Consensus Guidelines for Inadequate Growth (Previously “Failure to Thrive”)

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Northern California Pediatric Hospital Medicine Consortium

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Table of Contents

• Executive Summary (Objectives and Recommendations)
• Full Consensus Guideline
• Appendix 1: Inadequate Growth Admission Pathway
• Appendix 2: Inadequate Growth Inpatient Pathway
• Appendix 3: Pre-Admission and Transfer Checklists
• Appendix 4: Nutrition and Growth
• Appendix 5: Detailed History and Physical
• Appendix 6: Differential Diagnosis for Inadequate Growth

 

Executive summary

Objectives

• Standardize admission criteria and management of children younger than 5 years of age hospitalized for Inadequate Growth (previously failure to thrive)

• Avoid unnecessary lab testing and invasive work up, recognizing that the most common cause is inadequate caloric intake

• Support patients and families in safe, effective nutritional and follow up plans prior to discharge

Recommendations

• “Inadequate Growth” is a more descriptive and less judgmental term than “Failure to Thrive”

  • A practical working definition of the issue is “Inadequate growth over time, relative to standard growth charts, after considering age, gender, and genetic variation.”

  • Inadequate growth is the result of insufficient usable nutrition through inadequate intake of calories, insufficient calorie absorption, or excessive calorie expenditure.

• Hospital admission is not necessary for most children with Inadequate Growth and is often deleterious to the long-term care of many children with mild to moderate intake deficiency.

• Working with a primary care pediatrician, subspecialist, or community hospital clinician to determine whether the patient meets admission criteria is imperative.

•  Admission Criteria for non-medically complex children < 5yrs of age

  • Concern for underlying disorder requiring urgent workup (i.e., CHF, inborn error of metabolism)

  • Failure to respond to outpatient feeding plan/interventions over a reasonable period

  • Severe malnutrition or dehydration / seriously ill

  • Suspected abuse/ neglect

  • Desire for needs assessment in terms of feeding support/observed feeds (e.g., observation of mixing formula, lactation support, mechanics, and timeliness of feeding)

  • Need for teaching/coordination of supplies for initiation of NG feeds

• Routine labs and imaging are not recommended for patients without underlying conditions.

• Upon admission, obtain naked weight, thorough history and physical, and monitor patient on appropriate feeds for age with strict intake and output recordings. Consider RD, dysphagia, and social work consult.

• If patient is unable to demonstrate appropriate weight gain for age or feed safely by mouth, obtain subspecialty consult at that point.

• Discharge criteria:

  • Successful feeding plan in place, family has obtained all necessary supplies and teaching, follow up appointments are established, no concern for ongoing dehydration or inability to take in adequate calories for growth. Depending on age of the patient, demonstration of weight gain in the hospital may not be necessary prior to discharge.

Methods

This guideline was developed through local consensus based on published evidence and expert opinion as part of the UCSF Northern California Pediatric Hospital Medicine Consortium.

 

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Consensus Guidelines for Inadequate Growth (Previously “Failure to Thrive”)

Introduction

Criteria for use of guideline

• Inclusion criteria:  non-medically complex children < 5yrs of age admitted to the hospital solely for evaluation of inadequate growth or for whom hospitalization for inadequate growth is being considered.

• Exclusion criteria: Children with medical complexity, comorbidities, or clear organic pathology contributing to inadequate growth (e.g., profoundly neurologically impaired, metabolic disease, malabsorption, congenital heart disease). Children and adolescents >5yrs of age.

Background

• Definitions

  •  Definitions of “Failure to Thrive” (FTT) are fraught with difficulties and there is no consensus definition. Additionally, the term “Failure to Thrive” has potentially judgmental and negative connotations and has fallen out of favor. For the purpose of this guideline, we have decided to use instead “Inadequate Growth” which is more descriptive of the issue, with a practical working definition of “Inadequate growth over time, relative to standard growth charts, after considering age, gender, and genetic variation.”

  • This diagnosis should be considered in a child who is <3-5th% weight-for-length, who is crossing two major percentile lines on growth curves, or whose growth of length and/or head circumference are decelerating.

  • Of note, infants and young children may cross major percentile lines on growth curves during a normal course of growth.

  • Criteria for severe malnutrition are better established but still subject to some limitations: (see Appendix 4)

    • Weight/length z-score -3 or worse

    • BMI for age z score -3 or worse

    • Length z score -3 or worse

    • Mid-upper arm circumference z score -3 or worse

    • Weight gain velocity <25% of norm

    • Inadequate intake (<25% of estimated caloric/protein needs)

• Causes

  • Inadequate growth is the result of insufficient usable nutrition through inadequate intake of calories, insufficient calorie absorption, or excessive calorie expenditure.

• Epidemiology

  • From NASPGHAN (2019): About 1% of all children admitted to any hospital and 3 to 5% of all children admitted to a Children’s Hospital have inadequate growth (previously “failure to thrive”). About 10% of clinic visits in urban and rural outpatient settings are for concerns about growth and development. Up to 16% of 0–4-year-old children of families with low income are "stunted."

  • 80% of children with Inadequate Growth present before 18 mo. of age

  • The average cost of a hospitalization is ~$5000

  • Difficulty with retrospectively measuring the impact of Inadequate Growth – the discharge diagnosis may be different

Evaluation and Management

Admission (See Appendix 1-2 for Admission and Inpatient Pathways)

• Hospital admission is not necessary for most children with Inadequate Growth and is often deleterious to the long-term care of many children with mild to moderate intake deficiency.

• Before or at the start of the hospital admission, discussion with PCP or admitting subspecialists about concerns leading to hospitalization and attainable goals of hospitalization is imperative. Obtain NBS and any other pertinent results (see Appendix 1-3)

• Admissions on M-Th during daytime hours are preferable (when resources such as feeding therapists, nutrition, social work, specialists, and more specific diagnostic studies are readily available).

• Admission criteria:

• • Concern for underlying disorder requiring urgent workup (i.e., CHF, inborn error of metabolism)

  • Failure to respond to outpatient feeding plan/interventions over a reasonable period (see Appendix 1-3)

  • Severe malnutrition or dehydration / seriously ill

  • Suspected abuse/ neglect

  • Desire for needs assessment in terms of feeding support/observed feeds (e.g., observation of mixing formula, lactation support, mechanics and timeliness of feeding)

  • Need for teaching/coordination of supplies for initiation of NG feeds

History:

General Recommendation: Avoid blaming. Understand that many parents hold themselves personally responsible for their child’s inadequate growth or development or think that healthcare providers think they are; be supportive. (See Appendix 5 for more details)

• Maternal medical and pregnancy history

• Neonatal medical history

• Developmental milestones/concerns

• Recurrent infections

• Feeding and nutritional history

  • Age adjusted and age dependent diet diary

  • Food or formula intolerance

  • Stooling history

  • Reflux or emesis

  • Dysphagia

  • Diarrhea (malabsorption signs/symptoms)

  • Tiring or sweating with feeds

• Detailed Psychosocial history

  • Make sure to complete Social Determinants of Health Screening (i.e., screening for financial strain, food insecurity...etc.)

Physical Exam:

Focus on signs of underlying medical conditions including genetic disorders, metabolic conditions, congenital infections, other underlying medical conditions, signs of abuse or neglect. (See Appendix 5 for more details)

Other Data

• Growth charts: Use of appropriate growth charts is imperative. Fenton (for prematurity), CDC-WHO, WHO, and charts specifically for certain genetic conditions or disease patterns/syndromes, exist. (See Appendix 4)

• Observed feeds:

  • Evaluation of the child while feeding: Suck/swallow, presence of choking, coughing, stridor, spit-up, emesis, fatigue, diaphoresis.

  • Feeding techniques (pacing of feed, forced feeding, interpretation of feeding/hunger cues)

  • Feeding environment: distractions, positioning, etc.

  • Evaluation of the child–parent dyad (conflict over feedings, poor limit setting, lack of discipline, mealtime disruption)

  • Perceptions of parents/caregivers regarding the problem

• Newborn screen results – should be obtained PRIOR to hospitalization. (See Appendix 3)

• Daily weights and other measurements: There is some debate about the validity of daily weights, as an infant can empty a large bottle, or have a large bowel movement/urine output immediately before the daily weight. It is important to look at the weight trend. Weights should ideally be obtained on the same scale, naked. Accurate lengths using a stadiometer are required. Head circumference is best obtained by, or at least verified by an experienced observer/recorder. Discrepancies or out-lying measurements should trigger repeat measurements.

• Strict Is/Os: should be ordered for all hospitalized patients with Inadequate Growth.

• Calorie count: Order for all children taking solid foods. Formula-fed babies (or babies taking expressed breast milk from a bottle) do not need a calorie count as caloric intake can be determined from the volume of recorded intake. A calorie count is difficult in a breastfed baby given that the volume is unknown. Intake is instead documented as minutes feeding on each breast, which can still be useful as there are standard expectations around how long it should take a baby to feed. Weighing an infant immediately before and after feeds can be done if it is important to determine exactly how much volume an infant is receiving from breastfeeding. Alternatively, milk may be pumped and fed from a bottle for more exact intake measurement. Usually this is not necessary and is not typically done, though may be indicated in specific scenarios.

Labs

• There is no evidence that a panel of routine laboratory screening tests for Inadequate growth is indicated in the absence of clear suspected underlying condition or guiding evidence from the history, physical, and feeding assessment. The yield of a standard lab panel in these children is exceedingly low.

• Refeeding labs: Routine refeeding labs in otherwise stable patients admitted for inadequate growth should not be obtained.

Imaging

• Imaging studies are NOT routinely needed but may be warranted based on history/physical. For ex:

  • Consider skeletal survey for occult trauma IF physical abuse is suspected or physical signs are present on exam, consider brain MRI IF examination reveals microcephaly, macrocephaly, or congenital malformation or IF abusive head trauma, or consider pyloric US if history of vomiting/olive palpated on abdominal exam.

Consults

• Feeding therapist: While MDs and RNs should observe feeding, a formal feeding assessment is best documented by a feeding therapist and/or a lactation specialist if the child is breastfeeding. Thus, a dysphagia consult should be requested for all Inadequate Growth admissions and/or a lactation consult for all breastfeeding infants.

• Nutrition: Consult the clinical nutritionist for a detailed nutritional analysis and growth assessment as well as guidance in developing and implementing an individualized caloric supplementation plan. Children with Inadequate Growth will need supplemental caloric intake for catch-up growth. Nutritional consultation during initiation of a high-calorie age-appropriate diet is indicated. For infants, this may include recommendations for hypercaloric formula.

• Social work: An important part of the multidisciplinary team, particularly in cases in which housing/food insecurity or abuse/neglect are suspected to be a contributing factor.

• Subspecialists: Routine subspecialty consultation is discouraged. Sometimes, there are specific indications for gastroenterology consultation (e.g., suspected malabsorption), endocrinology consultation (e.g., short stature), or neurologic consultation (e.g. microcephaly). Inadequate Growth alone should not trigger routine subspecialty consultation.

Interventions

• All efforts should be made to allow the child to feed orally. Indications for NG tube supplementation might include failed outpatient management despite a several (3-6) month trial of increased oral caloric supplementation, or clear evidence after dysphagia consultation that oral-motor dysfunction is a likely contributor to poor growth.

• Should be guided by specific diagnosis

• Children with Inadequate Growth will need supplemental caloric intake for catch-up growth. Often supplementation starts with a 10-20% increase above the dietary reference intake for the child’s expected weight for age (or reported home intake). (See Appendix 4) Some children with Inadequate Growth need up to a 50% increase. Nutritional consultation during initiation of a high-calorie age-appropriate diet is indicated.

• General best practices

  • Eliminate high sugar “empty calories” such as soda/juices

  • In the older young child, offer solids before liquids

  • Consider vitamin and /or mineral supplements, especially zinc and iron

  • PROVIDE SUPPORT and EDUCATION to the FAMILY

    • Avoid blaming

    • Provide modeling behaviors regarding responses to cues, food preparation and feeding practices

    • Provide opportunities for positive reinforcement of desired behaviors in parents or caregivers, as well as the child

    • Avoid distractions during mealtimes: TV use, loud music, cell phone use, high traffic areas

Discharge

• There is no evidence that the traditional approach of documenting multiple days of in-hospital weight gain alters outcomes. Weight gain is expected over weeks to months, not days. If appropriate outpatient weight monitoring is arranged, keeping the child hospitalized solely to document weight gain may not be necessary.

• Discharge criteria:

  • No evidence of severe malnutrition which would require inpatient monitoring for refeeding syndrome.

  • No evidence of dehydration and assurance that the child can maintain goal hydration.

  • No serious intercurrent or underlying medical problem.

  • No psychosocial circumstances putting the child at risk for immediate harm.

  • Evidence that the patient can take sufficient calories to reasonably expect growth in the outpatient setting.

    • In infants less than 6mo of age, daily weight gain can be expected (see Appendix 4)

    •  In toddlers and children less than 5yrs of age, no further weight loss during the admission should be demonstrated prior to discharge

  • If NG feeds were initiated, appropriate parental teaching and home-based support has been arranged.

  • If parental mental health issues are identified, appropriate referrals have been made and follow-up plans firmly established.

  • There is a clear and detailed follow-up plan in place for close (weekly) outpatient weight monitoring.

    •  A critical part of discharge readiness includes verbal communication with the PCP. The discharge summary should document a clear plan about who specifically is following the child’s outpatient growth and feeding (often the PCP, but might be another provider or a gastroenterologist in certain cases). If NG feeds were initiated, it is mandatory to discuss with the PCP (and document in the discharge summary) who will manage the NG tube and any feed changes after discharge

  • Discharge instructions, at a minimum, should include (in the preferred language of the patient’s family):

    • Specific times/dates/locations of follow up appointments

    • Nutrition plan (mixing formula, amounts, timing, etc.)

    • PT/OT plan (positioning, bottle type, etc.)

    • NG/pump teaching if applicable

Transfer Considerations

**If in doubt, tertiary pediatric hospitalists are available via the access center to discuss (consider how are they providing a higher level of care).

Consider transfer to a tertiary referral center if:

1. Patient is not gaining weight in the hospital on appropriate nutrition.

2. If there is evidence of underlying disease or pathology requiring in-person subspecialists to manage.

   1. Consider having a subspecialist part of the transfer call.

3. If there is no available in-house dysphagia/OT consultant, dietician, or there are social needs or supports not available at the community center that are directly contributing to the diagnosis.

Prior to transfer, please see the Appendix 3 for documentation to send with the patient for highest chance of successful outcomes at the accepting institution.

References

Fiore, Darren, in conjunction with Steve Wilson, MD, Arpi Bekmezian, MD, and Karen Sun, MD (hospital medicine), Helen Sang, OTR (occupational therapy), and Hanna Kirsch, RD (registered dietician). “Standardizing Inpatient Failure to Thrive Management” UCSF-Mission Bay PHM Division Guideline, 12/2013.

Coe ME, Castellano L, Elliott M, Reyes J, Mendoza J, Cheney D, Gardner T, Austin JP, Lee CC. Incidence of Refeeding Syndrome in Children With Failure to Thrive. Hosp Pediatr. 2020 Dec;10(12):1096-1101. doi: 10.1542/hpeds.2020-0124. Epub 2020 Nov 9. PMID: 33168566.

Homan, Gretchen. “Failure to Thrive: A Practical Guide.” American Family Physician 2016; 94(4).

Jaffe, A.C.: Failure to Thrive: Current Clinical Concepts; Pediatrics in Review 2011;32;100; vol32 No.3 March 2011

Motil, K.J.: Poor weight gain in children younger than two years: Etiology and evaluation; UpToDate: literature review current through 12/2018 (last updated 1/2019).

Puls, H.T.: Failure to Thrive Etiology and In-Hospital Weight Gain; AAP Grand Rounds 2/2019

Puls, H.T.: Failure to Thrive Hospitalizations and Risk Factors for Readmission to Children’s Hospitals; Hospital Pediatrics; vol. 6, Issue 8, August 2016.

Sironak, A.P. : Failure to Thrive; Medscape; 5 Nov 2018

Thompson, R.E.: Increased Length of Stay and Costs Associated With Weekend Admissions for Failure to Thrive; Pediatrics 2013; 131;e805. Feb 25 2013

Sills, R.H. (1978). Failure to thrive: the role of clinical and laboratory evaluation. Archives of Pediatrics & Adolescent Medicine, 132(10), 967

Berwick, D.M., Levy, J.C., & Kleinerman, R. (1982). Failure to thrive: diagnostic yield of hospitalisation. Archives of Disease in Childhood, 57(5), 347-351.

Fryer Jr, G. E. (1988). The efficacy of hospitalization of nonorganic failure-to-thrive children: a meta-analysis. Child abuse & neglect, 12(3), 375-381.

Hobbs, C., & Hanks, H. G. I. (1996). A multidisciplinary approach for the treatment of children with failure to thrive. Child: care, health and development,22(4), 273-284.

Wilson, S.D. Failure to Thrive. 2007. In Zaoutis, L and Chiang, V. (ed): “Comprehensive Pediatric Hospital Medicine,” Philadelphia: Elsevier, Inc.

Wood, J. et al. (2009). Cincinnati Children’s Best Evidence Statement. Failure to Thrive Treatment Protocol

 

Published Children’s Hospital Guidelines / Pathways

Seattle Children’s Faltering Growth Pathway:
https://www.seattlechildrens.org/globalassets/documents/healthcare-professionals/clinical-standard-work/faltering-growth-pathway.pdf

 

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APPENDIX 1: INADEQUATE GROWTH ADMISSION PATHWAY

 

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APPENDIX 2: INADEQUATE GROWTH INPATIENT PATHWAY

 

 

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APPENDIX 3: Pre-Admission and Transfer Checklists

PCP Checklist: Please attach or fax the following documents to the packet:

• Newborn screen results

• Growth chart with as many data points as possible (HC, weight, and length); timeline of inadequate growth

• Birth H&P and newborn nursery discharge summary

• Attach most recent note, and/or a note containing the following elements:

  • Pre- and perinatal Hx

  • Past medical history

  • Medications/Supplementation

  • Family history

  • Psychosocial history

  • Physical exam

  • Detailed feeding history

  • Stooling and voiding pattern

• Developmental screens (ASQ etc.)

• Lactation consultant note (if applicable)

• OT/ST note (if applicable)

• Dietician note (if applicable)

• Social worker/case manager note (if applicable)

• Has this patient been referred to any subspecialists or services? Y / N

  • Regional center

  • Feeding clinic/OT/ST

  • Dietician

  • Lactation consultant

  • Social worker

• Call to hospitalist through Access center for handoff

Transfer checklist:

• H&P (containing at least the PCP checklist items)

• Discharge summary/transfer note with hospital course and interventions:

  • OT/ST; RD; lactation evaluation and observations?

  • Description of observed feeds

  • Type, volume, frequency of feeds

  • Intake and output:

    • Weight and Intake Tracker (see Appendix 4)

  • Labs/workup, if any

  • Medications, if any

  • Any social or medical concerns arising during admission?

• SW notes

• OT/ST notes

• Lactation notes

• A copy of the documentation from the PCP

• Phone call to hospitalist through Access Center for handoff at (877) 822–4453

 

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APPENDIX 4: Nutrition and Growth

1. Growth Velocity References

2. Energy Requirement References

3. Formula and Fortification Recipes

4. Intake and Growth Tracker Template

 

I. Growth Velocity References

1. WHO Growth Charts: Boys 0-24 months of age: length and weight for age percentiles

2. WHO Growth Charts: Boys 0-24 months of age: head circumference and weight for length percentiles

3. WHO Growth Charts: Girls 0-24 months of age: length and weight for age percentiles

4. WHO Growth Charts: Girls 0-24 months of age: head circumference and weight for length percentiles

5. CDC Growth Chart: Boys 2-20yrs: stature and weight for age percentiles

6. CDC Growth Chart: Boys 2-20yrs: BMI for age percentiles

7. CDC Growth Chart: Girls 2-20yrs: stature and weight for age percentiles

8. CDC Growth Chart: Girls 2-20yrs: BMI for age percentiles

II. Energy Requirement References

 

 

 

III. Formula and Fortification Recipes

Mixing Instructions for Concentrated Infant Formulas at HOME

These recipes are for standard, over the counter, infant formulas. The recipes assume that 20 kcal/ oz is reconstituted from powder in the ratio of 1 scoop (provided in the can) of powder to 2 fluid ounces of water or concentrated liquid mixed 1:1 with water.

Formula Made from Powder

Concentration	Level Scoops	Water (oz)	Final Volume (oz)
20 kcal/oz	1	2	2.2
22 kcal/oz	3	5.5	6.1
24 kcal/oz	3	5	5.7
27 kcal/oz	3	4.25	4.9
30 kcal/oz	4	5	5.9

These recipes are not applicable for Similac Neosure, EnfaCare or Neocate.

Always read package directions for proper handling of powdered formula. (i.e., packed versus unpacked scoop)

NOTE: Large volume recipes should be calculated by the RD for each individual formula due to significant variation in grams/cup and displacement.

Formula Made from Concentrated Liquid

Concentration	Concentrate (oz)	Water (oz)	Final Volume(oz)
20 kcal/oz	1	1	2
22 kcal/oz	2.5	2	4.5
24 kcal/oz	3	2	5
27 kcal/oz	2	1	3
30 kcal/oz	3	1	4

Formula Made from Concentrated Liquid (Large Volume)

Concentration	Concentrate (oz)	Water (oz)	Final Volume(oz)
20 kcal/oz	13	13	26
22 kcal/oz	13	10.5	23.5
24 kcal/oz	13	8.5	21.5
27 kcal/oz	13	6	19
30 kcal/oz	13	4	17

 

Similac Neosure (Abbott)/Enfamil EnfaCare (Mead Johnson)

Concentration	Level Scoops	Water (oz)	Final Volume (oz)
20 kcal/oz	2	4.5	5
22 kcal/oz	2	4	4.5
24 kcal/oz	3	5.5	6
27 kcal/oz	5	8	9
30 kcal/oz	3	4.25	5

Maternal breast milk fortification recipes

Infant formulas included in the recipes:

*All:

• Similac: Pro-Advance, Organic, Sensitive, Total Comfort, Isomil, PM 60/40, Neosure
• Enfamil: Infant +/- NeuroPro, Enspire, Gentelase, Enfacare, Nutramigen
• *Use unpacked, level teaspoons or scoops when measuring powder for these formulas

†Enfamil Pregestimil:

• Use packed teaspoons or scoops when measuring Pregestimil formula powder.

 

III. Intake and Growth Tracker Template

Patient Name:             Estimated Needs:

Record of Intake

Date	Wt (kg)	Intake	Total ml	kcal	protein	Comments: bottle/cup/type of milk/formula/etc.
		EBM/Formula:
		Milk
		Other
		Solid Foods
		TOTAL/kg
Date	Wt (kg)	Intake	Total ml	kcal	protein	Comments: bottle/cup/type of milk/formula/etc.
		EBM/Formula:
		Milk
		Other
		Solid Foods
		TOTAL/kg
Date	Wt (kg)	Intake	Total ml	kcal	protein	Comments: bottle/cup/type of milk/formula/etc.
		EBM/Formula:
		Milk
		Other
		Solid Foods
		TOTAL/kg
Date	Wt (kg)	Intake	Total ml	kcal	protein	Comments: bottle/cup/type of milk/formula/etc.
		EBM/Formula:
		Milk
		Other
		Solid Foods
		TOTAL/kg
Date	Wt (kg)	Intake	Total ml	kcal	protein	Comments: bottle/cup/type of milk/formula/etc.
		EBM/Formula:
		Milk
		Other
		Solid Foods
		TOTAL/kg

 

Nutrition and Growth Appendix References

1. Danner E, Joeckel R, Michalak S, Phillips S, Goday PS. Weight velocity in infants and children. Nutr Clin Pract. 2009 Feb-Mar;24(1):76-9. doi: 10.1177/0884533608329663. PMID: 19244151.

2. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements
   http://www.nap.edu/catalog/11537.html

3. Goldberg DL, Becker PJ, Brigham K, Carlson S, Fleck L, Gollins L, Sandrock M, Fullmer M, Van Poots HA. Identifying Malnutrition in Preterm and Neonatal Populations: Recommended Indicators. J Acad Nutr Diet. 2018 Sep;118(9):1571-1582. doi: 10.1016/j.jand.2017.10.006. Epub 2018 Apr 11. PMID: 29398569.

4. Growth Charts - WHO Child Growth Standards. Published January 11, 2019.
   Accessed May 14, 2021. https://www.cdc.gov/growthcharts/who_charts.htm

 

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APPENDIX 5: Detailed History and Physical

Focused Feeding and Elimination History

Factors	Evaluate
Breastfeeding	Frequency, length, number per day, longest interval between feedings, night vs day One or both breasts, history of engorgement, softer after feeding, use of nipple shield, any pain or difficulty with latch, nipple shape before and after feed If pumping, how much is produced (before or after feed) See or hear baby swallow (repetitive clicking noise, milk at corner of mouth) Falling asleep at breast (if yes, how long after initiating feed) Supplemental feeds (including fluids or solids) other than human milk or formula
Bottle Feeding	Frequency, length, amount per feed and per day, longest interval between feedings, night vs. day Formula mixing recipe, type, and concentration Bottle type, nipple type and size Food (including fluids or solids) other than human milk or formula
Dietary History	Dietary recall of typical daily intake Feeding problems – picky eating, food refusal, anorexia, food avoidance Excessive sugar sweetened beverages Taking greater than recommended (for age) volume of milk or formula Any restrictive or specialty diets (e.g., vegan) Any medications or supplements (including for child or mother if breastfeeding)
Indicators of Pharyngeal Swallow Dysfunction	Coughing, choking, or gagging with feeds Wet, gurgled vocal quality during or immediately after feeding Frequent upper respiratory tract infections, fevers, or pneumonia
Reflux	Coughing, choking, or gagging with feeds Spitting up/vomiting/rumination Respiratory symptoms with feeding Arching, irritability or discomfort with feeds Pain with swallowing or chest pain
Social	Caregivers at home, which caregiver(s) feed the child Is caregiver appropriately following child’s feeding schedule, need help with childcare, and/or receiving state or federal financial or nutritional support If bottle fed, does family have concerns obtaining formula Breast pump availability and type, if applicable Psychosocial stressors (Social needs, parental mental health or substance use disorders, family discord)
Elimination	Number of wet diapers and stool diapers per 24 hours Stool appearance (consistency, color) Presence of orange or red crystal/powder in diaper Presence of blood or mucus in stool Chalky, pale or acholic stools

 

History and Physical

General	Overall findings of malnutrition (e.g., cachectic appearance, decreased subcutaneous fat, decreased muscle bulk, relative macrocephaly) Fevers Lack of caregiver bonding or responsiveness to patient (single providers’ observations are likely insufficient to assess) Dysmorphic features (e.g., syndromic appearance) Detailed birth history (gestational age, weight, NICU course, maternal infections)
HEENT	Macrocephaly/microcephaly Jaundice or scleral icterus Nasal congestion or obstruction Cleft lip or palate or other palate dysmorphology Macroglossia Ankyloglossia (lip or tongue tie) Micrognathia or retrognathia
Respiratory	Stridor or stertor --At rest vs. during a feed Difficulty breathing Choking or gagging Tachypnea Abnormal breath sounds (e.g., wheezing, crackles)
Cardiac	Sweating and/or fatigue with feeds Murmurs Diminished or absent peripheral pulses
GI	Hepatosplenomegaly Abdominal distension Constipation, palpable stools Diarrhea Blood or mucus in the stool Vomiting, retching, regurgitation, rumination, spit-ups
Skin	Skin abnormalities (e.g., rash, diaper area/skin breakdown, birth marks, severe atopic dermatitis)
Neurologic	Depressed mental status, inconsolability and/or sleepiness Developmental delay Abnormal movements Abnormal tone
Immunology	Frequent infections

 

Observation of Feeding
If any of the following indicators are present, consider consulting speech therapy and/or lactation specialist.

• Decreased state for oral feeding (e.g., inconsolable, unable to stay awake, signs of discomfort)
• Unable to maintain latch on nipple
• Oral loss of fluid
• Observed signs of distress: coughing, congestion, changes in vital signs
• Feeding inefficiency: infant feedings lasting > 30 minutes
• Lack of caregiver awareness or response to infant’s cues for feeding readiness and disengagement

References

Children’s Hospital of Philadelphia - Inpatient Clinical Pathway for Evaluation/Treatment of Infants with Malnutrition (Failure to Thrive) < 12 months

https://www.chop.edu/clinical-pathway/infant-malnutrition-ftt-clinical-pathway

 

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APPENDIX 6: Differential Diagnosis for Inadequate Growth

Inadequate caloric intake

1. Gastroesophageal reflux

2. Inadequate breast milk supply or inadequate number of feeds

3. Ineffective latching or mechanical feeding difficulties (cleft lip/palate,
   micrognathia)

4. Incorrect formula preparation

5. Neglect or abuse

6. Parental mental illness

7. Poor feeding habits, inadequate offering or supervision

8. Poor oral neuromotor coordination.

9. Toxin induced gastrointestinal upset (e.g., heavy metal poisoning lead or other leading to anorexia, constipation, abdominal pain; insecticides/herbicides)

10. Poverty

11. New psychosocial stressor (e.g., divorce, job loss, new sibling, etc.)

12. Sensory-based feeding disorders in children with developmental disorders (e.g., autism spectrum disorder)

Inadequate nutrient absorption

• Anemia, iron deficiency

• Biliary atresia

• Celiac disease

• Chronic gastrointestinal conditions (e.g., irritable bowel), infections (bacterial overgrowth, C. diff., parasitosis, or rarely gastric tuberculosis).

• Cystic Fibrosis

• Inborn errors of metabolism

• Milk protein allergy

• Food Protein Induced Enteropathy (FPIES)

• Pancreatic cholestatic conditions

Increased metabolism

• Chronic infection (e.g., HIV/AIDS, tuberculosis)

• Chronic lung disease of prematurity

• Congenital heart disease

• Hyperthyroidism

• Inflammatory conditions (e.g., asthma, inflammatory bowel disease,
  rheumatologic conditions)

• Malignancy

• Renal Failure

 

Disclaimer

These clinical practice guidelines are based upon the evidence-based consensus opinions of consortium members affiliated with UCSF Benioff Children's Hospitals. They are intended to guide pediatric/neonatal providers, but do not substitute for individual clinical judgment. Evaluation and treatment of specific patients should be adapted based upon the unique conditions of each patient, family and clinical environment.

Northern California Pediatric Hospital Medicine Consortium. Originated 06/2019. Approved by UCSF Pharmacy and Therapeutics Committee: 09/2021

This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0 International License