Failure to thrive (FTT) in children is characterized by inadequate nutrition leading to poor growth and development, with causes often being multifactorial, including inadequate caloric intake, malabsorption, and family dynamics. Diagnosis involves monitoring weight percentiles, physical examinations, and selective laboratory testing based on symptoms, while management focuses on nutritional education and addressing underlying medical issues. Prognosis is generally favorable, with many children improving through intervention, although some may require long-term nutritional support.

1. Failure To Thrive (FTT)
Zach Jarou
Michigan State University
College of Human Medicine
January 23, 2013

2. Evolving Definitions of FTT
• FTT is not a syndrome, rather it is a physical
sign that a child is receiving inadequate
nutrition for optimal growth and development
• Older dichotomous view emphasized organic
(underlying medical condition, rare) vs. non-
organic causes (environmental, more common)
• Now appreciated to be most commonly
mixed/multi-factorial in cause

3. Chart-Based Definitions of FTT

4. Chart-Based Definitions of FTT
• Children younger than 3 years of age,
• Below 3rd or 5th percentile for age on more than
one consecutive occasion
• Weight drops down two major percentile lines
• Whose weight is less than 80% of the ideal
weight for age
• Below the 3rd or 5th percentile on the weight-for-
length curve

5. Pathogenesis
• Loss of calories through malabsorption
• Increased caloric expenditure (hyperthyroidism,
congenital heart disease, chronic pulmonary
disease)
• Inadequate intake of calories (most frequent)
• Poor strength or neurologic ability to suck, chew,
or swallow adequate amounts of food

6. Pathogenesis (cont.)
• Dietary factors
▫ Breastfeeding difficulties
▫ Improper formula mixing
▫ Poor transition to food (6 to 12 months of age)
▫ Excessive juice consumptions
▫ Avoidance of high-calorie foods
• Family conditions
▫ Inadequate knowledge of infant nutrition needs
▫ Mental health (depression, anxiety, substance use)
▫ Family chaos, child neglect, financial hardship

7. Physical Exam
• Neurodevelopmental status
• Neurocutaneous markings
• Dysmorphic features
• Nutritional status
• Dehyrdration
• Feeding observation
▫ Bottle feeding
▫ Spoon/self-feeding
▫ Creating proper social environment

8. Laboratory Tests
• A shotgun approach is not cost-effective
• Tests must be performed based on positive findings
from history and physical
• Additional lab and imaging tests are completed for
children who do not respond to dietary intervnetion
• Important to review newborn metabolic screening
tests for inborn errors of metabolism and
hypothyroidism
• Routine tests in children 6-18 months are for iron
deficiency, lead poisoning, TB, chronic UTI

9. Differential Diagnosis
• 1) FTT with microcephaly
▫ TORCH infections
▫ Teratologic & genetic conditions
▫ Brain injury
• 2) FTT with short stature
▫ Genetic syndromes (Russell-Silver, Turner, Down)
▫ Endocrine (hypothyroid, hypophosphatemic
rickets, growth hormone deficiency)
▫ Teratologic conditions (fetal alcohol syndrome)

10. Differential Diagnosis
• 3) FTT characterized by adequate height for age
and normal head circumference
▫ Inadequate calories offered
(inadvertent/intentional)
▫ Child unwilling to accept food that is offered (poor
apetite, oral aversion, food aversion, oromotor
dysfunction)
▫ Caloric loss through vomiting or malabsorption or
hypermetabolic state

12. Management
• Nutritional education
• Feeding intervention
• Continue to monitor growth response
• Treat underlying medical conditions
• More serious problems such as electrolyte
disturbances and dehydration often require
hospitalization

13. Prognosis
• Almost all children show adequate improvement
with intervention
• Many improve even without intervention as they
become more independent in feeding themselves
when hungry
• A small percent of “picky eaters” have anxiety
disorders and a few have autism spectrum disorders
• Children who require gastrostomy feeding tubes and
who have neurologic dysfunction interfering with
swallowing usually require enteral feeding for life

14. Prognosis (cont.)
• Some evidence of poorer cognitive and school
outcomes of FTT children
• Early iron deficiency anemia leads may lead to
irreversible developmental deficits
• Children experiencing calorie malnutrition may
have also experienced environmental deficits
(parental attention, emotionally/cognitively
stimulating home)
• Should be monitored for developmental and
behavioral problems

15. Pearls
• FTT due to poor food intake = weight falls first, sparing length and
head circumference
• Symmetric fall in weight and height suggests a chronic medical
condition
• Short stature below 50th percentile with relative sparing of weight
suggests an endocrine disorder
• early drop-off in head circumference suggests a lack of brain growth
• Children born with genetic conditions must have their growth
plotted on adjusted curves
• Wasting = decreased weight for height, acute malnutirion,
decreased subQ fat, measured by triceps skinfold thickness
• Stunting = decreased height for age, can be sign of chronic
undernutrition
• Important to take into account family stature (genetic potential)

16. References
• Gahagan S (2006). Failure To Thrive: A
Consequence of Undernutrition. Pediatrics in
Review; 27 (1): e1-e11. (link)
• Jaffe AC (2011). Failure To Thrive: Current
Clinical Concepts. Pediatrics in Review; 32 (3):
100-108. (link)