Investigate infant or child with

suspect failure to thrive (FTT)

By:
I Gusti Lanang Sidiartha
 Objective
• After this lecture participant know and
understand how to identified and manage
failure to thrive in infant and children
 Topic
• Normal growth:
• Definition
• Growth standard
• Failure to thrive:
• Definition
• Indicator/criteria
• Management
 Normal growth
• Normal growth is an indicator of child’s overall well
being.
• Deviation from growth velocity indicates:
– Psycho-social stress in the family
– Chronic diseases
– Emotional deprivation
– Inadequate nutrition
• Growth is an increase in size, weight, and or shape of
the body
• The increase of age is followed by the increase of body
weight or height
 Normal pattern of growth in
children (“S” shaped curve)

http://www.childhealth-explanation.com/normal-growth.html
Growth pattern of many organs
• The brain and the head
containing it develops
earlier than any other
tissue.
– At birth 25% of its adult
weight, and 90% at age
five.
• Lymphoid tissue reaches
its maximum just before
adolescence
• The reproductive organs
rapidly increase in
adolescence
 Normal growth velocity
different between sex in puberty periods
 Growth standard
• WHO-2005 growth standard
• CDC-2000 growth reference
• Other countries
• Indonesia: Kartu Menuju Sehat / KMS :
implementation of WHO growth standard
 Factors of growth influences
• Genetic
– Genetic: potential of height, IQ, eye or hair
color
• Environment
– Socio-economic
– Diseases
– Stimulations
– Nutrition
 Potensi Genetik TB
{(TB ayah + TB ibu) ± 13 cm} : 2
TB ayah 170 cm, Ibu 160 cm
Anak laki: Potensi Genetik
171,5 cm (P-25)  saat usia
5 th: TB 106 cm, BB 18 kg

TB ayah 160 cm, Ibu 150 cm

Anak laki: Potensi Genetik
161,5 cm (<P-3)  saat usia
Pada usia yang sama 5 th: TB 98 cm, BB 15 kg
anak akan memiliki
TB dan BB yang Potensi genetik anak
berbeda tergantung dapat berubah
potensi genetik karena nutrisi

ukk nutrisi & penyakit metabolik 14

 Failure to Thrive (FTT)

Failure to thrive is a term used to

describe inadequate growth or the
inability to maintain growth, usually
in early childhood.
FTT
• It is a sign of under nutrition, and because many
biologic, psychosocial, and environmental processes
can lead to under nutrition, FTT should never be a
diagnosis unto itself

• Recent studies show that children who failed to

thrive in infancy, especially in the first few months of
life are lighter and shorter at school age with adverse
intellectual outcomes including poor arithmetic
performance and poor work habits
Anthropometric indicator
• Height for age (H/A) measures the skeletal growth which
reflects the cumulative impact of events affecting nutritional
status that result in stunting and is also referred to as chronic
malnutrition.

• Weight for height or length (W/H), or wasting, which is a

measure of acute malnutrition.

• Weight for age (W/A) has less clinical significance by itself and
has to combine stature with current health conditions

• BMI is calculated by dividing weight in kilograms by the square

of height in meters, which is a measure of obesity.
FTT criteria
• Although the concept of FTT is widely
used, no consensus exists regarding its
specific definition. Anthropometric criteria
for assessing FTT are a matter of debate.

Jaffe, AC. Ped Rev 2011

WHO criteria for risk of FTT if
weight increment < P-5
Causes of FTT
• The causes of disease-related FTT in
children are multifactorial including
1. failure of a caregiver to offer adequate calories,
2. failure of the child to take in sufficient calories,
3. failure of the child to absorb nutrient
4. failure of the child to use sufficient calories, and
5. Increased metabolic demands
 Identification & Management
• History, physical examination, and observation
of the parent-child interaction in the clinical.

• A complete history should include a detailed

of:
– nutritional, family, and prenatal history;
documentation of who feeds and cares for the child;
further information regarding the timing of the
growth failure; and a thorough review of systems.
Laboratory: if indicated
• Typical screening laboratories include
CBC&diff, iron studies, ESR/CRP, and urine
analysis

• Second line:
– urine culture, allergy testing, stool studies, PPD and
HIV screen,
– serum aminoacids, urine aminoacids and organic
acids.
– Also may include bone age, skeletal survey, EKG
and endoscopies.
Treatment
• Treat the underlying diseases or anatomical
disorders

• Give nutritional intervention according to

the causes, clinical, and nutritional status:
– Oral supplementation
– Enteral or parenteral support
Catch-up growth
• The ‘catch-up’ growth during infancy can be directly related to
improved neurodevelopment

• Concern has been expressed that rapid growth during infancy

may be associated with the development of insulin resistance and
metabolic X syndrome

• Nutritional rehabilitation with high-energy intakes results in

increased weight gain and body fat, that is, the nature of the gain
is directly dependent upon the compositional nature of intake

• A diet that better meets protein requirements may be paralleled

by increased lean mass accretion.

Jackson, 1990; Latal-Hajnal et al, 2003; Ong, 2007.

WHO guidelines
• Following the recent WHO guidelines for catch-up growth, the
focus of dietary management during faltering growth has
changed from supplementing only with energy to optimizing
catch-up by providing adequate energy and protein

• These guidelines suggest that 8.9–11.5% of energy should be

supplied as protein, to provide optimal catch- up growth of lean
and fat mass (from 10 g/kg/day = 8.9 PE% to 20 g/kg/day
=11.5 PE%; 73:27 lean:fat mass)

• Multivitamin supplementation should be given to meet the

recommended dietary allowance, because these children
commonly have iron, zinc, and vitamin D deficiencies, as well as
increased micronutrient demands with catch-up growth.

WHO/FAO/UNU expert consultation, 2007

Summary
• The growth chart is the most basic daily work tool for
any pediatrician or others, whether in hospital or in the
community

• Growth monitoring should be considered as an ongoing

process in assessing the health and well- being of
children

• Nutrition teams with adequate nutritional interventions

are essential elements of clinical practice, and children
with or at risk of growth faltering should be identified
appropriately and followed up longitudinally
Summary
• FTT have severe consequences for health development,
behavior and school performance

• It is important to ensure that the nutritional management

plan is achievable and is regularly monitored to adjust for
the child’s specific nutritional requirements

• Appropriate assessment and intervention of cognitive

and emotional development is necessary for all children
with FTT

• Referrals to early intervention may be beneficial.

References
• Krugman SD, Dubowitz H. Failure to Thrive. American Family
Physician, 2003;68(5):879-84.
• Cole SZ, Lanham JS. Failure to Thrive: An Update. Am Fam
Physician, 2011;83(7):829-34.
• Block RW, Krebs NF. Failure to Thrive as a manifestation of child
neglect. Pediatrics, 2005;116:1234-7.
• Growth pattern in children and adolescent. http://www.childhealth-
explanation.com/normal-growth.html
• WHO growth standard
• CDC growth reference
• Homan GJ. Failure to Thrive: A Practical Guide. Am Fam Physician,
2016;94(4):295-9.
• Raynor P, Rudolf MCJ. Anthropometric indices of failure to thrive.
Arch Dis Child, 2000;82:364-5.
• Jeong SJ. Nutritional approach to failure to thrive. Korean J Pediatr,
2011;54(7):277-81.
Thank You
 SGD 1
• Anak laki, BBL 3 kg, PBL 50 cm. Hasil
penimbangan BB setiap bulan di Posyandu sbb: 3,8
kg; 4,7 kg; 5,3 kg; 5,7 kg; 5,85 kg; 5,95 kg; 5,95 kg.
Anak mendapat ASI dan susu formula dan mulai
mendapat pisang usia 6 bulan.
• Pertanyaan:
1. Apakah anak ini mengalami gagal tumbuh? apa dasar
diagnosisnya?
2. Pada usia berapa anak ini gagal tumbuh?
3. Apa kemungkinan penyebabnya?
4. Apa saran saudara untuk menanganinya?
5. Berapa target kenaikan BB anak ini?
 SGD 2
• Anak perempuan BBL 3,5 kg, PBL 50 cm. Usia 6
bulan BB 6,4 kg; usia 9 bulan BB 7 kg dan PB 68 cm.
Anak mendapat Asi sebulan dan dilanjutkan susu
formula dan mulai diberikan makanan tambahan
umur 6 bulan berupa pisang, biskuit, atau bubur
beras + wortel.
• Pertanyaannya:
1. Apakah anak ini gagal tumbuh? Apa dasarnya?
2. Pada usia berapa anak ini gagal tumbuh?
3. Apa kemungkinan penyebabnya?
4. Bagaimana tatalaksananya?
5. Berapa target BB nya?