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Failure to Thrive (FTT)

BASICS

  • FTT is a sign of inadequate nutrition, not a diagnosis.
  • Commonly defined as weight or BMI for age <5th percentile on multiple occasions or weight dropping ≥2 major percentile lines on growth charts.
  • Combination of anthropometric criteria over time recommended for diagnosis.
  • Pediatric considerations: genetic syndromes, IUGR, prematurity require different growth curves.
  • Some infants show constitutional growth delay, growing at slower rate but following new percentiles without true FTT.

EPIDEMIOLOGY

  • Predominant age: 6 to 12 months (80% <18 months).
  • Male and female equally affected.
  • 10% prevalence in primary care; 1-5% pediatric inpatient admissions.
  • More frequent in poverty.

ETIOLOGY AND PATHOPHYSIOLOGY

Grouped by mechanism:

  1. Inadequate caloric intake
  2. Breastfeeding difficulties, formula preparation errors, delayed food transition, feeding habits (excess juice), oral aversion, poverty, neglect.

  3. Mechanical problems: oromotor dysfunction, congenital anomalies, GERD, CNS/PNS disorders.

  4. Inadequate caloric absorption

  5. NEC, short bowel, biliary atresia, cystic fibrosis, celiac disease, milk protein allergy, vitamin/mineral deficiencies, environmental enteric dysfunction.

  6. Excessive caloric expenditure

  7. Hyperthyroidism, cardiopulmonary disease, HIV, immunodeficiency, malignancy, renal disease, obstructive sleep apnea.

  8. Defective utilization

  9. Metabolic disorders, congenital infections (TORCH).

RISK FACTORS

  • Psychosocial: poverty, parental mental health/cognitive impairment, poor parenting, abuse, substance abuse, social isolation.
  • Medical: IUGR, congenital abnormalities, prematurity, developmental delay, anemia, lead poisoning.

GENERAL PREVENTION

  • Educate parents on feeding and parenting skills.
  • Access to supplemental feeding programs (WIC).

DIAGNOSIS

History

  • Detailed prenatal, developmental, and medical history.
  • Feeding history: type, frequency, caregiver behavior, amounts, oral aversions.
  • Social history: family structure, socioeconomic status, hygiene, cultural beliefs, parental mental health, substance abuse.
  • Review systems: appetite, vomiting, stooling, urinary symptoms, activity.

Physical Exam

  • Use multiple anthropometric measurements over time (weight, height, head circumference).
  • Look for signs of malnutrition, dehydration, dysmorphic features, developmental status.
  • Observe caregiver-child interaction and feeding behaviors.

Differential Diagnosis

  • Constitutional growth delay, genetic syndromes, endocrine disorders, neurologic disorders, TORCH infections.

Diagnostic Tests

  • Labs rarely needed; considered after addressing feeding/nutritional causes.
  • Common: CBC, ESR, lead, electrolytes, renal/liver function, thyroid tests, urinalysis.
  • Additional as indicated: amylase/lipase, zinc, iron studies, IGF-1, genetic tests, stool studies, celiac screen, inflammatory markers, infectious workup.
  • Imaging: skeletal survey for abuse suspicion, bone age, swallowing studies, brain imaging if neurologic signs present, echocardiogram if murmur.

TREATMENT

General Measures

  • Evaluate caregiver-infant interaction and feeding technique.
  • Provide nutritional counseling and increase caloric intake gradually (~50% above age-related needs).
  • Consider supplementation or higher calorie formula.
  • Limit milk intake; avoid juice/soda.
  • Address social determinants (poverty, food insecurity) with referrals.
  • Monitor for complications from rapid refeeding (diarrhea, electrolyte abnormalities).

Medications

  • None specific for FTT.

Referral

  • Multidisciplinary care for complicated cases or failure to improve.
  • Consider feeding therapy, psychology, physical/occupational therapy.

Surgery/Procedures

  • Severe cases may require nasogastric or gastrostomy feeding.

ADMISSION

  • Consider for dehydration, severe malnutrition, suspected abuse, or failure of outpatient management.
  • Monitor for nutritional recovery syndrome during catch-up growth.

ONGOING CARE

  • Frequent follow-up initially (every 2-4 weeks), spacing out as progress occurs.
  • Monitor for recurrence and developmental progress.
  • Child protection involvement if neglect suspected.

DIET

  • Age-appropriate caloric needs:
  • Infants: ~120 kcal/kg/day (decreasing to 95 kcal/kg/day at 6 months).
  • Toddler: three meals + two snacks, 16-32 oz whole milk, avoid juice/soda.
  • Expected weight gain rates specified by age.

PATIENT EDUCATION

  • Avoid "food battles" during feeding.
  • Educate about feeding cues, preparation, and mealtime environment.
  • Refer to resources like AAFP and WIC.

PROGNOSIS

  • Most children improve with nutritional intervention.
  • Increased risk for future nutritional and developmental issues.

COMPLICATIONS

  • Related to underlying cause: developmental delay, behavioral problems, school difficulties, short stature.

REFERENCES

  1. Black MM, Tilton N, Bento S, et al. Recovery in young children with weight faltering: child and household risk factors. J Pediatr. 2016;170:301-306.

CODES

  • ICD10:
  • R62.7 Adult failure to thrive
  • R62.51 Failure to thrive (child)
  • P92.6 Failure to thrive in newborn

CLINICAL PEARLS

  • FTT is rarely due to medical disease alone; most often from underfeeding or feeding issues.
  • History and physical exam guide diagnosis; extensive labs/imaging often unnecessary initially.
  • Multidisciplinary approach critical for effective management.