By Dr. Ng Ruey Terng, Consultant Paediatrician, University of Malaya Medical Centre (UMMC)
M.D. (UPM), MRCPCH (UK), Master of Paediatrics (UM)
What is Failure to Thrive (FTT)?
The first few years of life are the period of rapid growth for most children. The process may slow down gradually later on. However, not every child will follow a similar pattern or standard of growth. Some may grow at a normal growth speed whereas some may take longer.
Children who fail to thrive (or grow) have their weight or rate of weight gain significantly below that of other children of similar age and gender. As a result, they will appear smaller and shorter than kids their age. When these kids reach their teenage years, they will also not display the common changes that most adolescents go through during puberty.
What causes FTT?
FTT is a general term. It mostly refers to a condition rather than a specific diagnosis. Children who fail to thrive, in general, have inadequate intake, storage, retention or utilisation of calories that are essential for growth. This could be attributed to a host of reasons.
FTT is not a medically diagnosed problem. It is mostly related to issues or challenges in nurturing and parenting. Some parents or caregivers may hold certain beliefs that result in inappropriate restriction of food variety and total calorie intake for the child. For example, fresh fruits are believed to induce cough in young kids and complementary diets such as meat, vegetables, grains and nuts are thought to be too hard for babies who have yet to start teething. In other instances, some parents or caregivers may also believe that such healthy foods or nutrition can cause food allergies.
Furthermore, there are parents or caregivers who choose to prepare formula milk in an overly diluted manner as some believe that the regular concentration will cause constipation in children.
Appropriate breastfeeding technique is another important factor as poor technique leads to poor latching and inadequate feeding of the baby. This further compromises breast milk supply due to poor breast stimulation. Besides that, poor feeding habits with persistent distractions such as electronic media, music, movies and even games during feeding time take the child’s attention and interest away from his or her meal. Ineffective and inappropriate handling of the child’s temperament during feeding time such as force feeding can also result in food refusal by the child in the long term.
Beyond identifying the challenges in parenting and nurturing that have contributed to FTT, it is important for us to also look at the possible underlying organic or medical causes of this condition.
For example, gastro-esophageal reflux disease, or GERD, which causes severe pain and discomfort after feeding, may cause a child to refuse to eat and this can have a negative effect on his or her calorie intake. Chronic or persistent diarrhea due to intestinal infection, structural abnormalities of the bowel or even inflammatory bowel disorder may result in significant nutrition and calorie loss that jeopardises the overall growth of the child.
Other chronic illnesses, such as urinary tract infection, recurrent chest infection and congenital heart diseases (especially in heart failure), may result in poor appetite or even interruption in feeding due to shortness of breath. Excessive energy expenditure due to the chronic illness will further worsen growth retardation of the child as calorie intake and retention requirement for the child’s growth will not be met. Additionally, some structural abnormalities of the mouth and throat, such as cleft lip or palate and narrowing of the esophagus may also result in feeding difficulties which affects overall growth.
How do I know whether my child is growing adequately?
Every child’s growth should be monitored at a fixed interval from birth till the age at which the child starts going to school. This monitoring process should include all the growth parameters, namely; weight, height and head circumference (till the child is at least five years old) and must be plotted on the standard growth charts according to gender.
The following parameters are accepted as the standard guide to diagnose or screen for FTT:
- When a child weighs less than the 3rdor 5th percentiles on more than one occasion
- When a child weighs less than 80% of the ideal body weight for his or her age
- When a child’s weight crosses the two percentile lines
It is important to note that there are children who will experience a brief period where their growth and development may slow down just as indicated above. Nevertheless, if they remain healthy and active physically, with appropriate developmental milestone and school performance, this shouldn’t be a cause for concern. These kids may experience a period of “catch-up growth” following this slowdown and they will eventually be back to the normal percentiles on the growth chart. Further questioning may even reveal a similar history in the family, either of their siblings or parents. This condition is known as “constitutional growth delay” and is entirely normal. Additionally, there are parents who are of small built and they can pass on this genetic trait to their offsprings. This is known as ‘familial short stature’ and should not be anything to worry about.
When should I be concern of my child’s growth and when should I seek the doctor’s advice?
In general, if there is an obvious change in the child’s appetite and eating pattern which result in a remarkable drop in weight, as well as changes in overall behavior such as reduction in activity, disinterest in playing, disinterest in his or her surroundings, feeling and appearing sleepy and lethargic most of the time, being unhappy and throwing frequent tantrums or a delay in basic developmental milestones such as sitting up, walking and talking at the usual age, a doctor’s advice and attention will be needed.
My child doesn’t seem to like drinking milk after the age of one. Should I be concern?
After the age of six months, milk shouldn’t be the main diet for the growing child. Instead, it should slowly be replaced by a variety of complementary diet. This is because, milk alone is no longer sufficient to meet the nutritional requirements for growth during this age, and that is why a ‘weaning diet’ should be introduced. In fact, studies have shown that when solid food is introduced too early (earlier than four months old) or too late (later than seven months old), a child will be at a higher risk of food allergies. The recommended ideal age for weaning is between four to six months.
Will a delay in the introduction of food groups with high allergenic potential such as shellfish, peanuts, legumes and eggs prevent food allergies?
Not necessarily so. Studies have shown that the early introduction (between four to six months of age) of food with high allergenic potential as mentioned is not associated with the increase rate of food allergy. On the flip side, it actually helps prevent food allergies, particularly in breastfed children. This even applies to children with a high risk of developing food allergies due to a strong family history and the introduction of a gluten diet to children who are at a high risk of developing celiac disease.
About the Writer :
Dr. Ng Ruey Terng has had over 12 years of experience in the medical field. Starting out at Hospital Kuala Lumpur in 2002, he then obtained his Masters of Paediatrics from University Malaya and received his Membership of the Royal College of Paediatric and Child Health (MRCPCH) from the United Kingdom after. In addition to practicing as a clinical specialist in paediatrics, he is also a medical lecturer and clinical fellow in paediatric gastroenterology, hepatology and nutrition at University of Malaya Medical Centre (UMMC) where he has been practicing for the past three years.