Failure to Thrive
Karen M. Kress, Jill C. Cash, Cheryl A. Glass, and Alyson Wolz
Definition
Failure to thrive (FTT) is an abnormality in which an individual fails to maintain nutritional health. FTT is a manifestation of an underlying problem, whether the problem is mental, physical, or psychological.
A.Adults: FTT is seen in adults who have a weight less than 80% of the ideal average body weight for the adult.
B.Geriatrics: FTT in the geriatric population is defined as a deterioration in functional status disproportional to disease burden. Signs are decreased appetite, weight loss of greater than 5% of their weight, decreased physical activity, along with dehydration, depression, and compromised immune status.
Incidence
A.It is estimated to occur in 5% to 35% of the elderly population, with nursing home residents having an occurrence rate of 25% to 40%.
Pathogenesis
A.Organic causes for FTT:
1.Gastrointestinal (reflux, celiac disease, Hirschsprung’s disease, and malabsorption).
2.Cardiopulmonary (cardiac diseases, congestive heart failure).
3.Pulmonary (asthma, bronchopulmonary dysplasia, cystic fibrosis).
4.Renal (diabetes insipidus, renal insufficiency, urinary tract infections).
5.Endocrine (hypothyroidism, adrenal diseases, parathyroid disorders, thyroid disorders, pituitary disorders).
6.Neurologic (mental retardation, cerebral hemorrhages).
7.Metabolic disorders (inborn errors of metabolism).
8.Congenital (congenital syndromes such as fetal alcohol syndrome, chromosomal abnormalities, perinatal infections).
9.Infectious (gastrointestinal infections, tuberculosis, HIV).
B.Inorganic (or psychosocial) causes pertain to family and social dynamics. It is common to see both organic and inorganic problems as causative factors for FTT.
C.Geriatric population:
1.Feel fuller with less food; this may be an endorphin response that decreases the adaptive relaxation of the fundus of the stomach.
2.Increased number of cytokines, which contributes to anorexia.
3.Diminished sense of smell or taste.
4.Dysphagia.
5.Medications.
6.Depression, delirium, dementia.
7.Alcohol or substance abuse.
Predisposing Factors
A.Geriatrics: Dementia, comorbidities (cancer, chronic infections, malabsorption syndromes, psychiatric disorders), limited mobility, despair.
B.Poverty.
C.Organic conditions with the major organs noted above.
D.Parents with psychosocial disorders.
E.Altered family processes.
Common Complaints
A.Weight loss that is unintentional.
B.Fatigue.
Patients do not always present for this problem. Many patients are diagnosed at a routine examination in the ambulatory setting.
Other Signs and Symptoms
A.Loss of subcutaneous fat tissue.
B.Muscle atrophy.
C.Alopecia.
D.Dermatitis.
E.Marasmus.
F.Kwashiorkor.
Subjective Data
A.Obtain detailed history of the patient’s diet. Note the differences between foods offered and foods eaten. If dietary supplements are used, note type, frequency, and amount taken.
B.Assess quality of nutrients offered to the patient. Consider knowledge deficit of care provider if inadequate:
1.Geriatrics: Is patient able to chew and swallow food offered? Are dentures well fitting? Are supplements being offered?
C.Query regarding financial resources, and if needed, does the family participate in low-income opportunities (food stamp programs, meals on wheels, etc.)?
D.Evaluate whether religious or unusual dietary beliefs/habits contribute to the food preparation, if inadequate.
E.Rule out any difficulty in swallowing or retaining ingested food.
F.Note regular bowel/bladder habits.
G.Note any recent illness, chronic or acute.
H.Rule out family history of cystic fibrosis or lactose intolerance.
I.Geriatrics: Evaluate nutritional screening using the Mini Nutritional Assessment. This tool is available at www.mna-elderly.com/forms/mini/mna_mini_english.pdf.
Physical Examination
A.Check temperature, pulse, respirations, blood pressure, height, and weight.
B.Inspect:
1.Observe overall appearance.
2.Observe oral pathology: Check for ill-fitting dentures, dental and gum condition.
3.Note muscle tone, strength, and movement.
4.Note social interactions among family members.
5.Note social skills of the patient.
C.Palpate:
1.Palpate abdomen, back, and extremities.
D.Percuss:
1.Percuss the abdomen.
E.Auscultate:
1.Auscultate the heart and lungs.
Diagnostic Tests
A.Complete blood count (CBC), urinalysis, electrolytes.
B.Thyroid panel, if indicated.
C.X-rays, if appropriate.
D.Serum albumin in geriatrics.
Differential Diagnoses
A.FTT: Inorganic versus organic etiology.
B.Weight loss.
C.Depression.
Plan
A.General interventions:
1.The plan is based on the cause of FTT.
2.Severe malnutrition requires hospitalization.
3.Obtain nutritional consult to evaluate the dietary needs for protein, iron, and other nutrients according to age and size.
B.Patient teaching:
1.Reinforce positive eating habits and encourage dietary meal planning.
2.Offer nutrition counseling with dietitian.
3.Educate the patient and family about the importance of meeting the dietary requirements for protein, iron, calcium, and other nutrients to prevent weight loss and loss of muscle and bone mass, and to prevent infection and other complications that can stress the body.
C.Dietary management:
1.Meal suggestions: Offer adequate time for meals (20–30 minutes), offer solid food before drinks/juices, and provide a pleasant environment for eating.
2.Socialization enhances mealtime. Encourage all family members to sit down and eat at least one meal a day together.
3.Provide handout for high-calorie foods (peanut butter, cheese, whole milk, etc.).
4.Consider exercise sessions for geriatrics to stimulate appetite.
5.Encourage patients to attend centers where meals are served as a group or have meals delivered to the home.
6.Encourage small, frequent meals with snacks between meals and before bedtime.
Weight gain with high-calorie supplements is commonly seen with patients who have a psychosocial etiology of FTT.
D.Pharmaceutical therapy:
1.High-calorie supplements are recommended for some patients (Polycose, Carnation Instant Breakfast, Ensure, Boost, Thrive).
2.Geriatrics: Short-term aggressive caloric replacement has been shown to be effective in reversing FTT. Severe malnutrition may require hospitalization with total parental nutrition. Medications used to increase appetite:
a.Megestrol 400 or 800 mg daily with meal.
b.Selective serotonin reuptake inhibitors (SSRIs) have been shown to be beneficial to help stimulate appetite and increase weight.
c.Mirtazapine (Remeron) 15 mg at bedtime.
Follow-Up
A.Two-week evaluation for weight measurements and to evaluate compliance with regimen at home. Routine visits recommended every 2 to 4 weeks to monitor progress.
B.Reevaluate patient in 1 to 2 months. After 2 months if no improvement or further loss is noted, refer to a specialist.
Consultation/Referral
A.A nutritional consult is helpful to assist the patient or food provider in providing adequate resources/calories for the patient.
B.Consider social services and visiting nurses for outpatient assistance in the home.
C.Occupational therapy may be useful to evaluate the patient’s capacity to plan and prepare meals.
Individual Considerations
A.Geriatrics:
1.FTT in the elderly may lead to a decline in physical and mental function. Aggressive treatment should be employed to improve the nutritional status of these patients.
2.FTT increases the risk of morbidity and mortality.
3.FTT increases the risk of depression and social isolation in the elderly.