Failure to Thrive (FTT) is slow physical development in a baby or child. It’s caused by a baby or child not having enough nutrition. A child with FTT is at risk for problems such as short height, behavior problems and developmental delays [1]. Failure to thrive (FTT) is a term used to describe inadequate growth or the inability to maintain growth, usually in early childhood. It is a sign of undernutrition and because many biologic, psychosocial and environmental processes can lead to undernutrition, FTT should never be a diagnosis unto itself [2]. Children with congenital (present at birth) heart disease may grow or develop more slowly than other children. Nutritional issues affect growth and development in children with congenital heart disease: Children with congenital heart disease may fall behind in their development [3]. Congenital heart diseases have a high morbidity and if not detected early carry a high mortality rate [4]. Many children with congenital heart disease are small.' Their failure to thrive usually dates from early infancy and postmortem studies suggest infants dying with congenital heart disease and failure to thrive are malnourished. There are several possible explanations for this: hypoxia and breathlessness may lead to feeding problems; anoxia or venous congestion of the bowel may result in malabsorption; peripheral anoxia and acidosis may lead to inefficient utilisation of nutrients; and increased metabolic rate may mean that recommended energy intakes are insufficient for normal growth and nutrition [5]. There is paucity of studies investigating failure to thrive and congenital heart disease. Thus, the present study, conducted in a tertiary care center, attempted to find association between Failure to Thrive (FTT) and Congenital Heart Disease (CHD) in newborns/infants.

Aims and Objectives

The aim of the study is to find association between failure to Thrive (FTT) and Congenital Heart Disease (CHD) in newborns/infant.

• Type of Study: Cross-sectional observational study

• Study Population: Children age between 0 to 1 year with suspected heart disease

• Study Period:1 year (July 2018 to June 2019)

Table 1: Socio-Demographic Characteristics of the Study Participants

Table 2: Diagnostic Performance of Failure to Thrive in Diagnosing CHD

• Setup for Study: Tertiary care set up

• Source: Outdoor and indoor services of department of pediatrics IGMC, Shimla

• Ethical Approval: This study was conducted after approval from ethical committee of IGMC, Shimla

• Data Collection: After taking pre informed consent for this study from parents or guardians, the data related to age, gender, altitude of residence was collected

Confirmation of CHD

Presence of CHD was confirmed based on echo-cardiographic evidence of CHD. All children suspected to have CHD based on initial symptoms underwent echocardiography examination using echo machine model I E 33 of Philips medical system pvt. ltd. using pediatric and neonatal probe by consultant cardiologist. The 2D echo images were obtained and reviewed real time from sub costal, apical 4 chambers, parasternal long and short axis and suprasternal views supplemented with color flow imaging. Pulse and continuous wave doppler interrogation as appropriate. The presence of CHD on echocardiography was taken as the CHD present.

Operational Definitions

Failure to Thrive: Weight consistently below the 3rd percentile for age and sex, progressive decrease in weight to below the 3rd to 5th percentile, or a decrease in the percentile rank of 2 major growth parameters in a short period.

Data Analysis

The data was reported as frequency and percentages for categorical variables and mean ± sd for continuous variable with normal distribution. The diagnostic performance was tested by calculating sensitivity, specificity, positive and negative predictive value using two by two tables. Two sited p-value of <0.05 was taken as the statistically significant. The data was analyzed using Epi Info version 7 software.

In our study there were 102 participants in total. Out of them 57 participants were ≤1 month of age i.e. 57(55.90 % of total, 29 (28.4%) between 2-6 months,16 (15.7%) between 7-12 months. There were 55 males and 47 females. Most of the participants i.e. 41 (40.2%) were residents of altitude ranging between 2000-3000 meters. In the present study, Failure to thrive was present in 17 (16.7%) out of 102 study participants (Table 1).

Failure to thrive was seen in 16 patients among all 79 diagnosed patients with CHD. Odd ratio was 0.22 with CI (0.03-1.57), with p-value of 0.14, which is not significant. The sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of failure to thrive in diagnosing CHD is 20.2 %, 95.6%, 94.1 % and 25.88% respectively (Table 2).

Traditionally, Failure to Thrive (FTT) was characterized as “organic failure to thrive” in which the child’s growth failure was ascribed to a major medical illness and “nonorganic failure to thrive” which was attributed primarily to psychological neglect or “maternal deprivation”. We now recognize that in all cases of “nonorganic” FTT and in many cases of “organic” FTT, the cause of growth failure is malnutrition, whether primary or secondary. Malnutrition not only jeopardizes the child’s growth but also impairs the child’s immune system and contributes to concurrent and long-term deficits in development and behavior [6].         

The present hospital based cross-sectional observational study was conducted among patients aged 0-1 year for a period of one year from July 2018 to June 2019. The primary aim of the study was to find association between Failure to Thrive (FTT) and Congenital Heart Disease (CHD) in newborns/infants. In the current study, 102 patients coming to pediatric OPD or indoor were included on the basis of criteria of suspicion and clinical parameters to detect CHD. 

In the present study, 79 (77.5%) patients (46 maleand 33 female) were detected to have underlying congenital heart disease out of total 102 patients. Maximum 57 (55.9%) patients were of ≤1 month of age group and among them 44 (77.19%) had underlying congenital heart disease. So therefore, it is essential to recognize congenital heart disease in the early stages as the deterioration is sudden and, most of the children with complex heart disease die at presentation or before any surgical intervention is made. 

In the present study, out of 79 study participants having underlying congenital heart disease, only 16 participants were diagnosed with failure to thrive. There was no statistically significant relation between failure to thrive and CHD in our study as most of participants were ≤1 month of age. The sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of failure to thrive in diagnosing CHD is 20.2 %, 95.6%, 94.1 % and 25.88% respectively.

Infants at particular risk of failure to thrive are those with cyanotic CHD and those with left to right shunts, pulmonary hypertension and right sided cardiac failure. With cyanosed infants, the severity of failure to thrive is not necessarily proportional to the degree of cyanosis. It is not clear why, as hypoxia, acidosis and consequent anaerobic metabolism influence cardiac efficiency. Metabolic inefficiency of the heart and other tissues contributes to failure to thrive by allowing little spare energy for growth.

Infants with failure to thrive, significant left to right shunts and pulmonary hypertension show increased resting energy consumption compared with body weight. These infants are usually grossly underweight.

Many infants with congenital heart disease have the challenge of living in a catabolic state requiring more calories for growth than most other children. These children have the dual challenge of being easily overwhelmed by an increase in fluids, thus requiring a high density of calories in a low volume of fluid [6]. 

A practical way to categorize FTT is according to calories, including inadequate caloric intake, inadequate caloric absorption, or excessive caloric expenditure [2].

Inadequate caloric intake is the most common etiology seen in primary care settings. In infants younger than eight weeks, problems with feeding (e.g., poor sucking and swallowing) and breastfeeding difficulties are prominent. Inadequate caloric absorption includes disorders causing frequent emesis (e.g., metabolic disorders, food insensitivities) or malabsorption (e.g., celiac disease, chronic diarrhea, protein-losing enteropathy). 

Excessive caloric expenditure usually occurs in the setting of a chronic condition, such as congenital heart disease. In these instances, FTT often develops during the first eight weeks of life [2].

In the present study, there was high specificity and Positive Predictive Value (PPV) of failure to thrive in diagnosing CHD. It is important to determine whether failure to thrive results from congenital heart disease or factors in the environment, such as abuse or neglect.

1. Stanford Children’s Health. “Failure to thrive.” Stanford Children’s Health, June 2021, https://www.stanfordchildrens.org/en/topic/default?id=failure-to-thrive-90-P02297.

2. Cole, S.Z. and J.S. Lanham. “Failure to thrive: An update.” American Family Physician, vol. 83, no. 7, April 2011, pp. 829–834.

3. Hoffman, J.I. and S. Kaplan. “the incidence of congenital heart disease.” Journal of the American College of Cardiology, vol. 39, no. 12, June 2002, pp. 1890–1900.

4. Maine Department of health and human services. “Failure to Thrive.” Maine DHHS, June 2021, https://www.maine.gov/dhhs/mecdc/population-health/wic/health/health-crg-thrive.shtml.

5. Gupta, H. et al. “Pulse oximetry for the early detection of congenital heart diseases.” International Journal of Medical Research Professionals, vol. 3, no. 4, 2017, pp. 227–231.

6. Poskitt, E.M. “Failure to thrive in congenital heart disease.” Archives of Disease in Childhood, vol. 68, no. 2, February 1993, pp. 158.