Failure to Thrive

Dear Lisa,

Despite seeing several Drs. my 18-mo.old has a bad skin condition, cannot gain wt.

“Getting Desperate from Korea”

Dear “Getting Desperate from Korea”,

It is so frustrating when your baby has a problem and you can’t seem to get to the bottom of it. Your child is very fortunate to have a mother who is so concerned and who has sought out help from your doctor. First, I would like to address the skin condition. Since you have already been to several doctors and you still do not have a diagnosis, it seems that it is time to seek the opinion of a Pediatric Dermatologist. A Pediatric Dermatologist has special training in childhood skin conditions and should be able to tell you the cause of your child’s rash. In some cases a skin biopsy may need to be taken if the skin condition cannot be identified through a physical examination. A skin biopsy can tell you what type of rash your child has.

The term used to describe a baby that doesn’t gain weight is “Failure to Thrive”. There are many reasons why a baby develops Failure to Thrive or doesn’t gain weight. The work up can be quite extensive and may take some time because there are so many factors that need to be addressed.

In the majority of children, problems gaining weight are caused by inadequate nutrition, problems with social interaction, gastrointestinal disease or neurologic disorders. (1)
Most cases of “Failure to Thrive” are due to insufficient nutrition. (1) The best way to determine if your child is receiving the right amount of calories is to keep a food diary. You can keep a food diary by writing down everything that your child eats and drinks in a 24 hour period for 3 days. Add up the amount of calories your baby takes in a typical 24 hour period.

Infants require at least 80 to 125 Kcal/kg per day for growth in the first year, then 70 to 115 kcal/kg for the next three years. (1) For example, since your child is 18 months old, he should take at least 70 calories per kg of his weight per day. If he weighs 10 Kg, then 10 X 70 = 700 calories. He would need to take at least 700 calories per day.

If you find that your baby’s intake is consistently lower than this recommendation you should bring your child and the food diary into your Doctor so that he can make recommendations in order to increase caloric intake. I find that many babies do not gain weight simply because they don’t ingest enough calories. Many times this occurs in babies who drink water which provides no nutritional value and contains zero calories. Other times this occurs in babies who ingest low fat food or low fat milk. Your doctor may recommend a consultation with a Nutritionist who will be able to guide you in the right direction.

When recording your baby’s food diary make note of any problems your baby may have with the process of eating. Does he have difficulties drinking from a cup, swallowing, sipping from a straw, chewing or handling his secretions? Does he have a problem taking food from a spoon or fork? Does he have excessive gagging or an aversion to certain textures? Some babies do not ingest the correct amount of calories because they have feeding problems such as an ineffective or uncoordinated swallowing mechanisms, difficulty chewing, or problems adjusting to different food temperatures or textures.

An 18 month old baby may experience difficulty manipulating food with his fingers or may not be able to use a fork or a spoon correctly. If you notice that your child is struggling in any of these areas it would be important to inform your Doctor. Children with certain developmental issues, low muscle tone, or oral motor dysfunction may need a consultation with a Speech and/ or Occupational Therapist in order to address the problem.

If your baby has no problems eating and is ingesting the appropriate amount of calories, then other causes for “Failure to Thrive” need to be investigated. Repeated history and physical examinations performed in the doctor’s office in conjunction with laboratory testing should rule out most of the common causes of Failure to Thrive. These common causes of Failure to Thrive include Pyloric Stenosis(which presents itself earlier in infancy), Congenital Heart Disease, Hypothyroidism, Liver Disease, Kidney abnormalities, HIV, Tuberculosis, Parasite infestation and urinary tract infection. (1) Since your baby was evaluated by a physician on multiple occasions you can ask him which disorders have been ruled out in and which disorders are still being considered.

Some infants do not gain weight because they have a Malabsorption problem which makes it difficulty for their body to absorb the nutrients that they need to grow. A milk allergy or wheat intolerance (also known as Celiac Disease) can both lead to problems gaining weight. Babies with a milk allergy develop symptoms including crying, irritability, colic, feeding refusal, failure to thrive, vomiting, regurgitation, wheezing, and sleep disturbances. (2) Children with Celiac Disease tend to develop symptoms between 6 months and 2 years old, following the introduction of gluten into their diet. The typical symptoms include impaired growth, abdominal distention, chronic diarrhea, muscle wasting, poor muscle tone, poor appetite and lack of energy. (3)

Gastroesophageal Reflux (GERD) is another common disorder found in children that may lead to insufficient weight gain. Children with GERD present with a variety of symptoms including poor weight gain, vomiting, irritability, disturbed eating, disturbed sleeping and arching of the head and neck. (2,4) When children diagnosed with GERD are treated with anti-reflux medication the symptoms subside and the children tend to gain weight.

All babies who experience Failure to Thrive associated with respiratory symptoms should be evaluated. Children with pneumonia or lung abnormalities can present with Failure to Thrive in conjunction with respiratory symptoms such as a cough or signs of a respiratory infection. If a child has Failure to Thrive along with a chronic cough, recurrent respiratory infections or stool problems, Cystic Fibrosis should be ruled out. (1)

The list of potential causes for Failure to Thrive is extensive. Repeat follow up examinations with your baby’s doctor are usually necessary before a diagnosis can be made. It is very important to report any additional symptoms that your baby may be experiencing. This information may aid in your child’s diagnosis. In some cases the expertise of a Pediatric Gastroenterologist may be needed in order to monitor, treat and identity the cause of a child's failure to gain weight.

I wish you and your baby good health and resolution of his symptoms.

References:
(1)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990: 229-231.
(2 )Edmunds A. Gastroesophageal Reflux Disease in the Pediatric Patient. Therapuetic Spotlight. 2005. August:4-12.
(3 )Gelfond D. Fassano A. Celiac Disease in the Pediatric Population. Pediatric Annals. 2006.35:4:275-279.
(4 )Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. 2006. April;35(4):250-266.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice About Common Childhood Health Problems