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Failure to Thrive: Terminology and Anthropometry« Back to Volume 23, Issue 3, November 2007 - Table of Contents In the February 2007 issue of the Archives of Diseases in Childhood, there are 6 articles or perspectives pertaining to one form of aberrant infant growth termed “failure to thrive” (FTT). As Hughes1 commented – except for infants with obvious disease (eg, cystic fibrosis, celiac disease), the operative definition of “non-organic” FTT in developed societies is not agreed upon, resulting in difficulty in establishing a clear diagnosis and in blurring the divide between a normal extreme and clinical illness; the latter perhaps associated with impaired development. However, a suboptimal nutritional state is usually recognized as one of the hallmarks of this entity.2 Olsen et al evaluated growth data from 6090 Danish children examined between 1 to 5 weeks of age, 2 to 6 months of age, and 6 to11 months of age in an effort to establish the prevalence of this growth pattern. Utilizing 7 anthropometric criteria of FTT (Table), they examined the concurrence of these criteria in establishing its presence. In this population of infants, 27% met one or more of the anthropometric criteria at either the earlier (3-6 months) or later (6-11 months) examinations. Only 1.3% of infants met the criterion “weight <80% of median weight for length,” and they were a good deal longer than other infants. Twenty-two percent of infants crossed 2 major weight percentiles downward, but they were substantially heavier at birth and throughout the study than were other children with FTT. None of the infants in this study were concordant for all 7 criteria, and approximately 70% of subjects with FTT met only one criterion. Significant under-nutrition, defined as BMI <5th percentile for chronological age, was present in only 2% of children screened. Olsen et al concluded that “... no single measurement ... is adequate to identify nutritional growth delay ... (or) to predict outcomes such as neurodevelopmental or behavioral outcomes.” Spencer reached the same conclusion; indeed this investigator stated unequivocally “weight monitoring is not a good screening test for FTT.”2
Lucas et al reviewed the literature reporting lay (primarily maternal) views on infant growth and well being. In this population, infant size was primarily utilized as an index of health and of the quality of care provided by the parent(s). While supranormal growth is not of concern, subnormal growth evokes anxiety and fear about the infant and self-recrimination. Wright and Weaver4 commented that it is essential to differentiate between size (a static measurement) and growth (a dynamic change) when assessing the likelihood of underlying illness in an infant with FTT and that aggressive intervention in the short, thin, normally growing and developing infant is unnecessary. Editor’s CommentGiven the many auxologic criteria (Table) for the identification of an infant with FTT and the observation that one criterion is little better than another, it appears that this diagnosis falls into those typified by “I can’t define it, but I know it when I see it.” The critically essential finding in most of these subjects is that despite a poor appetite, relatively restricted caloric intake, and low weight for stature, linear growth rate remains normal. (Indeed, this pattern of growth is the diametric opposite of the voracious infant/child who steadily gains weight and crosses weight and height percentiles!) It is particularly important not to designate the normal, slowly growing or small child as abnormal, both because of the need to avoid unnecessary diagnostic and therapeutic interventions as well as to support the parents’ confidence and sense of competence to care for their child and to avoid a misplaced charge of negligence. Clearly, the clinician needs to know not only her/his patient but also the child’s parents. The criterion for FTT of downward crossing of weight percentiles certainly reflects in most subjects normal variations of growth as such changes are indeed quite frequent.5 It is of interest that the term FTT has been adopted by the geriatricians to denote “an elderly patient who undergoes a process of functional decline, progressive apathy and a loss of willingness to eat and drink that culminates in death.”1 Were there such a precise definition for the pediatric population, the identification and management of such children would be far more precise. Allen W. Root, MD References - (linked to
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Volume 24 Number 1
May 2008
www.GGHjournal.com
ISSN 1932-9032
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