What are common pitfalls in diagnosing and managing failure to thrive (FTT) in children?

From the Guidelines

Diagnosing and managing poor weight gain in children requires a comprehensive approach to avoid numerous potential pitfalls, including failing to establish an accurate baseline, overlooking detailed dietary history, and inadequate physical examination, as highlighted in recent studies 1. When evaluating children with poor weight gain, it is essential to consider the following common pitfalls:

• Failing to plot growth consistently on appropriate growth charts, leading to delayed recognition of growth faltering
• Overlooking the importance of detailed dietary history, including specific amounts, frequency, and types of foods consumed
• Inadequate physical examination, which may miss underlying conditions like cardiac, gastrointestinal, or endocrine disorders that contribute to poor weight gain
• Laboratory testing that is either excessive or insufficient, with practitioners ordering unnecessary tests while missing targeted investigations based on clinical findings
• Incorrectly attributing poor weight gain solely to inadequate caloric intake without considering increased energy expenditure, malabsorption, or metabolic disorders
• Treatment plans that lack specificity regarding caloric goals, with recommendations like "increase calories" being too vague without concrete targets (typically 150% of normal requirements for catch-up growth)
• Premature use of appetite stimulants like cyproheptadine (typical dose 0.1-0.2 mg/kg/day divided twice daily) before addressing underlying causes
• Follow-up intervals that are too long, with optimal monitoring requiring weekly weight checks initially for severe cases
• Failing to recognize psychosocial factors affecting feeding dynamics, including parental anxiety, inappropriate feeding techniques, or food insecurity
• Delayed multidisciplinary involvement, with late referrals to dietitians, feeding specialists, or subspecialists when initial interventions fail As noted in a recent study on managing children with 22q11.2 deletion syndrome 1, growth restriction in infancy and childhood commonly shows a pattern of early deceleration of weight gain and stature, then weight gain recovery with less catch-up in stature. Another study on nutrition issues and management strategies in individuals with skeletal dysplasia 1 highlights the importance of maintaining an appropriate weight and improving dietary quality to prevent metabolic complications. Additionally, guidelines on nutrition care for infants, children, and adults with cystic fibrosis 1 emphasize the need for tailored nutritional support, including enteral tube feeding, to achieve adequate nutritional status and improve clinical outcomes. By being aware of these potential pitfalls and taking a comprehensive approach to diagnosis and management, clinicians can ensure timely intervention and improve outcomes for children with poor weight gain.

From the Research

Common Pitfalls in Diagnosing Poor Weight Gain in Children

• Failure to accurately plot growth parameters, leading to delayed diagnosis of failure to thrive 2, 3
• Inadequate caloric intake, which is the most common cause of failure to thrive 2
• Neglecting to consider underlying medical conditions, such as gastrointestinal or neurological disorders, that may contribute to poor weight gain 4, 5
• Not recognizing the importance of family support and proper nutrition in managing failure to thrive 2, 3
• Failing to identify and address behavioral problems that may accompany growth failure 4

Common Pitfalls in Managing Poor Weight Gain in Children

• Not providing adequate calories for catch-up growth, typically 150 percent of the caloric requirement for the child's expected weight 3
• Relying too heavily on laboratory evaluation, when a thorough history and physical examination may be sufficient 3
• Not considering the use of nutritionally complete hypercaloric infant formulas in cases of unsatisfactory weight gain and feeding difficulties 5
• Failing to implement a multidisciplinary approach to management, particularly in cases of persistent or severe failure to thrive 3
• Not recognizing the need for additional support and resources to help primary care providers manage poor weight gain in children 6

Additional Considerations

• The importance of early identification and intervention in preventing malnutrition and developmental sequelae 2, 3
• The need for careful consideration of all feeding options, including breastfeeding, before using special infant formulas 5
• The potential for variability in primary care providers' approaches to identifying and managing poor weight gain in children, highlighting the need for standardized guidelines and resources 6