Failure to thrive history and symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]

Overview

The most common presenting complaint is poor growth and failure to gain weight. The patient may have more specific complaints depending on the underlying cause. A few important complications include a diminished final weight and height, vitamin deficiencies and an increase risk of recurrence of failure to thrive. Not much data is available on the prognosis of failure to thrive as it is a multifactorial process. However, the duration of malnutrition is directly proportional to the cognitive and physical decline of the patient.

History

• Though the scope for differentials and investigations is broad, nothing is more specific and time efficient in diagnosing a patient with failure to thrive than an accurate history.
• Patients typically present with weight loss, signs of malnutrition and specific manifestations of environmental/psychological/ organic causes.
• Given the various psychological and environmental influences on failure to thrive, a physician should take a detailed history with a slight degree of skepticism.
• To obtain a complete picture, history taking should be performed when both parents are present. Hearing what only one parent has to say is analogous to examining a patient without a stethoscope.
• If the child is hospitalized, then a second history is often more valuable than the first as the physician may ask questions that did not spring to mind the first time along. Keen attention should be paid to the parents’ ability to provide details but also their attitudes to the entire history taking process. "Failure to Thrive: A Practical Guide - American Family Physician".
• The following are important history taking questions: "Failure To Thrive - StatPearls - NCBI Bookshelf".

• Important aspects of the patient's history are as follows:
  • Chief Complaints
    1. Poor weight gain, poor growth, baby not getting enough milk, crying too often, and refusing feeds
    2. Recurrent respiratory infections, gastroenteritis, fussiness, fatigue, irritability, stomatitis, cheilosis –vitamin deficiency or immunodeficiency syndromes, recurrent exposure to a parent who may be a primary contact.
    3. Urinary symptoms – frequency, urgency, foul smell, dysuria, fever of unknown origin, change in color
    4. Bowel habits – stool frequency, stool consistency, recurrent episodes of vomiting, blood or mucus in stool
    5. Poor development in terms or work habits or performance in school.
    6. Growth pattern -
    • Children with no remarkable history findings and a normal physical/behavioral examination may have a decreased growth of two major percentiles as they begin to match their genetic potential which may be set at a lower growth rate – Catch down growth.
    • Compare bone age and chronological age of the patient to differentiate between constitutional growth delay and familial short stature.
  • Feeding/Dietary History
    1. Breastfeeding mothers often have 3 complaints; the baby is either not getting enough milk, is crying too often, or refusing to breastfeed.

*** ‘Not enough milk’ may be low milk output due to poor attachment of the baby to the breast, retracted or sore nipples, use of bottles/pacifiers/fluids in place of  breastfeeds, psychosomatic disorders such as depression or the mother perceiving that her output is low when it is normal.  

• • • ‘Crying too often’ could be discomfort due to soiling of underwear, tiredness, colics, hunger, desire for comfort or an underlying medical condition.
  • ‘Refusal to feed’ indicates local problems such as oral thrush or ulcers or an underlying systemic disease.
    1. For children less than 6 months of age enquire about number of feeds in a day and usage of fluid other than breast milk
    2. For children more than 6 months of age enquire about quantity, type, serving size, consistency and frequency of meals as well as when solid foods were first introduced.
    3. Perform a 24 hour dietary recall – important to be as specific as possible.
    4. What is the frequency of feeds at both home and day care – how often does the child snack and does the snack spoil their appetite for the nutritious meals.
    5. Are there any cultural or religious food restrictions - awareness of the nutrient quantity of each food group is important.
    6. Where and when does the child eat and with whom? – this has an impact on the child’s development.
    7. Are feeding habits age appropriate – does the child eat with a spoon or is he/she helped?
    8. Is the parent’s child feeding technique appropriate – use of baby foods and table foods in the formula. If the formula is too diluted, it likely has less calories whereas if it is too concentrated then the infant may refuse to drink.
    • What is the position and placement of the infant during feeding and are caloric requirements being calculated? Can the child be fed passively, or does he/she have to be coerced?
    1. Are there any feeding difficulties - refusal, preferences, emesis, tachypnea, diuresis, or fatigue before or after feeds, impaired swallowing co-ordination – neuromuscular disorders or cleft lip/palate,
  • Social /Psychiatric/Psychological History
    1. Number of people living in the same house as the child and whether there is enough space.
    2. Parents’ outlook to parent child separation.
    3. Parents’ description of their childhood -defining, mention-worthy experiences.
    4. Parents’ attitude to conception and pregnancy. Was the pregnancy planned or was there ever a plan to terminate the pregnancy? Are either of the parents frequently outside due to occupational/social obligations (e.g. military service)?
    5. Feeding difficulties, excessive tantrums/ crying, sleep disturbances, sexual dysfunction, and irritability are signs of family dysfunction.
    6. Maternal mental health during and after the pregnancy – postpartum blues/depression.
    7. Have there been any previous reports to Children’s protective services agencies? - features of non-accidental trauma such as shaken baby syndrome (altered mental status secondary to subconjunctival hemorrhage, posterior rib fractures) , poor child patient interaction, poor child hygiene, an inconsistent history and parental guilt should arouse suspicion for child abuse or neglect.
    8. Financial status of the parents - ability to provide a safe and adequate environment to the child that ensures a healthy upbringing.
    9. Do either of them want to leave and were the parents married when the child was born? Is there a history of marital friction, infidelity, separation or is the parent a single parent?
    10. Are the parents mutually supportive or do they act impersonal (referring to each other as ‘he’ or ‘she’)?
    11. Are either of the parents hostile, agitated, or depressed? Are the verbal exchanges with the child comforting, aggressive or demanding?
    12. Enquire about whether adequate provisions directed to meeting the child’s calorie requirement are being arranged.
    13. Assess caregiver knowledge of the parent- whether the parents instill discipline in their child’s dietary habits. Does the parent inhibit unlimited access to high ‘empty’ calorie foods and drinks?
    14. Presence or absence of support systems – relatives, friends.
    15. Drug or alcohol abuse
    16. Whether benefits offered by social workers or government sponsored nutrition or home health visit programs are availed? Educate and encourage families that are not affording.
    17. What is the demeanor of the child? Fragmented sleep can cause a child to be moody and apathetic. Some authors have hypothesized a condition called infantile-anorexia nervosa where a child refuses to eat to attain control of the mother.
  • Development history
    1. Abnormal development may indicate a non-organic cause like neglect or the early onset of a neurodevelopmental disorder that may cause or exacerbate failure to thrive.
    2. Social disruption increases the risk of development delay in patients with failure to thrive.
  • Past history
    1. To rule out underlying organic disorders such as gastroesophageal reflux disease, atopy, urinary tract infections, milk protein allergy, congenital disorders, etcetera.
    2. History of past surgeries – to rule out secondary complications that may cause failure to thrive.
    3. History of previous visits to the hospital or emergency department – patient or parent exposure to communicable diseases e.g. tuberculosis.
  • Family history
    1. To rule out congenital disorders such as celiac disease, inflammatory bowel disease, renal tubular acidosis, renal failure, cystic fibrosis, constitutional growth delay, familial short stature, bipolar disorder, esophageal anomalies, endocrine disorders etcetera.
    2. Enquire about the height of the parents and relatives.
  • Antenatal/Postnatal History
    1. Complications before, during or after the pregnancy.
    2. Enquire for exposure to risk factors of congenital infections such as TORCH, Zika virus, syphilis, Epstein Barr virus, etcetera.
    3. Consumption of illicit drugs, alcohol, tobacco or other drugs for underlying medical conditions before, during and after the pregnancy. (fetal alcohol syndrome, sodium valproate, lithium, etcetera)

References

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