Failure to Thrive Multidisciplinary Approach

Clinical Question 1: Is there evidence to support admission versus outpatient management of a patient with FTT?

FTT Team Recommendation:

The FTT Team STRONGLY RECOMMEND based on low quality evidence use of a multidisciplinary approach and consideration of outpatient evaluation and management in a patient with FTT. 

Literature supporting this recommendation:

Historically, FTT was felt to be secondary to an organic (i.e. underlying medical disorder) or nonorganic condition (i.e. social dysfunction) with variation in the literature on the percentage of patients that would ultimately be discovered to have an underlying medical condition (Sills, 1978). Homer (1981)described patients with a combination of organic and nonorganic etiology and Berwick et al (1982)identified that patients from low socioeconomic backgrounds were more likely to be admitted for nonorganic FTT. With complicating factors for FTT patients, such as mixed etiology and limited resources secondary to low socioeconomic status, more focus has been paid to the role of a multidisciplinary approach to address the multitude of needs for these patients. Utilization of a multidisciplinary specialty clinic with health care professionals including pediatricians, dieticians, specialized nursing, social work, psychology and financial services have been shown to lead to improved outcomes as well as compliance for FTT patients (Hobbs & Hanks, 1996). In a study where patients received at home intervention including a health visitor, dietician, pediatrician and social worker were ultimately found to be heavier, taller and had reported better appetites compared to controls receiving standard therapy (Wright, Callum, Birks, & Jarvis, 1998). 

Evidence against hospitalization of patients with FTT was described by Berwick et al (1982) that identified growth during hospitalization is a poor predictor of organic versus nonorganic disease. Children were found to gain and lose weight irrespective of their final diagnosis of organic versus nonorganic FTT (Berwick et al). In addition, diagnosis of underlying disorders has not been improved with hospitalization (Berwick et al).

At Children's Mercy Hospitals and Clinics, the Ready, Set, Grow clinic offers this multidisciplinary team approach and should be considered as an adjunct to hospital admission or utilization for outpatient management after hospital discharge. Literature is not available for outcomes of hospitalized patients using a multidisciplinary approach. However, we recommend multidisciplinary approach in both patients requiring hospitalization and patients utilizing outpatient services. Not all patients with FTT will require the use of the Ready, Set, Grow clinic, however it should be considered for patients not responding to initial interventions.

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.

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