FTT has 3 basic causes
1. Inadequate caloric intake. More than 80% of children with poor growth do not have an underlying medical disorder.7 The initial workup, therefore, should include a thorough dietary and psychosocial history. Find out exactly what the child eats, how often he eats, and what behaviors he exhibits at mealtimes.
A detailed prenatal history (including birth weight and pregnancy complications) and medical history for both the child and parents can identify underlying metabolic, endocrine, or familial disorders. It is always important to look for signs of child abuse, because children with FTT are more likely to be victims of abuse than normal-weight peers.3 That said, other factors are responsible for poor nutritional intake in as many as 80% of cases.8
2. Inadequate caloric absorption (mal-absorption). This usually results from persistent emesis or malabsorption. Emesis can be caused by reflux, obstruction, medication, food sensitivities, or underlying metabolic disease. Malabsorption most often arises from chronic diarrhea, celiac disease, protein-losing enteropathy, food sensitivities, or excessive juice intake.
3. Excessive caloric expenditure. Such expenditure is associated with underlying medical conditions such as congenital heart disease, chronic hypoxia (pulmonary disease), hyperthyroidism, metabolic disease (diabetes, renal tubular acidosis), chronic immunodeficiency, recurrent infection, or malignancy.
FTT accounts for between 1% and 5% of all pediatric hospitalizations.9 Children who continue to exhibit poor growth despite adequate outpatient evaluation should be admitted to the hospital. Admission is also indicated if abuse is suspected.
Recommendations
The American Academy of Pediatrics recommends that physicians consider child neglect as a cause of FTT, particularly in cases that do not resolve with appropriate medical intervention.3
The American Gastroenterological Association10 and World Gastroenterology Organization11 recommend that physicians consider celiac sprue in children presenting with FTT. Interestingly, the Cochrane Database of Systematic Reviews suggests that there is little systematic evidence to support routine growth monitoring in children.12