What is the best approach to manage a 14-year-old patient with failure to thrive?

Management of Failure to Thrive in a 14-Year-Old Patient

The best approach to manage a 14-year-old patient with failure to thrive requires a comprehensive nutritional assessment followed by targeted nutritional rehabilitation with high-energy and high-protein diet, while simultaneously investigating and addressing the underlying cause. 1

Initial Assessment

• Definition criteria: Identify if patient meets one of these criteria:

  • Weight below the 10th percentile for age
  • Weight that crosses two or more major percentile lines downward
  • Weight-for-height below the 10th percentile 1

• Growth parameter assessment:

  • Plot weight, height, and BMI on CDC growth charts (appropriate for patients >2 years)
  • Calculate weight-for-height ratio
  • Determine rate of weight gain/loss 1

Diagnostic Evaluation

• Nutritional assessment:

  • Detailed 3-day food diary to calculate actual caloric intake
  • Assess for disordered eating patterns, particularly avoidant/restrictive food intake disorder which is common in adolescents 2
  • Evaluate family food security and mealtime dynamics

• Medical evaluation (targeted based on history and physical findings):

  • Screen for chronic conditions common in adolescents with growth failure:
    • Inflammatory bowel disease
    • Celiac disease
    • Endocrine disorders (thyroid dysfunction, growth hormone deficiency)
    • Chronic infections
    • Malabsorption syndromes 3

• Psychosocial assessment:

  • Screen for depression, anxiety, and other mental health conditions
  • Evaluate for potential neglect or abuse if indicated 4
  • Assess school performance and social functioning

Treatment Plan

1. Nutritional rehabilitation:

   • Calculate energy requirements using Schofield's equation for resting energy expenditure, then add factors for physical activity and catch-up growth 1
   • For adolescents (7-12 years), provide 55-65 kcal/kg/day during recovery phase 1
   • Increase meal frequency and caloric density of foods
   • Consider high-calorie nutritional supplements between meals

2. Address underlying causes:

   • Treat any identified medical conditions
   • Provide appropriate mental health interventions if psychological factors are present
   • Implement behavioral strategies for feeding difficulties

3. Monitoring protocol:

   • Follow weight gain weekly until stable improvement is established
   • Aim for appropriate catch-up growth (though specific targets may differ from younger children)
   • Assess for signs of refeeding syndrome in severely malnourished patients 1

Multidisciplinary Approach

• Core team members:
  • Primary care physician to coordinate care
  • Registered dietitian for detailed nutritional planning
  • Mental health professional for psychological assessment and support 5
  • Consider adolescent medicine specialist referral for complex cases

When to Consider Hospitalization

• Severe malnutrition (weight-for-height Z-score < -3)
• Medical instability (abnormal vital signs, electrolyte imbalances)
• Failed outpatient management
• Suspicion of abuse or neglect
• Severe psychosocial impairment of the caregiver 1

Common Pitfalls to Avoid

1. Focusing only on weight without addressing underlying causes
2. Overlooking psychological factors common in adolescents
3. Failing to involve the adolescent in treatment planning
4. Not considering potential for eating disorders, which have peak onset during adolescence 2
5. Inadequate follow-up and monitoring of progress

Early intervention is crucial as failure to recognize and treat growth faltering may result in decreased adult height and cognitive potential 2. A multidisciplinary approach has been shown to improve weight gain, parent-adolescent relationships, and cognitive development 6.