Failure to Thrive (FTT)- My Child Needs to Gain Weight

As a pediatric occupational therapist, I have worked on a pediatric feeding team. I definitely learned some things from the other specialists, such as speech therapists, nutritionists, and developmental pediatricians. Since not all communities and families have access to a multidisciplinary feeding team, I thought I would share some of the things I learned.

Some children have multiple medical issues, but most children are referred for being underweight, some severely so. One of the first orders of business is to determine how the child’s growth rates.

There are generally four charts used to plot children’s growth. There is a plot of weight for age, height for age, head circumference for age, and weight for height. Failure to thrive is a diagnosis given for children who fall below the 5^th percentile on the growth curve, and are technically below the curve.

When undernourished, the body will try to preserve weight, height, and head circumference, in that order. The first measure to fall on the growth chart will be weight, and then height. When the head circumference falls on the chart, then the child’s brain is at risk for less than optimal development.

One of the most important measures of a child’s nutritional status is the growth chart plot of weight versus height (also referred to as "stature"). Believe it or not, plenty of pediatricians plot weight vs age and height vs age, and do not calculate weight for height. Sometimes doctors incorrectly assess that the child is severely underweight, because the child is short statured, and their weight, which may be appropriate for their height, is low compared to other children that age.

Imagine applying this logic to adults. Plot two females who are 30 years old and weigh 140 lbs. On a weight for age chart, the two women would look exactly the same. If one woman is 4’10”, she would be overweight, and above the 50^th percentile. If the other woman was 6’ tall, she would be underweight, and below the 50^th percentile.

Hopefully you can now see why the weight for height measure is the much more important than either of the measures compared to the child’s age. If in doubt, ask your pediatrician to let you see the growth charts, or plot your own. Growth charts are available on the CDC website.

A nutritionist or dietitian will usually assess the child’s nutritional intake. Some request a 3-day food diary, and some ask for one or even two weeks. The idea is to get a representative sample of what the child typically eats, and calculate daily and weekly caloric intake.

A food diary should include absolutely everything the child consumed, with dates, times, and amounts. Include all food and beverages, including water. Estimate amounts of food in teaspoons, tablespoons, quarter cups, half cups, ounces, etc.

If you are not familiar with estimating weights and measures, weigh or measure the food before giving it to your child, then weigh or measure the leftovers, and subtract to come up with an accurate food diary entry.

Like doctors or any other medical provider, nutritionists are not all the same. My favorite nutritionist gave the most practical and relate-able advice. After assessing calories and calculating totals from the food diary, he would say “This is how many calories your child is averaging each day.” Then he would tell families how many calories the child needed to maintain their current weight, and how many calories they needed to gain weight. Some special needs children, like those with cerebral palsy, burn more than average calories, and therefore need more than average number of calories to maintain or gain weight.

My favorite nutritionist was really great about working with families to build on the foods that their child already eats. There are things that you can add to foods to increase the calorie count, but the pairings need to be compatible.

Oils: good quality vegetable oil, olive oil, coconut oil, flaxseed oil, hemp oil

Butter: butter, ghee

Milk: whole milk, evaporated milk, half and half, whipping cream, heavy cream, sour cream

Cheese: American cheese, cheddar cheese, cream cheese

Potato Flakes

Carnation Instant Breakfast Powder

Syrup: maple syrup, corn syrup, molasses

Condensed milk

Evaporated milk

Powdered milk

Sometimes our feeding team recommended experimenting with flavors. These things did not add significant calories, but sometimes made the food more appealing, and therefore the child would eat more. For example, some families noted that their child liked sour things like pickles, or that they liked ketchup on a lot of foods.

Condiments: ketchup, mustard, barbeque sauce

Sour and tart: vinegar, pickle juice, sauerkraut juice

Sweet: agave, stevia, carrot juice, apple juice

Salty: soy sauce, liquid aminos

Many times families feel compelled to push baby foods and table foods with their young child, or special needs child. They mistakenly believe that their child is missing out on calories and nutrients because they are still on formula for their primary nutrition. This is a huge misconception!

There is virtually NOTHING as rich in calories or nutrients as formula or Pediasure. If the child’s weight is critically low, it is much better to get the child to consume as much formula or Pediasure as possible, and forgo the fruit and vegetable purees, and fruit juices.

Vegetables are about 25 calories per half cup. Fruits and juices are about 60 calories per half cup. These calories do not compare to formula or Pediasure. Formulas are about 20 to 28 calories per ounce, but can be mixed more concentrated to boost calories. Pediasure has 30 calories per ounce.