Pediatrics
Neonatology
Failure to Thrive (infant, Child)

Failure To Thrive in Infants and Children

Introduction

Failure to thrive (FTT) is a critical topic for the MCCQE1 exam, particularly in the Pediatrics and Neonatology sections. This comprehensive guide will help Canadian medical students prepare for questions related to FTT, focusing on Canadian guidelines and practices.

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FTT is not a specific disease but a descriptive term used when a child's physical growth and development are significantly below age-appropriate standards.

Definition and Diagnosis

In Canada, FTT is typically defined as:

  1. Weight for age below the 3rd percentile on multiple occasions
  2. Weight deceleration crossing two major percentile lines on a growth chart
  3. Weight for length below the 3rd percentile
  4. A rate of weight gain that is significantly below the expected rate for age
  • Use of WHO growth charts for children 0-2 years
  • CDC growth charts for children 2-19 years
  • Emphasis on weight-for-length in infants

Etiology

Understanding the causes of FTT is crucial for the MCCQE1 exam. They can be broadly categorized into:

  1. Inadequate caloric intake
  2. Inadequate caloric absorption
  3. Excessive caloric expenditure

Step 1: Assess Caloric Intake

  • Evaluate feeding practices
  • Check for proper latching in breastfed infants
  • Review formula preparation in bottle-fed infants

Step 2: Consider Absorption Issues

  • Look for signs of malabsorption
  • Check for celiac disease, cystic fibrosis, or other GI disorders

Step 3: Evaluate Caloric Expenditure

  • Assess for chronic diseases increasing metabolic demand
  • Consider hyperthyroidism, chronic infections, or malignancies

Clinical Presentation

Canadian medical students should be familiar with the following signs and symptoms of FTT:

  • Poor weight gain or weight loss
  • Delayed developmental milestones
  • Irritability or apathy
  • Thin, loose skin
  • Visible ribs and prominent bones
  • Weak cry
  • Poor muscle tone

Diagnostic Approach

For the MCCQE1 exam, remember this Canadian-focused approach to diagnosing FTT:

  1. Detailed history (including psychosocial factors)
  2. Physical examination
  3. Growth chart plotting
  4. Nutritional assessment
  5. Developmental screening
  6. Laboratory investigations (as indicated)

MCCQE1 Tip: Canadian Growth Charts

Be familiar with both WHO and CDC growth charts used in Canada. Know when to use each and how to interpret them correctly.

Management

Management of FTT in Canada follows a multidisciplinary approach:

  1. Address underlying causes
  2. Nutritional rehabilitation
  3. Parental education and support
  4. Close follow-up and monitoring
  5. Referral to specialists as needed (e.g., pediatric gastroenterologist, dietitian, social worker)
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In the Canadian healthcare system, family physicians and pediatricians often collaborate with public health nurses and community resources to manage FTT cases.

Canadian Guidelines

The Canadian Paediatric Society provides specific guidelines for FTT management:

  1. Use of WHO growth charts for children 0-2 years
  2. Emphasis on breastfeeding support
  3. Screening for postpartum depression in mothers
  4. Early intervention programs for at-risk families
  5. Regular developmental screening using standardized tools

Key Points to Remember for MCCQE1

  • FTT is a descriptive term, not a specific diagnosis
  • Always consider child protection issues in FTT cases
  • Understand the use of different growth charts in Canada
  • Know the common causes of FTT in the Canadian population
  • Familiarize yourself with the CanMEDS roles in managing FTT (especially Communicator and Health Advocate)

Sample Question

# Sample Question

A 6-month-old girl is brought to the clinic for a well-baby visit. She was born at term with a birth weight of 3.2 kg. Her current weight is 5.8 kg (below 3rd percentile), length is 64 cm (25th percentile), and head circumference is 42 cm (50th percentile). The mother reports that the baby is exclusively breastfed and feeds every 3-4 hours. Which of the following is the most appropriate next step in management?

- [ ] A. Immediately start formula supplementation
- [ ] B. Admit the infant for inpatient nutritional rehabilitation
- [ ] C. Order a full septic workup
- [ ] D. Perform a detailed feeding assessment and observation
- [ ] E. Refer to a pediatric endocrinologist

Explanation

The correct answer is:

  • D. Perform a detailed feeding assessment and observation

Explanation: In this case of potential failure to thrive, the most appropriate next step is to perform a detailed feeding assessment and observation. This aligns with Canadian guidelines emphasizing the importance of breastfeeding support and thorough evaluation before interventions.

Option A is premature without assessing feeding techniques. Option B is too aggressive at this stage. Option C is unnecessary without signs of infection. Option E is not indicated as the initial step. The correct approach involves evaluating feeding practices, which may reveal issues with latching, milk transfer, or feeding frequency that can be addressed through education and support.

References

  1. Canadian Paediatric Society. (2021). A health professional's guide to using growth charts. Retrieved from https://www.cps.ca/en/documents/position/growth-charts (opens in a new tab)
  2. Shields, B., et al. (2017). Management and investigation of failure to thrive in Canadian primary care: A clinical practice guideline. Canadian Family Physician, 63(6), e285-e293.
  3. World Health Organization. (2006). WHO Child Growth Standards. Retrieved from https://www.who.int/tools/child-growth-standards (opens in a new tab)
  4. Centers for Disease Control and Prevention. (2010). CDC Growth Charts. Retrieved from https://www.cdc.gov/growthcharts/ (opens in a new tab)
  5. Cole, S. Z., & Lanham, J. S. (2011). Failure to thrive: An update. American Family Physician, 83(7), 829-834.
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