FAILURE TO

THRIVE

Learning outcomes
Identify normal growth pattern in an infant
Define and discuss the causes of failure to thrive
in an infant
Demonstrate the importance of a feeding history
Explain the principles of infant nutrition
Plot and interpret the growth parameters on a
growth chart
Describe the nutritional requirements of normal
growth
Formulate the approach to management of a child
with failure to thrive

HISTORY TAKING

Chief complaint
Patient M, a 10 month old girl
presented to HKL with
- Fever
- Cough

3 days

History of presenting illness

Fever
- intermittent but no documented
temperature
- no chills and rigors
Cough
- sharp, dry cough
- worsening for the past 3 days
- no post-tussive vomiting
- no paroxysmal cough
- no facial congestion

 There had been previous similar episodes,

occurring almost once every month since birth.
All relieved by syrup Paracetamol (PCM) .
Current episode, cough was more severe and
PCM did not relief the fever.
There was no rapid breathing noted by the carer.
Has history with sick contact
No history of travelling

Past medical history

VSD diagnosed at Hospital Ampang Putri 3 months ago.
Currently under HKL pediatric cardiology follow up

Past surgical history

Nil

Allergic history
Allergic to formula milk rashes

Birth history
Born in Klinik Mesra, Gombak
Delivered at term with birth weight of
2.6kg
No NNJ
No NICU admission
*perinatal history incomplete as
patient was an orphan

Diet history
Had a history of feeding difficulties since birth.
- Reduced milk intake since birth (3 oz 2 hourly)
- Takes longer time to finish her milk ( up to 1
hour)
- Associated with sweating

- Reduction in milk intake for the past 2 months

1. 3oz 2oz (1 hour)
2. Perioral cyanosis
3. Rapid breathing
4. Sweating

 Exclusive breastfeeding up to 1
month old.
Took formula milk since then.
Developed allergies (rashes) but no
diarrhea or vomiting
Changed to Isomil at 3 months old
after consulting physician at Hospital
Ampang.

 Isomil milk was prepared by her

carer. 1 spoon in 2 oz of water.
Feeding was done every 2 hours
Took up to 10 bottles daily
Maximum intake per feeding was 4
oz (in 2 hours)
Weaning at 6 months porridge,
crushed meat and eggs.

 Patient tried to drink the milk but there

was always difficulty finishing the milk
rapid breathing and cyanosis.
Carer did try to get the patient to drink.
Patient refused after a few times by
pushing away the feeding bottle.
Carer noticed patient did not gain weight
for the past 1 month and was less active.
There was no history of diarrhea,
abdominal distention or vomiting
PU and BO were normal

Drug history
Syrup Furosemide ( 7 mg tds )
Syrup Spironolactone ( 6.25 mg )
Syrup Captopril ( 0.6 mg tds )

Family history
23 y/o
Indonesian

Patient M,
10 months old

Immunization history

Completed up to date
No post-immunization complications

Social history
Stays in rumah kebajikan Nur Hidayah
Mother passed over care of child to
centre after patient was 1 month old.
Mother currently not staying in
Malaysia
Father could not be traced either.
No financial restrains in caring for the

Developmental history
Components

Actions

Gross motor

Rise to sitting from supine

Stands alone for a few seconds
Pulls to stand and goes down
holding to support
Crawling

Fine motor and vision

Attentive to people
Mature pincer grasp
Able to find partially hidden toy
Object permanence
Watches falling toy in field of
vision

DEVELOPMEN
TAL AGE :
Hearing
and speech
10
MONTHS Shouts for attention

Responds to own name

Babbles tunefully
Understands bye bye
Imitates adult facial expression

Social behavior

Plays peek-a-boo

PHYSICAL
EXAMINATION

General Examination
Alert & active, pink, no dysmorphic features, not in respiratory
distress
Cyanosed during crying but no peripheral cyanosis
No clubbing, leuconychia, palmar erythema, bruises, rash
No conjunctival pallor or jaundice
Hydration status was fair
No muscle wasting
No pitting oedema
Pulse rate: 142 beats/min, good volume, normal rhythm, no
radial-radial and radial-femoral delay
Respiratory rate: 32 breaths/min
Blood pressure: 104/50 mmHg
Temperature: 36.5 C
length: 68cm (25th centile)
Weight: 6.7kg (3rd centile)
Head circumference: 43cm (25th centile)

Cardiovascular Examination
No scar or chest deformity
Apex beat is palpable at 5th intercostal space on the left midclavicular line. displaced
There is a palpable thrill at left sternal edge
No parasternal heave
1st and 2nd heart sounds were heard
Pansystolic murmur at left sternal edge, radiation to the right
sternal border, Grade 4/6

Respiratory Examination
No scar, prominent vein, no chest deformity (pectus
excavatum, pectus carinatum)
No intercostal or subcostal recession
Cervical lymph nodes were not palpable
Apex beat was displaced
There was good air entry bilaterally. Vesicular breath
sounds, no added sounds.

Abdominal examination
Abdomen was not distended, soft, non-tender, moves with
respiration
No scar, dilated vein, swelling
Umbilicus was centrally located, inverted
No hepatosplenomegaly
Kidney is not ballotable
Bowel sound is heard, normal tone

Neurological Examination
Peripheral nervous system was intact
All cranial nerves were intact

INVESTIGATION
Chest radiology
Cardiomegaly
Hyperinflated chest with perihilar haziness

Echocardiography
Peri-membranous ventricular septal defect (+
3mm)

Clinical summary
Patient M, a 10 month old girl with a history of recurrent
chest infections, presented with intermittent fever
unresolved with syrup PCM, associated with a sharp, dry
cough for 3 days. Diagnosed with having VSD 3 months
ago. She had poor feeding since birth which
deteriorated for the past 2 months. During feeding,
there was perioral cyanosis, sweating, rapid breathing
.
On examination, the apex beat is displaced. There was a
pansystolic murmur graded 4/6 best heard at the left
sternal edge which did not radiate.
Echocardiogram showed a peri-membranous ventricular
septal defect

Provisional diagnosis
Ventricular Septum Detect, currently
in failure, with acute bronchiolitis

MANAGEMENT
Problem :
1.Feeding difficulties
2.Recurrent chest infection
3.VSD in failure

1. Feeding difficulties
Review by the dietitians :
Energy needed : 150 kcal / kg / day
Protein needed : 4 mg / kg / day
Advice carer on high protein and high calorie diet.
To increase high milk dilution in view of patient not taking
much (small volume/feed).
- (1 and half scoops of Isomil in 2 oz / 2 hours x 10 bottles
per day)
To add potato/ pumpkin in porridge daily
- Rice porridge (1 cup per meal ) for lunch and dinner +
chicken/ fish ( 1 matchbox size/ day) + vegetables +
potato/pumpkin (1 exchange/ day) + oil (1 tablespoon/
meal)
To encourage intake of biscuits / bun as tolerated.

2. Recurrent chest infection

Supportive treatment (home)
Make sure patient was well hydrated.
Tepid sponging if fever.

Prevention
Avoid over crowding.
Avoid contact with the infected person.

3. VSD in failure
Syrup Furosemide ( 7 mg tds )
Syrup Spironolactone ( 6.25 mg )
Syrup Captopril ( 0.6 mg tds )

IDENTIFY NORMAL
GROWTH PATTERN IN
AN INFANT

Normal growth is the progression of changes in

height, weight, and head circumference that are
compatible with established standards.
Normal growth is a reflection of overall health and
nutritional status.
Understanding the normal patterns of growth enables
the early detection of pathologic deviations (eg, poor
weight gain due to a metabolic disorder, short stature
due to inflammatory bowel disease) and can prevent
the unnecessary evaluation of children with acceptable
normal variations in growth
Benchmarks used to evaluate normal growth:
Weight
Length/height
Head circumference (HC)

WEIGHT
Newborn normally will lose 10-15% of their birth weight due
to:
I. Excretion of excess extravascular fluid
II. Possibly poor intake (intake improves as colostrum is
replaced by higher fat milk, as infant learn to latch on and
suck more efficiently, and as mother become more
comfortable with geeding technique)
.
.
.

Babies usually regain their birth weight by the 7-10th day

Double birth weight by 5 month age
Triple birth weight by 1 year of age

. Weight gain :
0-3 months - 1.0 kg/month
3-6 months - 0.5 kg/month
6-9 months - 0.33kg/month

HEAD CIRCUMFERENCE
At Birth AGE

13.5 inches (35 cm)

GROWTH IN HEAD CIRCUMFERENCE

( cm/mo)

0-3 mo

2.00

3-6 mo

1.00

6-9 mo

0.50

9-12 mo

0.50

1-3 yr

0.25

4-6

1cm/yr

LENGTH
Preterm infants = average 0.81.0cm/week.
Term infants
= average 0.69Age
Length
0.75cm/week.
Birth
50cm
6 months

68cm

1 year

75cm

3 years

90cm

4 years

Double birth length

(100cm)

5 12 years

5 cm yearly

HOW TO PLOT GROWTH

PARAMETERS ON A
GROWTH CHARTS

WHO GROWTH CHART RECOMMENDED CUT OFF CRITERIA

INDICATORS FOR FURTHER ASSESSMENT

INTERPRET GROWTH
PARAMETERS ON A
GROWTH CHART

Growth chart (patient)

 Length in our patient:

-25th centile at birth
- Increase to between 25th and
50th centile at 3rd months of life
- Constantly between 25th and
50th centile till 10 months of life.
Her length is equivalent and
appropriate to the age.

 Weight
10th centile at birth till 1 month
Drop to between 3rd to 10th centile for the
next 2 months
On the 3rd centile during 6th month of life
Below 3rd centile during 9th and 10th
month of life

Thus there is failure to thrive.

DEFINE AND DISCUSS

THE CAUSES OF
FAILURE TO THRIVE IN
AN INFANT

DEFINITION

Given to malnourished
infants & young
children who fail to
meet expected
standards of growth :
Fails to gains weight /
length / head size /
development.

Related to organic,
environment and
psychosocial causes.
Nelson, essential of Peadiatrics, 6th edition.

DEFINITION
Suboptimal weight gain in infants and
toddlers
Inadequate weight gain when plotted on a
centile chart
Mild FTT Fall across 2 centile lines
Severe FTT Fall across 3 centile lines
Illustrated textbook of peadiatrics, 4th
edition

DIAGNOSED BY:

Weight that falls or remains below the

third percentile for age
OR
Weight that decreases, crossing two
major percentile lines on the growth
chart over time
OR
Weight that is less than 80% of the
median weight for the height of the
Nelson, essential of Peadiatrics, 6 edition
child
th

CAUSES OF FAILURE TO THRIVE

Gastrointesti
nal (GIT)

Infections

Neurologic

Congenital /
anatomic

Metabolic

Renal

Environment
al

GASTROINTESTINAL CAUSES
GERD
Malabsorption syndromes
Celiac disease
Pancreatic insufficiency (cystic fibrosis)
Hepatobiliary causes (biliary atresia)
Hirshprung disease

Leads to inadequate nutrient absorption.

INFECTIONS
Parasitic infections
URTI (pharyngitis, tonsillitis, otitis media, etc.)
UTI
Sinusitis
HIV/ immune deficiency

Inadequate nutrient intake as well as increase

nutrient requirement

NEUROLOGICAL
1. Cerebral palsy
2. Neuromuscular disease
3. Degenerative and storage disease

1. Inadequate nutrient intake due to

swallowing dysfunction.
2. Defective utilization of nutrients
(glycogen/lipid)

Congenital causes
Chromosoma
l disorder
Down
Syndrome

(Intrauterine
growth
restriction)
IUGR

Congenital
infection

Extreme
prematurity

Cleft palate

Metabolic causes
Congenital hypothyrodism
Storage disorder
Amino and organic acid disorder

Renal cause
Chronic renal failure

Non- organic/environmental
Inadequate
Feeding problems

availability
of food
insufficient breast
milk or poor
technique,
incorrect
preparation of
formula

Infant difficult to
feed resist
feeding or
disinterested

Insufficient of
unsuitable food
offered

Lack of regular
feeding times

Conflict over
feeding,
intolerance of
normal feeding
behaviour

Cooking problem
and famine

Low
socioeconomic
status

Poor
maternalinfant
interaction

Psychosocial
deprivation
Maternal
depression

Poor
maternal
education

Neglect or child
abuse
Includes factitious illness
deliberate
underfeeding to
generate failure to thrive

DEMONSTRATE THE
IMPORTANCE OF A
FEEDING HISTORY

The importance of a feeding

history

To know the current nutritional intake

To provide the better look at correlating the
infants development with the types of food
offered.
To assess the adequacy of nutritional intake
for growth.
To screen for undernutrition or nutritional
deficiency.
To detect the causes of undernutrition and
exclude other causes of FTT
Planning of management

Feeding history
Types of
feeding :

Breastfeeding
Formula feeding
Weaning

Breastfeeding history
History

Comments

1. Ask if the baby is

breast fed or bottled fed

Full term newborn babies can obtain all the

nutritional needs from breast milk in their
first 4-6 months (only breastmilk can supply
the secretory Ig A, lactoferrin, peroxidase,
lysozyme).

2. The duration of
exclusive breastfeeding
and mixed breastfeeding

Exclusive breastfeeding reduces infant

mortality due to common childhood
illnesses such as diarrhoea or pneumonia,
and helps for a quicker recovery during
illness.

3. Frequency per day

Demand or timed
Well term babies should be given breast
feed on demand. (usually 8-12 times/day)

4. Strength of sucking

Good sucking reflex means that the baby is

well. Otherwise baby may be too weak to
suck.

5. Any difficulty in
breastfeeding

The common reasons to quit breastfeeding

are:
Low milk production

Formula feeding history

History
1. Type of formula

Comments
Infant, special, soy formula

2. The amount and frequency of 1 oz= 30mls

The milk requirement
milk intake
Day 1: 60mls/kg/day
Day 2-3: 90mls/kg/day
Day 4-6: 120mls/kg/day
Day 7 onwards: 150mls/kg/day

3. Preparation of feeds and

hygiene

Bottle sterilization, water source

4. Who feeds the baby

Placement of the infant for feeding

Weaning
History

Comments

1. Ask about weaning

and when did the
weaning start.

Food is needed after 6 months of age in

addition to milk to satisfy the increasing
energy demands of the infant.
However, babies should not be started on
foods other than milk before they are 4
months old as their kidneys and digestive
system are not fully developed.

2. The types of solid

food introduced

Normally cereals are introduced and mix

with food such as stewed fruits, mashed
banana and pumpkin.
Gradually, at around 8 months, an eating
pattern of 3 meals a day should emerge.
The type and quantity of food taken for
breakfast, lunch and dinner should be
obtained to quantify total calorie intake.

3. Ask about the feeding

pattern (Abnormal
feeding pattern can
cause malnutrition)

Refusal (selective to mode of feeding or to

a specific parent or selective for some
types of food)
Fixation (willingness to ingest only 1 type

EXPLAIN THE
PRINCIPLES OF
INFANT NUTRITION

Calorie requirement:
Term infants : 110 kcal/ kg/ day
Preterm infants : 120-140 kcal/
kg/ day
WHO recommends the following:
1. Exclusive breastfeeding for the first six months
of life to achieve optimal growth, development
and health
2. Infants should receive nutritionally adequate
and safe complementary foods while
breastfeeding continues for up to two years of age
or beyond.

Types of feeding
1. Breastfeeding exclusive (0-6 months)
-Milk of choice
-Term healthy infants should be breast fed asap within the first
hour.
- Human Milk Fortifier (HMF)
*add to expressed breast milk in babies < 32 weeks or <
1500g.
*give extra calories, vitamins, calcium and phosphate
2. Formula feeding(modified cows milk)
- Only be given if there is no supply of breast milk
- Unmodified cows milk
*unsuitable
*too much protein and electrolytes
*inadequate iron and vitamins
a)Preterm Formula : for babies born <32 weeks or < 1500g
b)Normal Infant Formula
: For babies born >31 weeks or >
1500g
3. Specialised infant formula
- Cows milk-based formulas
- Soy formulas

Complementary Food and Weaning

1. Complementary feeding of semisolid food is recommended by approximately 6
months as exclusively breastfed infants require additional protein, iron and zinc.
2. Relatively high-fat and calorically dense diet is needed to deliver adequate
calories due to increased activity.
3. General signs of readiness for weaning:
- holds head and sit unassisted
- brings objects to mouth
- shows interest in food
- able to track spoon and open the mouth
4. Examples:
- Vitamin-fortified and iron-fortified dry cereal
- Mixed cereals (oat, corn, wheat and soy) provide greater variety to older
infants
- Juice (in cup and limited to 4 oz daily)
5. Honey should not be given before 1-2 years of age (risk of infantile botulism)

DESCRIBE THE
NUTRITIONAL
REQUIREMENTS FOR
CHILDREN

INTRODUCTION
1. Nutrient needs determined by:
Body size
Growth rate
Age

2. A childs requirement is higher than an

adults.
3. Nutritional deficiency are more
commonly seen in infancy as young
children have fewer body reserves of
all nutrients.

Source: National Coordinating Committee on Food and Nutrition

(2005)

Recommended Nutrient Intake (RNI)

1. RNI for children do not differ for boys
and girls except for energy.
2. All RNI values has a margin of safety
except for energy
3. RNI for most nutrients is higher than
physiological needs of most children.
4. If nutrient intake of a child less than
RNI, it does not necessarily mean child
has nutritional problem.

Nutrient Recommendations
Based on Malaysian Dietary
Guideline (MDG) 2010:
Key message 12:
Practice exclusively breastfeeding
from birth until six months and
continue to breastfeed until two
years of age.

Key recommendations:

Prepare for breastfeeding during pregnancy

Initiate breastfeeding within one hour of birth
Breastfeed frequently and on demand
Give only breast milk to baby below six months with no
additional fluid or food
Continues to give babies breast milk even if baby is not
with the mother
Introduce complementary foods to baby beginning at six
months of age
Lactating mothers should get plenty of rest, adequate
food and drink to maintain health
Husbands and family members should provide full support
to lactating mothers

Cereal Products and Tubers group

Fruits

Vegetables

Fish, Poultry, Meat and Egg

Fish, Poultry, Meat and

Egg(2)

Milk

FORMULATE THE APPROACH TO MANAGEMENT

OF A CHILD WITH FAILURE TO THRIVE

Calories required for catch-up

Children with failure to thrive require
150% of Recommended Daily
Requirement of calories
Schedule: Replacement calories
needed per day for malnourished and
catabolic infant
Age 0-6 months:
130-150 KCal/kg/day (high)
150-220 KCal/kg/day (very high)

ORGANIC FAILURE TO
THRIVE

Treat underlying medical

condition
Caloric supplementation

Depend on severity and underlying

medical problems.
The responds depends on : (Specific
diagnosis, medical management,
severity of the failure to thrive.)

Monitor amount of protein

In children with renal failure

NON ORGANIC FAILURE TO THRIVE

Home visit
- By health visitor
- Assess eating
behavior
- Provide support

Speech & language

therapist
- Feeding disorder
therapy

Direct practical
advice following
observation

Paeds dietician
- Assess quantity &
composition of food
intake
- Recommend
strategies to increase
E intake

Clinical psychologist
& social services

Nursery placement
- Alleviate stress at
home
- Assist feeding

Solid food -> liquid

Environmental distraction minimized
Eat with other people
Not force-fed
Rule of 3 : 3 meals, 3 snacks, 3 choices

Limit intake of :
water
juice
Emphasize intake of : highcalorie foods
soda
peanut butter (??)
low-calorie
beverages
whole milk
cheese
dried foods
High-calorie liquids :
High-calorie
supplementation Carnation Instant
breakfast with whole
:
milk
Duocal
Formulas containing
Polycose
>20cal/oz Pediasure,

THANK YOU!