What are the criteria for admitting a newborn with failure to thrive to a healthcare facility?

Admission Criteria for Newborns with Failure to Thrive

Newborns with failure to thrive should be admitted to a healthcare facility when they have weight below the 10th percentile for age with evidence of malnutrition, dehydration, or when there are concerns about the infant's safety in the home environment.

Definition and Classification

Failure to thrive (FTT) in newborns is characterized by inadequate growth and weight gain, typically defined by:

• Weight below the 10th percentile for age
• Weight that crosses two or more major percentile lines downward on standard growth charts
• Weight-for-height below the 10th percentile

Admission Criteria

Medical Indications for Admission

• Severe malnutrition: Weight-for-age or weight-for-height significantly below the 5th percentile 1
• Dehydration: Clinical signs of dehydration including decreased skin turgor, dry mucous membranes, sunken fontanelle
• Acute medical complications: Hypoglycemia, electrolyte imbalances, hypothermia
• Feeding difficulties: Inability to tolerate oral feeds, persistent vomiting, or severe gastroesophageal reflux
• Evidence of underlying medical condition: Suspected metabolic disorder, congenital heart disease, or other organic causes requiring immediate intervention

Social Indications for Admission

• Suspected neglect or abuse: When FTT is potentially related to inadequate care or supervision 2
• Unsafe home environment: Concerns about the ability of caregivers to provide adequate nutrition
• Failed outpatient management: Lack of improvement despite outpatient nutritional interventions
• Need for close observation: To assess feeding dynamics, parent-child interactions, or response to nutritional interventions

Level of Care Determination

According to the American Academy of Pediatrics guidelines on levels of neonatal care 3:

• Level I (Well Newborn Nursery): Can stabilize newborns with FTT until transfer to higher level of care
• Level II (Special Care Nursery): Appropriate for infants ≥32 weeks gestation and ≥1500g with moderate illness expected to resolve rapidly
• Level III (NICU): Required for infants <32 weeks, <1500g, or with critical illness regardless of gestational age
• Level IV (Regional NICU): For cases requiring complex surgical intervention or specialized care

Evaluation Process for Admission Decision

1. Growth parameter assessment:

   • Plot weight, length, and head circumference on appropriate growth charts
   • Calculate weight-for-length ratio
   • Determine rate of weight gain/loss

2. Clinical assessment:

   • Vital signs including temperature
   • Hydration status
   • Physical signs of malnutrition (muscle wasting, loss of subcutaneous fat)
   • Dysmorphic features suggesting genetic syndromes

3. Feeding assessment:

   • Observation of feeding technique
   • Assessment of suck-swallow coordination
   • Evaluation of parent-child interaction during feeding

4. Social assessment:

   • Parental knowledge of infant feeding
   • Home environment safety
   • Access to adequate nutrition and healthcare
   • Presence of support systems

Special Considerations

Underlying Medical Conditions

Certain conditions may present with FTT and require specific admission criteria:

• Congenital athymia: CD3+ T lymphocytes <50 cells/μL with failure to thrive requires admission to a specialized center 3
• Cystic fibrosis: FTT with respiratory symptoms may require admission for evaluation and management 3
• Skeletal dysplasia: FTT with dysmorphic features may require genetic evaluation 3

Premature Infants

Extremely preterm infants (born before 28 weeks gestation) have different growth patterns and higher risk of FTT 4. They should be evaluated using adjusted age and appropriate growth charts.

Common Pitfalls to Avoid

1. Misdiagnosis of normal growth variation: About 25% of normal infants will shift to a lower growth percentile in the first two years of life and then follow that percentile; this should not be diagnosed as FTT 1

2. Failure to consider adjusted age: Premature infants should be evaluated using their corrected gestational age

3. Overlooking non-medical causes: Social factors often contribute significantly to FTT and should be thoroughly assessed

4. Delayed intervention: Early intervention is essential to prevent long-term sequelae from nutritional deficiency 5

5. Inappropriate level of care: Ensuring the infant is admitted to the appropriate level of care based on severity and underlying conditions

By following these criteria, healthcare providers can ensure that newborns with failure to thrive receive appropriate and timely intervention to improve outcomes and prevent long-term complications.