So you see a child with
failure to thrive.
There’s this enormous list of
things that this might be.
What do you do to try and parse down
what is the problem in these children?
First is, as always, take a good history.
So it’s critical to get a good
perinatal and prenatal history
so you can understand whether
this child has problem
that are rendering
them unable to grow.
An example would be did they sustain a
TORCH infection or a congenital infection
that’s resulting in having
a difficulty with growing.
Obviously in the history, we need a
growth and developmental history.
We need to get all those
growth chart points
and find out when exactly this
child stopped growing and why
because that may give us
clues as to etiology.
And critical is understanding what
is this child’s dietary habits.
How often do they feed?
How much do they feed?
What do they feed upon?
These are all critical elements
of the dietary history.
A review of systems is important because
like we showed in previous slides,
there are so many different
diseases that this could be
that fully understanding everything that’s
going on with these children is a key
to developing a clue as
to what the problem is.
Family history is important because many
of these conditions are inherited.
And so we may get a clue
as to what’s going on.
And lastly, and this is most
important, psychosocial factors.
Remember, child neglect is the number one
cause of failure to thrive in infants
and understanding how the parents
relate to their child is important.
Many parents who aren’t
relating well to their child
will be reluctant to discuss
this with the doctor
for fear of being turned in for
child abuse or child neglect.
So asking unobtrusive and not very invasive
questions that get at this is important.
Questions like, “How is your baby to get
along with?” can be very revealing.
Next, we do a thorough physical exam.
Do a thorough physical
exam that’s going to get
at one of these underlying
And remember things like
may be a clue to a malnutrition problem.
For example, if a patient has signs and
symptoms of a fat soluble vitamin deficiency,
that a clue that they’re having
a problem with absorption.
Next, we sometimes get labs in
these kids, but not always.
And let me just me pause right here
and discuss what we typically do.
So oftentimes in these children,
because psychosocial reasons are so common
for infants with failure to thrive,
we will admit the child to the
hospital with no labs whatsoever,
do a thorough history and physical exam.
And if nothing’s obvious,
we will watch them in-house
and simply feed the child and watch
them grow and get daily weights.
If the infant is gaining
weight in the hospital
it’s a great clue that there
is not an organic problem
fuelling this child’s
inability to gain weight.
But if a child is not gaining
weight in a supervised setting,
then we might have to worry about
what else could be going on
and we start obtaining labs.
We might get a CBC
to look for anemia,
we would get serum electrolytes to look
for chronic acidosis or some other cause.
Renal tubular acidosis is an unusual
cause of failure thrive in some infants.
We might check renal or hepatic functions
on labs, LFTs, the BUN and creatinine
to get a sense of whether
there’s some organic failure
that is underpinning
this failure to thrive.
And remember, chronic
infections are a cause
and if you had to choose one infection
that can go below the radar,
it’s the urinary tract infection.
So often, we’ll check a
urinalysis and a urine culture.
Sed rate and CRP is helpful
for understanding if there’s
an underlying problem such
as cancer or infection.
The tTG is our clue to celiac disease.
And we’ll get an IgA level
with that to make sure
that it’s not artificially
low from the low IgA level.
And then also, rarely, we’ll worry about
the hormones that are driving growth.
One thing that people sometimes
forget during the first year of life,
the primary hormone responsible
for growth is not growth hormone.
During the first year of life, the
primary hormone is the thyroid hormone.
And after that, the growth
hormone takes over.
So in infants under a year of age, thyroid
hormone is our first thing we go for
and in older children who
have stopped growing,
we worry about growth hormone deficiency.