What is the primary treatment for a toddler diagnosed with failure to thrive (FTT)?

Primary Treatment for Failure to Thrive in Toddlers

The primary treatment for a toddler with failure to thrive (FTT) is nutritional rehabilitation with a high-energy and high-protein diet, targeting 150 kcal and 3g protein per kg body weight daily, divided into 4-6 meals per day. 1

Diagnostic Criteria

• Weight below the 10th percentile for age
• Weight crossing two or more major percentile lines downward
• Weight-for-height below the 10th percentile
• Severe malnutrition: weight below 70% of expected weight-for-height (Z-score < -3)

Assessment Process

1. Growth parameter evaluation:

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

2. Nutritional assessment:

   • Detailed dietary history (24-hour recall, 3-5 day diet record)
   • Feeding behaviors and patterns
   • Caregiver-child interactions during feeding

3. Medical evaluation:

   • Physical examination for signs of underlying medical conditions
   • Assess hydration status
   • Check for signs of systemic illness

Treatment Algorithm

Step 1: Calculate Energy Requirements

• Use Schofield's equation to determine resting energy expenditure (REE)
• Add factors for physical activity and catch-up growth
• Alternative: Double the REE for catch-up growth
• Target weight gain: 17-20 grams/kg/day 1

Step 2: Implement Nutritional Interventions

• For breastfed infants:

  • Increase feeding frequency
  • Consider fortifying expressed breast milk

• For formula-fed infants:

  • Use high-energy/protein infant formula
  • Increase caloric density (up to 30 kcal/oz)

• For toddlers on solid foods:

  • Increase meal frequency (4-6 meals/day)
  • Fortify foods with extra fats/oils
  • Provide calorie-dense foods
  • Add nutritional supplements as needed

Step 3: Monitor Progress

• Weekly weight checks initially
• Adjust nutritional plan based on response
• Target energy requirements by age:
  • Infants (0-1 year): 75-85 kcal/kg/day
  • Toddlers (1-7 years): 65-75 kcal/kg/day 1

Indications for Referral

• Severe malnutrition (Z-score < -3) with medical instability: immediate referral to emergency room
• Failure to respond to outpatient nutritional management
• Suspected underlying medical condition requiring specialist evaluation
• Concerns about neglect or psychosocial issues

Multidisciplinary Approach

A team-based approach is essential and should include:

• Primary care physician
• Nutritionist/dietitian
• Feeding specialist (occupational therapist)
• Social worker (if psychosocial issues identified)
• Subspecialists as needed (gastroenterologist, endocrinologist) 2

Common Pitfalls to Avoid

1. Overlooking psychosocial factors: Most cases of FTT involve inadequate caloric intake due to behavioral or psychosocial issues 2
2. Excessive laboratory testing: Routine laboratory testing rarely identifies a cause and is not generally recommended 2
3. Delayed intervention: Early detection and intervention minimize long-term disadvantages in growth, behavior, and development
4. Neglecting follow-up: Children discharged from acute care should be scheduled for follow-up within 24-48 hours 1
5. Refeeding syndrome: In severely malnourished children, increase food intake gradually and monitor electrolytes (phosphate, magnesium, potassium) 1

Early identification and appropriate nutritional management are critical for preventing long-term consequences of FTT, including impaired cognitive development and immune function 3.