Description

Failure to thrive (FTT) or weight faltering describes a pattern of growth that is below established standards for age and gender. Anthropometric FTT is defined as any one of the following:

• Weight (or weight for length/height) <2 standard deviations below mean
• Weight deceleration of >2 major percentile lines after a previously established pattern
• Weight <75% of median weight for chronologic age
• Weight <80% of median weight for length
• Weight for chronologic age <5th percentile
• Body mass index for chronologic age <5th percentile
• Length for chronologic age <5th percentile

Epidemiology

• FTT often begins in the first 6 months of life but may not be diagnosed until after 1 year of age.
• It is difficult to accurately determine FTT incidence or prevalence as there is neither consensus on the best definition of FTT nor concordance between definitions. Depending on definition selected, prevalence can range from 1% to 22% based on an analysis of infants from a Danish Birth Registry.

Risk Factors

No single risk factor uniformly predicts FTT.

• Substantiated child abuse or neglect is 4 times more likely in FTT children compared to non-FTT children. However, maltreatment is a primary concern in only 4–5% of FTT cases.
• Family poverty was traditionally believed to be an important risk for FTT. However, recent prospective studies of large populations seen in general pediatric clinics have either been equivocal or failed to show poverty to be an important risk factor.
• Maternal mental health vulnerabilities such as depression and other individual and family stressors may play a role in some patients although the research has been equivocal.
• Currently, there is consensus that FTT involves a multiplicity of overlapping dietary, developmental, social, and medical concerns.

General Prevention

Advice should be straightforward, practical, and tailored to specific needs.

• Primary prevention
  • Addresses proper formula and food preparation, feeding quantities and frequencies, community-based nutrition support programs, and mental health resources
• Secondary prevention
  • Involves early identification by regular growth monitoring
• Tertiary prevention
  • Requires creation of an individualized treatment plan that addresses specific factors (dietary, developmental, social, and medical) adversely affecting a child’s ability to meet caloric needs
  • Long-term, coordinated multidisciplinary efforts involving home visiting nurses, dietitians, social workers, primary care providers, and medical subspecialists are critical to success.

Pathophysiology

• Inadequate caloric intake
  • Dietary
    • Breastfeeding difficulties
    • Diluted or inappropriately prepared formula
    • Food fads or restrictions
    • Excessive juice consumption
  • Developmental/neurologic
    • Oral motor difficulties
    • Central nervous system abnormalities
  • Social
    • Unavailability of food
    • Parent–child interaction disorders
    • Mental health or behavioral disorders affecting child’s appetite
    • Mental health disorders affecting caregiver’s parenting abilities
    • Disorganized meal times
    • Neglect (omitting feeds or creating environment not conducive to feeding)
  • Medical
    • Adenotonsillar hypertrophy
    • Cleft lip and/or palate
    • Dental pain and decay
    • Congenital cardiac disease
    • Gastroesophageal reflux disease
    • Dysphagia
• Inadequate absorption or utilization
  • Food allergies or intolerances
  • Inflammatory bowel disease
  • Gastrointestinal (GI) malformations
  • Pyloric stenosis
  • Hepatitis
  • Cystic fibrosis
  • Parasitic infections
  • Inborn errors of metabolism
• Increased caloric expenditure
  • Hyperthyroidism
  • Chronic infections
  • Chronic immunodeficiencies
  • Malignancy
  • Pulmonary disease
  • Cardiac disease
  • Renal disease

Etiology

• Historically, FTT was classified as organic (secondary to medical illness) or inorganic (secondary to psychosocial concerns). This categorization is obsolete. It places inordinate emphasis on organic conditions. In outpatient primary care settings, an identifiable organic disease likely contributes to FTT in <18% of children age ≤2 years.
• Children with FTT may eat less. An undemanding child temperament, low appetite, and disinterest in food may either cause or result in FTT.
• FTT children also have significantly fewer positive mealtime interactions with caregivers. Family dysfunction, caregiver incompetence, lack of knowledge about child development, and caregiver mental health vulnerabilities can affect a caregiver–child feeding relationship.

Commonly Associated Conditions

Severe, chronic FTT may have significant adverse effects on cognition, attention, and behavior.