB: check recent change eating behaviour re:
infection
1. PEM ;- of which stunting and underweight are
commonest presentations
2. Micronutrient deficiency ;- zinc deficiency often
underestimated, & Iodine deficiency
geographically determined.
3. Recurrent infections ~ PEM (vicious cycle)
Infections
HIV etc.
Tuberculosis
Other (much less common) immune
deficiencies resulting in recurrent infection
Anthropometric indicators
GROWTH :- weight and length or height for
age
WASTING:-weight for length or for height
COMBINED STUNTING & WASTING :-
cross - tabulation of wt // ht by ht // age
BMI (wt / ht 2 ), not used commonly in this
context
When is failure to thrive not due to PEM and ~
poverty and recurrent or severe infection
History is important : plus recognition of
atypical home or socioeconomic background.
Search for evidence -> CVS, lung, renal or
developmental problem.
You will of course be considering HIV status.
Do basic investigations if possible :- renal & liver
biochemistry; think about child’s psychosocial
affect.
Emotional & behavioural signs of
importance
1. Attention seeking : e.g. in an orphanage & often
misunderstood by visiting professionals
2. Atypical in level of activity & speech either e.g. noisy,
restless, destructive, demanding or apathetic, wary, flat
affect, detached , depressed, silent or poor language (may
or may not be evidence of regression in language or in
major motor milestones )
Carers’ behaviour:- poor interaction or ‘trying to impress’
care activities. NB: watch interaction during feeding. child
may fear (hot) food.
When marginal undernutrition is exacerbated by
coexisting systemic illness, there are grave implications for
morbidity & outcome .
Failure to thrive in our context
We expect that much failure to thrive is due to PEM
in all its complexity.
Where there is marginal food security ; PEM may
be exacerbated by coexisting systemic disease.
In ‘well to do’ families unexpected F to T needs
checking.
BUT new stresses and societal changes bring new
risks of e.g. non organic failure to thrive.
