Advancing Learners Pediatric Clinical Reasoning and Knowledge
Key Points
- Not enough calories getting into the body, e.g. not eating enough, regurgitation, serial or multiple illnesses
- A processing or metabolic problem within the body, e.g. increased metabolic needs like fever, significant trauma, etc.
- Food not being absorbed for some reason, e.g. diarrhea, inflammatory bowel disease, short gut syndrome, etc.
Growth parameters are important vital signs for children and teenagers and in children we monitor weight, length and head circumference. Pediatricians may seem obsessed with growth parameters as we are always evaluating them for every clinical encounter.
Importantly, if a child is growing well, then likely they actually are well and do not have significant underlying disease. When the growth parameters are not tracking, then the reason for that needs to be elucidated.
Failure to thrive means persistent weight below the 3rd percentile for age in infants and young children or that the rate of weight gain is significantly below expected standards for their age and sex.
Failure to thrive does not mean that the child is small if they are growing at the appropriate velocity for their age, gender and genetic potential. Two good references for growth velocities can be found Guo et.al., DOI: 10.1016/s0022-3476(05)82045-1 and Kalberg et.al., DOI: 10.1016/s0022-3476(05)82045-1
Not gaining weight usually is due to three major categories:
The cause may be easily identified (e.g. child with oral aversion), or quite often is multifactorial with more than one of these major categories being involved.
Evaluation includes a comprehensive history, physical exam and at least basic laboratory testing. It may include more extensive testing, including a bone age for the child. A social history is always important to determine if there is unrecognized food insecurity within the household, different types of feeding practices or beliefs where the child may not be being provided adequate nutrition, or if there is frank child neglect.
Treatment starts by trying to identify and treat the underlying causes. Increasing calories in an appropriate manner for the age, circumstances, and personal and cultural preferences is also usually started. For example, increasing the caloric density of breast milk or formula for infants, calorie boosting for older children and teenagers by adding calorically dense foods to the diet (e.g. often dairy products, oils, nut butters, additional protein, etc.). Nutritional supplements (i.e. Pediasure® Ensure® Carnation Instant Breakfast®) can also be used. For some special needs children, enteral feeding is needed. Those with some type of oral aversion can also work with feeding specialists.
Food is expensive and special diets can add to the costs which can be financially difficult for families. Social workers may be able to identify additional food, financial and other resources to assist the family.
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Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa