Failure to Thrive Defined as suboptimal growth and weight gain seen on a growth chart.

Fall across 2 centile lines on growth chart = mild Fall across 3 centile lines on growth chart = severe

Repeat observations are essential and FTT is difficult to assess off one reading However a reading below 0.4th centile should always prompt investigation. Mostly due to inadequate food intake. NB it is normal for an infant to lose 10% of birth weight in first few days of life Causes: Inadequate intake Inadequate retention Malabsorption Failure to utilise nutrients Increased requirements Inadequate intake Organic causes Impaired suck/swallow o Cleft lip/palate, neurological disorders Anorexia o Chronic illness leading to anorexia Crohns, renal disease, cystic fibrosis etc Non-organic causes Inadequate availability of food o Poor feeding techniques o Socioeconomic status Pyschosocial deprivation o Poor maternal bonding o Poor maternal education Neglect/abuse o Including factitious illness to cause deliberate FTT Inadequate retention Severe gastro-oesophageal reflux disease Malabsorption Coeliac disease Cystic Fibrosis Cows milk protein intolerance Cholestatic liver disease Short bowel syndrome Post-Necrotising enterocolitis Failure to utilise nutrients

Chromosomal abnormalities IUGR or extreme prematurity Metabolic disturbance

Increase requirements Hyperthyroidism Cystic fibrosis Malignancy Infection (HIV, immunodeficiency) Congenital heart disease Chronic renal failure Investigations: Detailed history including: Food diary PMH Familial growth patterns Family history Developmental history Social history Examination should focus on eliciting signs of organic disease Further information may be needed from health visitors, GP or other professionals involved in the family care Investigations for organic disease: FBC o Anaemia, neutropenia, lymphopenia (immune deficiency) U+E o Renal disease LFT o Liver disease TFT o Thyroid disease C-reactive protein o Inflammation Iron studies o Iron deficiency anaemia IgA tissue transglutaminase antibodies o Coeliac disease Urine dipstick, microscopy and culture o Urine infection, renal disease Genetic testing o Chromosomal abnormalities CXR and sweat test o Cystic fibrosis

Management: Mostly managed in primary care with an MDT approach: Health visitor Paediatric dietician Speech and language therapist (if feeding disorder) Social services (may be appropriate) Hospital admission only needed for children <6months with severe FTT needing active refeeding References Tom Lissauer, Graham Clayden, Illustrated Textbook of Paediatrics. Fourth Edition, 2012