Although failure to thrive (FTT) is a relatively common presentation in the emergency department, many emergency clinicians are unsure of how to properly work up a pediatric patient with this condition. Obtaining a thorough history and physical examination will likely reveal the cause of FTT. Although most laboratory testing has low diagnostic yield, they may be indicated in certain circumstances. Radiologic testing is normally not indicated unless the history or physical examination point to a specific etiology. This issue reviews the etiology, pathophysiology, and management of patients with FTT, with the goal of improving outcomes while minimizing unnecessary testing, decreasing cost, and expediting emergency department care.
Your first patient is a previously healthy, vaccinated 6-month-old boy who presents with poor weight gain. The child has been seen by his primary care provider multiple times within the last several weeks, and the mother is very concerned because he has not shown any improvement. The child was born at term via spontaneous vaginal delivery, did not spend any time in the NICU, and has been well. Despite this, in the past 2 months, the patient has gone from the fiftieth percentile on his growth curve to less than the thirtieth percentile. The patient has not had any vomiting or diarrhea and has been urinating and moving his bowels normally. On physical examination, he is smaller than expected, but otherwise his vital signs are unremarkable, as is the remainder of his physical examination. You inform the family you are going to review his chart, and as you leave the room, you wonder what is going on with this patient. Could it be a metabolic or cardiac abnormality? Is it a problem with the gastrointestinal or respiratory system? What if this is a manifestation of neglect? What tests should you order for the patient? Should you be starting him on IV fluids? Should this patient be admitted to the hospital or discharged home? Do you need to call social work?
Before you can begin to formulate a plan for your first patient, you are presented with another case. The patient is a previously healthy 2-month-old girl who was brought in by her mother, who is in tears. This is the mother's first child. The girl was born full-term via normal spontaneous vaginal delivery without any complications. The mother had limited prenatal care, as she didn’t know she was pregnant. The mother reports that the baby has had all of her regular well-child checks and no issues were noted, but the girl has not gained weight in over a month and she has not been able to get her in to see her PCP. The mother says that bottle feedings are not going as well as they used to, and the baby now takes close to an hour to finish a 3-ounce bottle. The mother is unable to provide any further history, and the examination shows no focal findings. Reviewing the patient’s growth chart, you see that she’s fallen below 2 major percentile lines. You wonder where you should start with your workup… What is the most likely diagnosis? How do you manage and disposition this patient safely?
Failure to thrive (FTT) is a fairly common complaint in emergency medicine, accounting for approximately 1% to 5% of admissions for patients aged < 2 years.1 Total prevalence is likely higher, given that FTT is commonly dealt with by primary care providers in the outpatient setting. Additionally, studies have shown that FTT may often go unrecognized.2 Traditionally, FTT has been considered an ailment that tends to disproportionately affect those in lower socioeconomic classes or in rural communities.3 However, newer research suggests that slow weight gain at an early age is associated with short parental height rather than parental occupation and educational level.4
Although there is not an exact definition for FTT, several criteria are used to identify patients with FTT, with some being more pertinent to the emergency setting than others. Definitions of FTT, such as weight deceleration crossing more than 2 percentile lines, weight for chronological age below the fifth percentile, and length for chronological age below the fifth percentile,5 are definitions that can be applied in the ED setting.
Organic FTT results from an identifiable medical source, whereas nonorganic FTT results from social factors and other unidentifiable medical causes. Up to 90% of cases of FTT have no identifiable cause and are categorized as nonorganic.6 Though less common than nonorganic causes, organic causes of FTT are many, and include cardiovascular, pulmonary, gastrointestinal, and endocrine pathologies.7
Although FTT is an extensive topic, many aspects are not pertinent to the patient’s emergency department (ED) visit; this issue will focus mainly on topics that are high-yield for the emergency clinician. This issue of Pediatric Emergency Medicine Practice reviews the etiologies and diagnostic workup of the most common presentations of FTT in pediatric patients presenting to the ED, with a focus on which relevant diagnostic studies should be obtained and when they are warranted.
A literature search was performed using Google Scholar, the Cochrane Database of Systematic Reviews, and PubMed. Search terms included: failure, thrive, growth deficiency, childhood neglect, malnutrition, and growth failure. A total of 277 articles published between 1960 and 2018 were reviewed. There is a general paucity of literature regarding guidelines for patients presenting to the ED with FTT. There has also been little new research on this topic in recent years. There are many models suggesting that the interplay between social and organic factors contributes to FTT in a child. Nonetheless, there are no clear guidelines on the workup or disposition for these patients; most current recommendations are based on traditional dogma. There are several reasons for this. First, FTT has no single universally accepted criterion to make the diagnosis. Second, most publications focus on longitudinal follow-up and risk factors for FTT. When available, current accepted practices will be adapted, based on current consensus.
1. “I couldn’t find the right growth chart.”
The United States Centers for Disease Control and Prevention growth charts provide information for patients ranging from 2 to 20 years of age; the World Health Organization growth charts provide information for patients ranging from birth to 2 years of age. Awareness of readily available resources can help make an appropriate diagnosis in a shorter period of time.
3. “I didn’t know which tests to order, so I ordered everything to be sure I didn't miss anything.”
There is a dearth of literature supporting the utility of routine laboratory testing in patients with FTT. Overtesting can result in increased time in the ED, increased discomfort to the patient, and increased medical expense. Knowing which laboratory studies are indicated in screening for organic causes of FTT can decrease superfluous testing.
5. “My patient was brought in for poor weight gain; I assumed it was nonorganic FTT.”
Rushing to a diagnosis is a common mistake with FTT. When an infant comes in with poor weight gain, some emergency clinicians may immediately diagnose the patient with FTT without obtaining a proper history and physical examination, or they may assume the poor weight gain is nonorganic and miss an important medical cause for the condition.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.
Vincent Calleo, MD; Ryan Surujdeo, MD, Asalim Thabet, MD
John W. Harrington, MD; Gretchen Homan, MD, FAAP
March 2, 2020
April 2, 2023
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.
Date of Original Release: March 1, 2020. Date of most recent review: February 15, 2020. Termination date: March 1, 2023.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: For more information, please call Customer Service at 1-800-249-5770.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAP Accreditation: This continuing medical education activity has been reviewed by the American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per year. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.
AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Calleo, Dr. Surujdeo, Dr. Thabet, Dr. Harrington, Dr. Homan, Dr. Mishler, Dr. Claudius, Dr. Horeczko, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive any commercial support.
Earning Credit: Two Convenient Methods: (1) Go online to www.ebmedicine.net/CME and click on the title of this article. (2) Mail or fax the CME Answer And Evaluation Form with your June and December issues to Pediatric Emergency Medicine Practice.
Hardware/Software Requirements: You will need a Macintosh or PC with internet capabilities to access the website.
Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit https://www.ebmedicine.net/policies.