When should a child with failure to thrive be referred to the emergency room (ER)?

When to Refer a Child with Failure to Thrive to the Emergency Room

Children with failure to thrive should be referred to the emergency room when they have severe malnutrition with medical instability, dehydration, acute weight loss, or when there are concerns for abuse or neglect that pose an immediate safety risk.

Urgent Referral Criteria

Medical Instability

• Severe dehydration (dry mucous membranes, decreased skin turgor, sunken eyes/fontanelle)
• Lethargy or altered mental status
• Hypoglycemia
• Hypothermia
• Severe electrolyte abnormalities
• Hemodynamic instability (abnormal heart rate, blood pressure)

Nutritional Red Flags

• Weight below 70% of expected weight-for-height (Z-score < -3) 1
• Crossing of two or more major percentile lines with acute symptoms 2
• Evidence of severe protein-calorie malnutrition (edema, muscle wasting)
• Failed outpatient management with continued weight loss 3

Safety Concerns

• Suspected abuse or neglect requiring immediate intervention 4
• Unsafe home environment that poses immediate risk
• Caregiver unable to provide basic care due to severe psychosocial impairment 3

Assessment Parameters

Growth Evaluation

• Plot weight, length, and head circumference on appropriate growth charts:
  • WHO standards for children 0-2 years
  • CDC charts for children >2 years
  • Condition-specific charts for special populations (Down syndrome, prematurity) 2

Clinical Evaluation

• Assess hydration status
• Evaluate for signs of systemic illness
• Check vital signs (temperature, heart rate, respiratory rate, blood pressure)
• Examine for edema (may indicate severe malnutrition or other medical conditions)
• Assess neurological status

Management Considerations

Energy Requirements

For severely malnourished children requiring therapeutic feeding:

• 150 kcal and 3g protein per kg body weight/day 1
• Feeding should be done in 4-6 meals per day 1
• Severely malnourished children may require nasogastric feeding initially 1

Refeeding Risk

• Children with severe malnutrition (weight-for-height Z-score < -3) are at risk for refeeding syndrome 1, 5
• These children should be started on nutrition gradually with close monitoring of electrolytes

Outpatient vs. Emergency Care Decision Algorithm

1. Refer to ER immediately if ANY of these are present:

   • Severe dehydration or electrolyte disturbances
   • Altered mental status or lethargy
   • Weight-for-height Z-score < -3 (< 70% of expected) with medical instability 1
   • Evidence of abuse or neglect requiring immediate intervention
   • Failed outpatient management with continued weight loss

2. Consider outpatient management if ALL of these are present:

   • Medically stable
   • Adequate hydration
   • Mild to moderate malnutrition (weight-for-height Z-score > -3)
   • Safe home environment
   • Reliable caregivers
   • Access to follow-up care

Follow-up Care After ER Assessment

For children discharged from the ER:

• Schedule follow-up within 24-48 hours
• Implement a nutritional plan targeting 17-20 g/kg/day weight gain 2
• Consider a multidisciplinary approach including:
  • Nutritional counseling
  • Home nursing visits
  • Social services involvement
  • Behavioral therapy when indicated 3

Remember that approximately 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 failure to thrive 6. Careful attention to growth patterns and thorough history is essential to distinguish normal growth variation from true failure to thrive requiring intervention.