• Failure to thrive (FTT) is a term used to describe infants and children who fail to meet standards for appropriate growth. FTT is more a sign or symptom of an underlying problem than a final diagnosis or disease state.
• The different criteria for malnutrition are: mild, weight for age 75% to 90% of median; moderate, weight for age 60% to 74% of median; and severe, weight for age less than 60% of median.

• Congenital syndromes
• Chromosomal abnormalities
• Congenital heart disease
• Hirschsprung disease
• Pyloric stenosis
• Malrotation
• Vascular slings

• Hepatitis
• Tuberculosis
• Human immunodeficiency virus (HIV)
• Parasitic infection
• Urinary tract infection
• Chronic sinusitis

• Inadequate caloric intake due to emotional deprivation
• Maternal depression
• Poor feeding techniques
• Poor child–caretaker interactions
• Improper formula preparation
• Household chaos
• Lack of proper environment for mealtimes
• Parental drug/alcohol abuse
• Child abuse/neglect
• Lead/mercury poisoning
• Hypervitaminosis
• Fetal exposure to alcohol/anticonvulsants

• Malabsorption (lactase deficiency, celiac disease)
• Cystic fibrosis
• Renal tubular acidosis
• Diabetes mellitus
• Thyroid disease
• Pituitary disease
• Adrenal disease
• Parathyroid disease
• Galactosemia
• Aminoacidurias
• Organic acidurias
• Storage diseases
• Hypercalcemia

• Food allergies
• Inflammatory bowel disease
• Chronic lung disease, including aspiration

• Gastroesophageal reflux (GER)
• Chronic constipation

• Cerebral palsy
• Oral-motor dysfunction
• Structural abnormalities
• Degenerative diseases
• Diencephalic syndrome

• Chronic renal insufficiency

• Sickle cell disease
• Thalassemia
• Iron-deficiency anemia

• Rickets
• Osteogenesis imperfecta
• Chondrodystrophies

• Upper airway obstruction, including adenoidal hypertrophy
• Acquired heart disease
• Dental abnormalities (caries, infection)

• Is the malnutrition acute or chronic, symmetric or asymmetric? With acute malnutrition, weight is the first parameter to be affected, leading to wasting. After weeks to months of malnutrition, stunted linear growth occurs. Finally, with long-standing and/or severe malnutrition, head circumference is affected. Symmetric FTT suggests long-standing malnutrition, chromosomal abnormalities, congenital infection, or teratogenic exposures as etiologies.
• When growth failure is recognized, the prenatal, developmental, and nutritional history must be complete. Search for indicators of diminished intake, excessive losses, and medical diseases. The physical examination should be thorough. The laboratory evaluation is guided by the results of the history and physical examination. Although some laboratory tests can be useful in the evaluation of FTT, random screening in search of a medical diagnosis is usually unrevealing, and is not recommended.

Question: When did the FTT begin?
Significance: Consideration of the age at which growth failure begins can be helpful in determining the cause of the failure. See the table entitled “Causes of Failure to Thrive” in Section VIII of this book.

Question: Does the child have a medical problem that explains the FTT?
Significance: Ask about symptoms that would lead you to believe the child has a medical illness, including vomiting, chronic diarrhea, abdominal distention, exercise intolerance, developmental problems, etc.

Question: What is the child’s typical daily diet?
Significance: Because FTT is more commonly an environmental problem, the child’s feeding history may yield clues to the problem. Have the parent describe in detail what the child eats and drinks each day, the daytime schedule, how formula is prepared. Determine who is responsible for meal preparation, when and where the child eats, and what problems the parent identifies related to mealtime.

Question: Are there indications of parental stress, drug abuse, or other family factors that may be contributing to the child’s growth failure?
Significance: Children do not live in isolation, and growth failure may be a manifestation of family dysfunction.

Finding: Changing growth patterns on a plotted growth chart.
Significance: In practice, FTT is identified when a child’s weight falls below the fifth percentile for age, when the weight falls more than two major percentile groups, or when the weight for height is below 80% of the median.

Finding: Look for wasted, thin extremities, with loose skin hanging from the buttocks; temporal wasting; thin, sparse hair or alopecia.
Significance: Signs of malnutrition.

Finding: Otitis media, respiratory infections
Significance: Children with FTT have more infections than age-matched controls.

Finding: Cheilosis, or cracking and irritation at the corners of the mouth.
Significance: Riboflavin and other vitamin B complex deficiencies.

Finding: Edema
Significance: Protein deficiency

Finding: Oropharyngeal abnormalities (dental caries, tonsillar hypertrophy, submucosal clefts, etc.).
Significance: These factors may interfere with eating.

Finding: Neurologic abnormalities
Significance: Cerebral palsy and other neurologic abnormalities may result in oral-motor dysfunction, swallowing incoordination, and difficulty eating.

Finding: Bruises, burns, patterned cutaneous injuries
Significance: These injuries suggest possible child abuse.

Test: A complete blood count (CBC)
Significance: Used to identify iron-deficiency anemia

Test: Lead level
Significance: Used to identify lead poisoning

Test: Urinalysis and urine culture
Significance: Screens for urinary tract infection and renal tubular acidosis.

Test: PPD
Significance: Screens for tuberculosis.

Test: Serum electrolytes, protein, albumin, prealbumin, calcium, phosophrus, magnesium
Significance: Serum metabolic screening can assess for underlying metabolic problems, renal insufficiency, and are indicated to help prevent the refeeding syndrome. The refeeding syndrome includes potentially dangerous disorders in serum phosphorus, calcium, potassium and other minerals and electrolytes at the time of reintroduction of nutrition, in severely malnourished children.

• Children meeting criteria for severe malnutrition are at risk for refeeding syndrome, and should be hospitalized.
• Early hospitalization of the severely malnourished child focuses on slowly reinstituting nutrition while avoiding potentially life-threatening changes in electrolytes. In the most severe cases, life support and hyperalimentation are needed. Hospitalization provides a controlled environment in which to assess the causes of growth failure, and determine the child’s caloric needs for catch-up growth.
• Therapy aimed at improving and sustaining the child’s nutrition, however, needs to continue well after the child is discharged from the hospital and requires frequent weight checks, careful monitoring, and support of the family.

• Child welfare should be notified immediately of any child not thought to be safe at home because of evidence of abuse or severe neglect.

Q: How can you differentiate between FTT and alternative diagnoses related to growth?
A: Recognize that 3% to 5% of the population will naturally fall below the 3rd to 5th percentile using growth charts. These children usually are proportional (normal weight for height). Growth velocity and height for weight determinations can be helpful in identifying children with malnutrition.

Q: How quickly will a child respond to nutritional therapy?
A: Initiation of catch-up growth depends on the severity of the malnutrition. Initially, weight gains of 2 to 3 times the normal growth rate for age may be observed. Weight gain will precede improvements in height. Months of refeeding are required to restore the patient’s weight for height, stature, and head circumference.

• Suggestion of medical disease: Children should be referred to the appropriate medical or surgical specialist.
• Indications of child abuse or neglect: State laws in every state require that physicians report suspected child abuse and neglect to child welfare agencies for investigation.
• Multidisciplinary team referral: For children with moderate FTT, those who do not improve after therapy has been initiated, or families with psychosocial problems, nutritionists, nurses, social workers, feeding specialists, and psychologists can participate in providing continual assessment and care to the child and family.

• Remember that medical and psychosocial causes of malnutrition often coexist and should be considered.
• Don’t forget to ask about how much juice the infant or toddler drinks. This is a common cause of FTT.
• In cases of moderate-severe neglect, it may be necessary to increase the caloric density of the child’s foods, as many malnourished children can not increase the volume of food ingested to meet the requirement for catch-up growth. A diet with approximately 30% to 35% more energy and nearly twice the amount of protein is needed for catch-up growth.
• Remember to provide a multivitamin.
• Continued, close follow-up of the malnourished child is essential in order to prevent recurrent growth failure and to monitor the child’s development, which can be adversely affected in moderate and severe growth failure.

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