Failure to Thrive Evaluation

1. See Also
   1. Delayed Growth
   2. Failure to Thrive
   3. Failure to Thrive Causes
   4. Failure to Thrive Diagnosis
   5. Failure to Thrive Red Flags
   6. Failure to Thrive Management
2. 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 infant gestational age (<24 months)
      2. 35% of Small for Gestational Age infants <5% at age 4
3. 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
4. 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 (e.g. Milk, juice, water, 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
5. 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. Alcohol Abuse or Drug Abuse
      8. Consider physical, psychological or marital problems
6. History: Past Medical
   1. Birth: Gestational age, birth weight, complications
   2. Chronic medical conditions (e.g. Anemia, Asthma)
   3. Acute illness (Otitis Media, Gastroenteritis)
7. History: Family
   1. Short Stature
   2. Failure to Thrive in siblings
   3. Mental illness
8. 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 10-14 day observation in hospital
9. 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
10. Exam: Complete Physical
    1. Decrease in skin fold thickness and Subcutaneous fat
       1. Suggests malnutrition
    2. Dysmorphic features in Congenital Dysorders
    3. Focus on evaluation for Failure to Thrive Red Flags
    4. Identify findings suggestive of physical abuse or neglect
11. 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
    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
12. Imaging
    1. Skeletal XRay of hands and wrist for bone age