Definition:

1. Inadequate weight gain.
2. If weight falls below 5^th percentile for age, or if weight drops more than 2 percentile groups.
3. Compare average daily weight gain in grams to the normal values.

1. 0-3months        26-31g/day                              108 kcal/kg/d
2. 3-6months        17-18g/day                              108 kcal/kg/d
3. 6-9months        12-13g/day                              98 kcal/kg/d
4. 9-12months      9g/day                                      98 kcal/kg/d
5. 1-3 years          7-9g/day                                  102 kcal/kg/d
6. 4-6 years          6 g/day                                     90 kcal/kg/d

4. Weight drops off before height or head circumference is affected.
5. Often combination of both biologic and psychologic complications that require treatment.

1. Prenatal
1. IUGR: asymmetric IUGR with HC and length normal vs. symmetric.  Asymmetric with a better prognosis.
2. Symmetric IUGR- search for teratogens, congenital viral infections, or syndromes.
3. Prenatal exposure to drugs such as cocaine, marijuana, and cigarettes associated with lower birth weight, but not significant impairment in postnatal weight or height.
4. When microcephaly predates FTT, it suggests neurologic cause.
5. Correct for prematurity: HC until 18m, weight until 24m, height until 40m.
2. Newborn
1. Reflects incorrect formula preparation, failed breastfeeding, inadequate number of feedings.
2. Bonding problems with mother-infant.
3. Impediments to feedings- cleft lip/palate
3. Early infancy
1. Onset around 4 m/o suggests underfeeding- help family with support services.
2. If the child has been recently weaned from the breast, milk protein intolerance or improper formula preparation are possibilities.
3. Celiac disease, HIV, CF, GER, congenital heart disease, oral-motor dysfunction.
4.  Later infancy
1. Onset at 7-9mo. usually suggests an autonomy struggle- educate and counsel.
2. Food intolerance to recently introduced solid foods occasionally occurs.
5. Toddlers
1. Weight gain and appetite normally decrease after the first year- parents often become intrusive causing constant battles, food wars.
2. Acquired illness, significant stress (birth of sibling) can precipitate weight loss at this age.

1.  Red flags:

2. Dietary history- parents account of all meals, snacks, drinks, where, when, how and by whom the child is fed.  Assess parental attitudes and eating habits.
3. Common problems:
1. Overdilution of formula
2. Cereal, food in bottle
3. Excessive intake of juice, soda, or water
4. Inappropriate food consistency
5. Infrequent feedings
6. No set feeding times
7. No high chair
8. Grazing
9. Distractions
10. Struggles over feeding

4. Physical examination
1. Plot all parameters on growth charts.
2. Skin, hair, nails:  scaling skin in zinc deficiency, rough skin in hypothyroidism, edema in protein deficiency, alopecia areata in hypervitaminosis A or syphilis, central cyanosis in heart disease.
3. Dental caries can interfere, tongue enlargement, cleft lip and palate
4. Signs of malignancy or chronic illness, esp HIV- lymphadenopathy, splenomegaly, endocrine abnormalities (thyromegaly, precocious/ambiguous genitalia).
5. Screening tests- poor nutrition and psychosocial factors are the most frequent causes, thus there is limited value in laboratory testing.
1. Lead toxicity, iron deficiency
2. UA, urine culture, electrolytes (RTA)
3. PPD and candida control (TB or anergy)
4. HIV
5. Serum thyroxine and TSH.
6. Serum protein/albumin, AP (decreased in zinc def, increased in rickets), BUN, CR- to rule out renal disease.
7. Further testing dictated by clinical presentation

1. Correct identified problems and suggest simple ways to increase caloric intake.
2. Goal is “catch-up growth”- at 2-3 times the average rate for age.
3. Daily multivitamin may help- allows parent to focus on calories alone.
4. Calorie enrichment of food is mainstay of therapy- can increase to 24 cal/oz formula (one 13-oz can of concentrated formula with 8-oz water).
5. Follow weight closely- 3-4 days for neonate, two weeks in older child.
6. If no catch-up growth within the first month, more intensive assessment is necessary.

1. Determine the caloric intake.
1. Divide the ave caloric requirement for the child’s age by the child’s % of median weight for age.
2. If reliable history cannot be obtained, may need hospitalization

2. Explore reasons for low intake.
1. Medical causes not obvious on history: Infectious- giarida, parasites, chronic UTI, chronic sinusitis; Mechanical- adenoid hypertrophy, dental lesions, vascular slings, GER; Neurologic- oral-motor dysfuntion; Toxic/metabolic- lead, iron deficiency, zinc deficiency; GI- celiac disease, malabsorption, chronic constipation.
2. Social/psychological problems- economic issues, marital stress, homelessness, domestic violence, parental employment, parental substance abuse, children of younger mothers.
3. Poor absorption or utilization: if takes adequate calories, and still does not grow, then problem is either malabsorption, increased metabolic demands, decreased ability to utilize nutrients.  Consider CF.
3. Hospitalization
1. Severe malnutrition
2. Intensive outpatient management has failed, usually after trial of 3-4 months.
3. Immediate threat to child’s safety.
4. 10-14 days with adequate caloric intake is sufficient to demonstrate appropriate weight gain.

1. Secondary immune dysfunction, micronutrient deficiencies, developmental delays.
2. Suffer repeated GI and resp infections- cycles may develop that lead to cumulative nutritional deficits.
3. Children with FTT benefit from aggressive medical management of any illnesses.
4. Influenza shots needed.
5. Risk of cognitive, emotional, and behavioral problems.
6. Interdisciplinary team is necessary.