It’s important to note that infants show considerable variability in their early weeks, with five per cent shifting up or down two inter-centile spaces between birth and six weeks of age.
‘Failure to thrive’ is usually caused by the following factors:
- inadequate intake of food, through fussy eating or a poor diet
- impaired absorption of nutrients (where there could be the presence of mucosal disorders like coeliac disease)
- excessive energy expenditure (where there could be underlying chronic disease)
- excessive losses (eg; where a child might be experiencing chronic diarrhoea).
Assessment for ‘failure to thrive’
A GP assessment to determine ‘failure to thrive’ is vital to recognise and address these issues early, to prevent developmental or cognitive delays in a child. It is recommended that assessments for ‘failure to thrive’ include the following:
1. Medical history and physical examination to exclude red flag signs and symptoms suggestive of an underlying medical cause. Signs and symptoms to observe include:
- dysmorphic features
- edema
- hair colour/texture change
- heart murmur
- hepatomegaly
- altered mental status
- skin rashes
- wasting
- poor parent-child interaction
2. Dietary history to assess adequate calorie intake.
3. Assessment for possible underlying emotional and/or psychosocial issues.
Management options for GPs
If ‘failure to thrive’ is suspected, the following management options are available to GPs before a referral is made to a specialist:
1. Dietitian referral and input - with a view to assess and optimise calorie intake.
2. Consider urine, stool and blood investigations as clinically indicated, including:
- urine for microscopy, culture and sensitivity
- stool infection screen to look for: fat globules, fatty acid crystals, reducing substances, alpha 1 antitrypsin, faecal elastase (in presence of chronic diarrhoea)
- bloods: full blood count, urea and creatinine, electrolytes, liver function tests, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), glucose, thyroid function tests, coeliac screen, immunoglobulins and nutritional bloods (ie; calcium, magnesium, phosphate, B12, folate, vitamin D, zinc and iron studies)
3. Continue periodic surveillance and monitoring of growth parameters.
When to refer to a gastroenterologist
Referral should be made to a gastroenterologist in the presence of red flags (as indicated above), where there is suboptimal weight gain despite good calorie intake or when there is a suspected underlying medical cause.
Once the child is referred, a gastroenterologist will consider:
- Other investigations including gastroscopy and/or colonoscopy to assess for mucosal and absorption issues.
- Collaborative immunology, allergy, metabolic and genetics workup, as clinically indicated
- Multidisciplinary input and need for hospitalisation for observed feeding, nutritional rehabilitation and monitoring for re-feeding syndrome.
- Need for parenteral nutrition, in severe cases.
- Long term surveillance for optimal growth and cognitive development.
