Failure to Thrive - Criteria for Diagnosis

Failure to thrive is a condition in which nutrition is insufficient to maintain adequate growth. It can result from many factors, such as inadequate intake, increased metabolic demand, decreased nutrient absorption, and increased nutrient losses. Sometimes multiple factors play a role. There are many different anthropometric criteria for the diagnosis, some of the more common will be described below.

Common Anthropometric Criteria

Failure to thrive should be considered when a child is less than the 5th percentile among children of the same sex and corrected age for: weight, weight velocity, weight for length, length, or BMI. The diagnosis of failure to thrive may still be considered for children above the 5th percentile for the aforementioned growth parameters if their weight is less than 75% of median weight for age or length; or if two major percentiles lines have been crossed in regard to weight for age or weight for length. Now, keep in mind that a portion of healthy infants also cross 2 major percentile lines on the weight-for-age growth chart. Nonetheless, careful consideration of an underlying cause is warranted whenever one of these criteria are met. Other criteria, such as average daily weight gain may also be taken into consideration. And I would also like to note that in premature infants, corrections for gestational age should be made for weight until 2 years of age.

Video Lecture

Head Control - Developmental Milestones

Prone position

1st and 2nd months of life

Newborns typically have very little head control and need neck support when held and while feeding. During this first month, an infant may move their head from side to side. By the end of the month, most infants can briefly raise their head off the table.

3rd and 4th months of life

The infant can hold their head at a 45° angle for a sustained period by the third month of life. By the fourth month, they can hold their head up approximately vertically.

Sitting/Pulled to sit

1st and 2nd months of life

When the infant is pulled to a sitting position, the head typically lags behind the body for the first few months of life. That is, the infant’s head flops backward if unsupported while maneuvering. Early head control develops by the second month, but the head still bobs when the infant is held in the sitting position.

3rd and 4th months of life

The infant attempts to keep their head steady when pulled to a sitting position by three months of life. By four months, their head is steady in the seated position. At this age, the head should not lag behind the body when moving from lying to sitting position.

6th month of life

At six months, it is typical for the infant to raise their head in anticipation of being lifted.

Red Flags

All of these skills are typically acquired by the aforementioned chronological ages. The absence of a particular head control by the specified age signifies a delay. Concerning findings include:

• Infant cannot raise their head while on their tummy by 2 months of age

• Infant does not have any head control by 3 months of age

• Infant cannot hold their head steady while sitting by 4 months of age

• Infant's head lags when being pulled to a sitting position at 5 months of age

The presence of any of these so-called red flags may indicate a significant motor delay and the need for further assessment or pediatric neurologic consultation.

Video Lecture

Head Injury

Criteria for performing a CT Head Scan in Children (NICE Guidelines 176)

Official Version

The official version can be found on the national institute of health and care excellence via the link below.

NICE clinical guideline 176: https://www.nice.org.uk/guidance/cg176/resources/imaging-algorithm-pdf-498950893

National Clinical Guideline Centre: https://www.nice.org.uk/guidance/cg176

Adaptation

The NICE guidelines have been adapted below to be more colourful, and hopefully a little easier to follow.

Video Lecture

Reference

1. National Institute of Health and Care Excellence. Head injury: assessment and early management [internet]. [London]: NICE; 2014 [updated 2019 Sep; cited 2020 May]. (Clinical guideline [CG176]). Available from: https://www.nice.org.uk/guidance/cg176/chapter/1-Recommendations#assessment-in-the-emergency-department-2