II. Evaluation: Step 1 - Review Growth Patterns

  1. See Growth Assessment
  2. See Height Measurement in Children
  3. See Weight Measurement in Children
  4. Head Circumference
  5. Expected Weight gain (g/day)
    1. Age 0 to 3 months: 26-31 grams weight gained per day
    2. Age 3 to 9 months: 13-18 grams weight gained per day
    3. Age 9 to 14 months: 10-11 grams weight per day
    4. Age 15 to 24 months: 7-9 grams weight per day
  6. Plot weight, height and Head Circumference
    1. Correct Premature InfantGestational age (<24 months)
    2. 35% of Small for Gestational Age infants <5% at age 4

III. Evaluation: Step 2- Determine if Failure to Thrive is present and to what degree

  1. See Failure to Thrive Diagnosis
  2. See Failure to Thrive Red Flags
  3. Evaluation below is in light of distinguishing Failure to Thrive Causes

IV. History: Nutrition

  1. Dietary intake
    1. Consider detailed 1-3 day diary of dietary intake
    2. Quality and Quantity of food
    3. Does the child feed themself (e.g. spoon, cup)
    4. Psychosocial events around feeding time
      1. Is the child distracted or not supervised?
      2. Are there food battles or food refusal?
    5. Discuss food preparation (e.g. formula too dilute)
    6. Beverages
      1. Milk amounts (excessive?)
      2. Nonnutritive drinks such as juice soda
  2. Stool habits (e.g. frequency and consistency)
  3. Consider dietary or nutrition Consultation
  4. Pica history
  5. Nursing or Breast Feeding history
    1. Infequent brief feedings
    2. Maternal ingestion of milk suppressant
      1. Alcohol
      2. Diuretics
    3. Inadequate milk supply
    4. Nipple problems
    5. Inadequate milk let down
    6. Poor suck
    7. Maternal malnutrition
    8. Maternal exhaustion or Major Depression

V. History: Social

  1. Interference with adequate caretaking
  2. Risk factors
    1. Economic stress
    2. Disorganized family
    3. Social isolation
    4. Parental depression
    5. History of parent loss
    6. Overworked parent
    7. Parental Alcohol Abuse or Drug Abuse
    8. Intimate Partner Violence or other abuse
    9. Consider physical, psychological or marital problems
    10. Restricted home diet due to health, cultural, religious or nutritional beliefs

VI. History: Past Medical

  1. Birth
    1. Gestational age <37 weeks
    2. Low birth weight (<2500 g or <5 lb 8 oz)
    3. Complications
  2. Congenital anomalies
    1. Autism
    2. Developmental Delay
    3. Cerebral Palsy
    4. Trisomy 21
  3. Chronic medical conditions
    1. Anemia
    2. Asthma
    3. Gastroesophageal Reflux disease
    4. Poor Oral Health or Dentition
  4. Acute illness
    1. Otitis Media
    2. Gastroenteritis

VII. History: Family

  1. Short Stature
  2. Failure to Thrive in siblings
  3. Mental illness

VIII. Exam: Observe interaction between parent and child

  1. Feeding and non-feeding times
  2. Decreased, inconsistent, or nonmutual interactions
  3. Maladaptive parent-child feeding interactions
  4. Consider observation in hospital with multispecialty evaluation

IX. Exam: Assess for Developmental Delay

  1. Gross Motor function from neuromuscular weakness
  2. Social skills and Expressive Language
    1. Gaze avoidance
    2. Minimal smiling
    3. Non-responsive to people
    4. Inappropriately friendly to strangers
    5. Bizarre behavior
    6. Apathy
    7. Poor hygiene

X. Exam: Complete Physical

  1. Decrease in skin fold thickness and Subcutaneous fat
    1. Suggests malnutrition
  2. Dysmorphic features in Congenital Dysorders
  3. Identify findings suggestive of physical abuse or neglect
    1. Observe for parent-child interactions
  4. Focus on evaluation for Failure to Thrive Red Flags
    1. Cacchexia
      1. Malignancy
      2. Type I Diabetes
    2. Cognitive deficits
      1. Developmental Delay
    3. Heart Murmur
      1. Congenital Heart Disease
    4. Hepatomegaly
      1. Chronic illness, infection or malnutrition
    5. Edema
      1. Renal or hepatic disease

XI. Labs

  1. Indications
    1. Failure to Thrive Red Flags are present
    2. Refractory course despite adequate caloric replacement
  2. Efficacy
    1. Normal in 98% of Failure to Thrive
      1. Consider obtaining only if no improvement
      2. Sills (1978) Am J Dis Child 132:967-9 [PubMed]
  3. Initial labs
    1. Urinalysis and Urine Culture
    2. Serum Comprehensive Metabolic Panel (electrolytes, Renal Function tests, Liver Function Tests)
    3. Complete Blood Count
    4. Thyroid Function Tests
    5. Erythrocyte Sedimentation Rate (ESR) or C-Reactive Protein (C-RP)
  4. Specific Labs if indicated by history and physical
    1. Stool for fat content
    2. Stool for Ova and Parasites
    3. Serum complement levels
    4. Immunoglobulin levels
    5. Serum Calcium
    6. Seum Phosphate
    7. Serum Albumin
    8. Beta Carotene
    9. Echocardiogram
    10. HIV Test
    11. Hepatitis B Surface Antigen
    12. PPD or Tb Quantiferon
    13. Cystic Fibrosis testing (if not done with Newborn Screen)

XII. Imaging

  1. Skeletal XRay of hands and wrist for Bone Age

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