Failure to Thrive, Congenital Heart or Renal Disease, Infants with Malabsorption
Failure to Thrive (FTT)
Definition1: Traditionally, FTT was characterized as “organic failure to thrive” in which the child’s growth failure was ascribed to a major medical illness, and “nonorganic failure to thrive” which was attributed primarily to psychological neglect or “maternal deprivation”. We now recognize that in all cases of “nonorganic” FTT and in many cases of “organic” FTT, the cause of growth failure ismalnutrition, whether primary or secondary. Malnutrition not only jeopardizes the child’s growth but also impairs the child’s immune system and contributes to concurrent and long-term deficits in development and behavior.
Management of failure to thrive includes an assessment of and therapy for malnutrition as well as an evaluation of the social and medical context in which they occur.Situations that can lead to failure of a child to appropriately gain weight and grow include:
- Inadequate caloric intake.These could include children that are hypersensitive to texture as in children with autistic disorders or children that are on severely restricted diets as in Dan diets, ketogenic diets or vegan diets. These children need to be followed closely for adequate nutrient (protein and vitamin) and micronutrient intake. Failure to thrive due to inadequate caloric intake also may be the result of neglect or abuse and if suspected must be reported to DHHS.
- Ahypermetabolic staterequiring a higher than expected need for calories. Some of these disorders may require a lower volume of fluid intake as well as an increase in calories resulting in a higher caloric density.
- Chronic respiratory disorderslike bronchopulmonary dysplasia
- Chronic infectious diseaseslike HIV
- Cardiovascular disorders and renal diseases
- Malabsorptionof food resulting in inadequate energy retention.
Many infants with congenital heart disease, chronic lung disease and/or kidney disease have the challenge of living in a catabolic state requiring more calories for growth than most other children. These children have the dual challenge of being easily overwhelmed by an increase in fluids, thus requiring a high density of calories in a low volume of fluid. Any child with a diagnosis of congenital heart disease, renal disease or chronic pulmonary disease should be approved for the use of Similac PM 60/40 if prescribed by their provider.
Malabsorption can occur in infancy for a variety of reasons including injury to or congenital abnormalities of the intestinal mucosa or loss of significant intestinal surface area, such as in short gut syndrome, which may impair digestion and absorption. Decreased pancreatic enzyme production, as in cystic fibrosis, and cholestatic liver disease (biliary atresia, alpha-1-antitrypsin deficiency, etc.) particularly impair digestion and absorption of dietary fats and fat-soluble vitamins.
- Infants with abnormalities of the intestinal mucosa or with shortened intestinal length may require an extensively hydrolyzed or amino acid-based formula with glucose polymers rather than disaccharides.
- Infants with pancreatic insufficiency or cholestasis may require a medium chain triglyceride-enriched formula and supplemental fat soluble vitamins.
Care of children with malabsorption should proceed under the guidance of a pediatric gastroenterologist or pulmonologist.
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