Review article

http://dx.doi.org/10.3345/kjp.2011.54.7.277
Korean J Pediatr 2011;54(7):277-281

Nutritional approach to failure to thrive

Su Jin Jeong, MD Failure to thrive (FTT) is a term generally used to describe an infant
or child whose current weight or rate of weight gains is significantly
Department of Pediatrics, CHA Bundang Medical below that expected of similar children of the same age, sex and
Center, CHA University, Seongnam, Korea ethni­city. It usually describes infants in whom linear growth and head
circumference are either not affected, or are affected to a lesser degree
than weight. FTT is a common problem, usually recognized within
the first 1-2 years of life, but may present at any time in childhood.
Most cases of failure to thrive involve inadequate caloric intake
caused by behavioral or psychosocial issues. The most important
part of the outpatient evaluation is obtaining an accurate account of
a child’s eating habits and caloric intake. Routine laboratory testing
rarely identifies a cause and is not generally recommended. FTT, its
evaluation, and its therapeutic interventions are best approached by
a multi-disciplinary team includes a nutritionist, a physical therapist, a
psychologist and a gastroenterologist. Long term sequelae involving all
areas of growth, behavior and development may be seen in children
Received: 16 May 2011, Accepted: 27 May 2011
suffering from FTT. Early detection and early intervention by a multi-
Corresponding author: Su Jin Jeong, MD disciplinary team will minimize its long term disadvantage. Appropriate
Department of Pediatrics, CHA Bundang Medical Center, nutritional counseling and anticipatory guidance at each well child visit
CHA University, 351 Yatap-dong, Bundang-gu, Seongnam
463-712, Korea may help prevent some cause of FTT.
Tel: +82-31-780-5230, Fax: +82-31-780-5239
E-mail: jinped@cha.ac.kr
Key words: Failure to thrive, Inadequate caloric intake, Nutritional
Copyright © 2011 by The Korean Pediatric Society counseling, Multi-disciplinary team
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-
nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction A combination of anthropometric criteria, rather than one criterion,

should be used to more accurately identify children at risk of FTT.
There is no consensus on which specific anthropometric criteria Weight for length is a better indicator of acute under-nutrition and
should be used to define failure to thrive (FTT)1-4). In routine clinical is helpful in identifying children who need prompt nutritional
practice, the three weight criteria that can be used to described FTT treatment6). This is an index of fat stores that defines whether a
are a child younger than 2 years whose weight is below the 3rd or 5th patient suffers from acute malnutrition. Any weight change below
percentile for age on more than one occasion, a child younger than the 5th percentile may indicate a child is at risk of FTT7). Finally,
2 years whose weight is less than 80% of the ideal weight for age, some children who falter in growth parameters actually demonstrate
and a child younger than 2 years whose weight crosses two major a normal variant of growth, such as children of small parents who are
percentiles downward in a standardized growth grid using the 90th, growing to their full genetic potential, large for gestational age infants
75th, 50th, 25th, 10th, and 5th percentiles as the major percentiles5). who regress toward the mean, children with constitutional delay in

277
278 SJ Jeong • Nutritional approach to failure to thrive

growth, or premature infants whose growth parameters are normal consumption, excessive juice consumption, and parental avoidance of
when corrected for gestational age8). When uncertain, a weight for high-calorie foods often lead to FTT13).
age that falls below the 5th percentile or a weight deceleration that Family factors can contribute to inadequate caloric intake at any
crosses two major percentile lines should prompt the use of additional age. These include mental health disorders, inadequate nutritional
growth indices, such as weight for length or weight velocities, to knowledge, and financial difficulties. Poverty is the greatest single risk
confirm the growth trend. factor for FTT in developed and developing countries. Importantly,
child neglect of abuse must be considered, because children with
Prevalence FTT are four times more likely to be abused than children without
FTT14).
Most of the time, insufficient growth is detected in a routine visit Inadequate caloric absorption includes disorders causing frequent
to the pediatrician or the family practitioner. Many parents do not emesis (e.g., metabolic disorders, food insensitivities) or malabsorption
seem to notice the situation until it is brought to their attention. In (e.g., chronic diarrhea, protein losing enteropathy). Excessive caloric
most instances, FTT is insidious and gradual. It can be missed by a expenditure usually occurs in the setting of a chronic condition,
carefully maintained growth chart. such as congenital heart disease, chronic pulmonary disease, or
Estimates of the incidence of FTT vary widely depending on the hyperthyroidism. In these instances, FTT often develops during the
terminology and the population studied: first eight weeks of life.
· Growth deficiency affects 10% of the rural outpatient pop­
ulation. The same percentage applies to high risk groups such as the Clinical approach to failure to thrive
homeless9).
· FTT accounts for 1 to 5% of pediatric hospital admission for The parents often do not recognize the subtle slowing of growth
children younger than 2 years in the United State. National and state in their child in close day to day living. The family and the child’s
surveys indicate that as many as 10% of the children seen in primary caregiver should be carefully evaluated with a thorough review
care practice have signs suggesting inadequate growth5).
· In inner city emergency department, approximately 15 to 30% of
Table 1. Pathological Causes of Failure to Thrive
young children who receive acute care services show signs of growth
Inadequate food intake
deficits5). Lack of appetite
· Up to 15 to 20% of hospitalized children younger than 2 years Chronic illness or anemia
from a medically indigent population met the criteria of FTT5). Psychosocial disorder
Food not available
Type or volume of food not appropriate
Etiology Feeding technique, parental-infant interaction problems
Withholding of food
Reduced absorption or digestion of nutrients
Failure to thrive may result from a variety of “organic” and Pancreatic insufficiency
“non­organic” causes for a combination of both. In evaluation Loss of damage to callous surface
Excessive loss of nutrients
of a child with FTT, the diagnostic efforts should be directed
Vomiting
toward determining whether the child has one or a combination Gastro-intestinal : gastro-esophageal reflux, obstructions
of the following factors contributing to the etiology: inadequate Central nervous system causes: increased intracranial pressure, drugs
Systemic illness: urinary tract infection or other infection, metabolic
caloric intake, inadequate caloric absorption, or excessive caloric
disorders
expenditure8,10). There is increasing recognition that in many children Malabsorption/diarrhea
the cause is multi-factorial and includes biologic, psychosocial and Inflammatory bowel disease. Pancreatic insufficiency, colitis
Renal losses
environmental contributors11). Furthermore, in more than 80 percent Renal failure / renal tubular acidosis
of cases, a clear underlying medical condition is never identified. Table Diabetes mellitus or diabetes insipidus
1 provides a differential diagnosis of FTT. In adequate caloric intake Inability to properly utilize ingested nutrients
Chromosomal or genetic abnormality
is the most common etiology seen in primary care settings. In infants Metabolic disorder
younger than eight weeks, problems with feeding (e.g., poor sucking Endocrine disorder
and swallowing) and breast feeding difficulties are prominent12). After Excessive utilization of energy
Chronic illness (e.g.. cardiac disease, liver/renal failure, endocrine disorders,
then, transitioning to solid foods, insufficient breast milk or formula infection, anemia)
 Korean J Pediatr 2011;54(7):277-281 • http://dx.doi.org/10.3345/kjp.2011.54.7.277 279

of family history. Thus, history taking is the most important Table 2. Red Flag Signs and Symptoms Suggesting Medical Causes of
investigative technique in the evaluation of FTT. The differential Failure to Thrive
diagnosis is vast, but in most cases, there are sufficient symptoms and Cardiac findings suggesting congenital heart disease or heart failure (e.g.,
murmur, edema, jugular venous distention)
signs that lead to a specific diagnosis. The following data should be Developmental delay
included in the history6). Dysmorphic feature
Failure to gain weight despite adequate caloric intake
· Feeding: breast feeding or formula feeding, formula preparation,
Organomegaly or lymphadenopathy
volume consumed, who feeds the infants, position and placement Recurrent or severe respiratory, mucocutaneous, or urinary infection
of the infant for feeding, timing and introduction of solids, stool or Recurrent vomiting, diarrhea, or dehydration
vomiting patterns associated with feeding, strength of suck. Accurate
measurement of caloric intake of infants and children should be done · Head circumference is normal and weight is slightly reduced
by proper diet history. proportionate to height in children with constitutional growth delay,
· Developmental history: gestational and perinatal history genetic dwarfism or endocrinologic disorders.
(age and parity of mother, medical complication of pregnancy, · Head circumference is normal and weight is reduced out
use of medications, use of drugs, use of alcohol, substance abuse, of proportion to height in most infants with FTT, especially if
smoking, complications during delivery), developmental milestones, malnutrition results from inadequate caloric intake, malabsorption,
temperament. or altered metabolism.
· There may be specific behavior characteristics of the child that Other decisions the physician must make after examination
play an important role. These characteristics include disrupted is whether to admit the child to the hospital. Such decisions may
sleeping and eating patterns and behavior that is moody, demanding, be influenced if abuse or neglect is suspected; if the caretaker is
rejecting, or distractible. Some authors have suggested that a subset psychosocially impaired; or if serious malnutrition (60% below ideal
of infants may refuse to eat in an attempt to achieve some degree body weight)15), traumatic injury, hypothermia, low pulse rate, or low
of autonomy and control over their mothers and have termed this blood pressure is present. Physicians should also seek red flag signs or
infantile anorexia nervosa. symptoms of medical conditions that might be causing FTT13) (Table
· Psychosocial history: family composition, employment and 2).
financial status, stress, potential isolation, child rearing beliefs, history Further examination beyond growth parameters should include
of maternal depression, the caretaker’s history of childhood neglect or a thorough general examination including inspection for any phy­
abuse. sical signs of neglect or abuse, dysmorphic features, skin rashes,
· Family history: heights, weights, illness, development that may examination of the mouth for the presence of a cleft palate and
indicate constitutional short stature, inherited disease, developmental quality of sucking movements. The chest reveals signs of chronic
delay. respiratory or cardiac disease. The abdomen may be distended due
It is important to observe the infant and caretaker while feeding to malabsorption, or there may be organomegaly. Observe the
and playing. This provides clues about their interactions, the child’s general appearance and look for body fat and muscle wasting.
caretaker’s feeding technique, or inappropriate response to the Examination of skin, hair, and mails is in valuable.
infant’s physiologic or social cues. The infant may avoid eye contact or
withdraw from physical attention or may show poor suck or swallow Investigations
or aversion to oral stimulation.
Investigation should be guided by the history and examination.
Physical examination Infants who are either unwell or have significant positive physical
findings will require immediate investigation and consideration of
A complete and carefully physical examination is essential. Plot the pediatric referral, while those who are generally well with no positive
patient’s weight, recumbent length in infants younger than 2 years, findings may no immediate investigations16). In those requiring
and the head circumference on a standard growth curve specific for investigation, full blood examination, erythrocyte sedimentation
gender. This information helps to narrow the etiology of FTT. rate, electrolytes including urea, creatinine, calcium and magnesium,
· Head circumference, weight and height are proportionately and urine for culture and urinalysis are helpfully as an initial group
reduced in infants and children who have hereditary and congenital of screening tests. If there are specific concerns raised in the history,
defects. other investigation may be indicated. In children where significant
280 SJ Jeong • Nutritional approach to failure to thrive

doubt persists and tests have been unhelpful, pediatric review and adolescents. A supplement with a multivitamin with additional
sometimes a period of hospitalization for a trial of observed feeding specific nutrients is recommended. The rule of 3’s is quite helpful - 3
and further investigation may be helpful17). meals, 3 snacks, and 3 choices23).
If a disease or medical condition is identified on history, physical
Management examination, or additional testing, the correct approach will vary
depending on the condition. Appropriate management may include
FTT has serious implications, especially for brain development. If instituting specific treatment of the condition, or seeking consultation
malnutrition becomes severe and chronic during the first year of life, from a subspecialist or other health care professional for further
the child’s neurologic development may be permanently affected, evaluation and management recommendations. Enteral tube feedings
making early recognition and prompt intervention critical. or gastrostomy should be considered for patients in whom oral enteral
A multidisciplinary team approach is essential for management, feeding dose not achieve adequate caloric intake.
with the involvement of a pediatric gastroenterologist, a nutritionist, Refeeding should proceed cautiously, because significantly under­
a social worker, an occupational therapist, a speech and physical nourished children may develop diarrhea, vomiting, and circulatory
therapist, a psychologist and behavioral and developmental spe­ decompensation24).
cialists18). Close follow up should be performed in the physician’s office,
The goals of management of FTT are following: including evaluation of height and weight. Multi-disciplinary
· Provision of adequate calories, protein, and other nutrients interventions should be considered to improve weight gain, parent
· Nutritional counseling to the family child relationships, and cognitive development. The catch-up
· Monitoring of growth and nutritional status height will lag several months behind the catch-up weight. Thus the
· Specific treatment of complications or deficiencies nutritional intervention should be until appropriate height for age is
· Long term monitoring and follow up reached.
· Education of the family on social land nurturing techniques Finally, although medications such as megestrol (Megace) or
· Supportive economic assistance cyproheptadine have been shown to help promote weight gain in
Whenever possible, the underlying cause of FTT should be children with cancer related cachexia, they have not been studied
addressed and treated. However, caloric supplementation is the major in other causes of FTT25). Growth hormone therapy also has not
contributor to the management of FTT. Nutritional requirements been widely studied in children and adolescents who are not growth
can be assessed with the use of a formula for calories and protein19). hormone deficient and is not recommended for management of
Catch -up growth requirement (kcal/kg/d) = [calories required for FTT26).
age (kcal/kg/d) × ideal weight for age (kg) ]/[actual weight (kg)]
If a diagnosis of FTT is made and no medical conditions are sug­ Prognosis
gested on examination, appropriate guidance for catch-up growth
should be made. Age appropriate nutritional counseling should There is consensus that severe, prolonged malnutrition, which
be provided to parents16,17,20,21). For parents of breastfed infants, is common in developing countries, can negatively affect a child’s
recommending breastfeeding more often, ensuring lactation support, future growth and cognitive development27). A history of FTT was
or discussing formula supplementation until catch up growth is associated with short stature, poor math performance, and poor work
achieved may helpful17). Parents of formula fed infants may be habits. A systemic review showed that FTT during the first two years
instructed on how to make energy dense formula by concentrating of life was not associated with a significant reduction in intelligence
the ratio of formula to water during periods of catch up growth20,21). quotient, although some long term reductions in weight and height
The child’s diet must be fortified for caloric density by using were present28). The possibility of long term cognitive and behavioral
concentrated formula or by adding glucose polymers or extra lipids. sequelae is present. Lastly, child with a history of FTT are at increased
Toddlers should be offered solid food before liquids and avoid risk of recurrent FTT, and their growth should be monitored closely.
excessive juice or milk consumption because this can interfere with
proper nutrition22). Nutritional supplements may be given until catch References
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