Failure to thrive (FTT), also known as weight faltering or faltering growth, indicates insufficient weight gain or absence of appropriate physical growth in children. FTT is usually defined in terms of weight, and can be evaluated either by a low weight for the child's age, or by a low rate of increase in the weight.
The term "failure to thrive" has been used in different ways, as no single objective standard or universally accepted definition exists for when to diagnose FTT. One definition describes FTT as a fall in one or more weight centile spaces on a World Health Organization (WHO) growth chart depending on birth weight or when weight is below the 2nd percentile of weight for age irrespective of birth weight. Another definition of FTT is a weight for age that is consistently below the fifth percentile or weight for age that falls by at least two major percentile lines on a growth chart. While weight loss after birth is normal and most babies return to their birth weight by three weeks of age, clinical assessment for FTT is recommended for babies who lose more than 10% of their birth weight or do not return to their birth weight after three weeks.
In veterinary medicine, FTT is also referred to as ill-thrift.
Signs and symptoms
Failure to thrive is most commonly diagnosed before two years of age, when growth rates are highest, though it can present among children and adolescents of any age. Caretakers may express concern about poor weight gain or smaller size compared to peers of a similar age. Physicians often identify FTT during routine office visits, when a child's growth parameters such as height and weight are not increasing appropriately on growth curves.
The characteristic pattern seen with children with inadequate nutritional intake is an initial deceleration in weight gain, followed several weeks to months later by a deceleration in stature, and finally a deceleration in head circumference. Inadequate caloric intake could be caused by lack of access to food, or caretakers may notice picky eating habits, low appetite, or food refusal. FTT caused by malnutrition could also yield physical findings that indicate potential vitamin and mineral deficiencies, such as scaling skin, spoon-shaped nails, cheilosis, or neuropathy.
Children who have FTT caused by a genetic or medical problem may have differences in growth patterns compared to children with FTT due to inadequate food intake. A decrease in length with a proportional drop in weight can be related to long-standing nutritional factors or genetic or endocrine causes. Disorders that cause difficulties absorbing or digesting nutrients, such as Crohn's disease, cystic fibrosis, or celiac disease, can present with abdominal symptoms. Symptoms can include abdominal pain, abdominal distention, hyperactive bowel sounds, bloody stools, or diarrhea. FAS has also been associated with failure to thrive. Additional, medical conditions including parasite infections, urinary tract infections, other fever-inducing infections, asthma, hyperthyroidism and congenital heart disease may raise energy needs of the body and cause greater difficulty taking in sufficient calories to meet the higher caloric demands, leading to FTT. As many as 90% of failure to thrive cases are non-organic.
|Mothers with depression are more likely to have breastfeeding difficulties and may have decreased desire to interact with their children, which may lead to decreased feeding
|1 in 10 women in the US experience symptoms of depression
1 in 8 women experience symptoms of postpartum depression, or depression after childbirth
|Decreased motor function and coordination leads to difficulty feeding
|Impaired oral motor coordination and poor suck causes difficulty feeding
|Discomfort and pain after eating may cause poor appetite or refusal to feed
|Projectile vomiting after eating and inability of food to enter small intestine leads to dehydration and weight loss
|Food avoidance or restriction leads to inadequate nutritional intake
|Disruption in the breakdown of nutrients and to utilization of nutrients to produce energy
|Inability to drink milk leads to poor growth; discomfort after drinking milk may also lead to food refusal
|Damage to intestinal lining leads to problems with nutrient uptake
|Shortage of functioning intestines leads to malabsorption of nutrients
|Necrotizing enterocolitis is the most common cause in infancy
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|Cystic fibrosis
|Disorder in production and clearance of mucus leads to problems with lung and gastrointestinal function
|Problems with mucus clearance leads to issues with the pancreas and other gastrointestinal organs, leading to malabsorption of nutrients
|Underdevelopment of bile ducts leads to malabsorption of fats, difficulties with absorbing vitamins and other nutrients, and poor oral intake of food
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|Pancreatic insufficiency
|Inability of pancreas to produce sufficient enzymes necessary for digestion and absorption of nutrients, leading to symptoms such as chronic diarrhea and greasy stools
|Malabsorption of fats and inability to digest nutrients such as fat-soluble vitamins leads to poor weight gain
|Elevated metabolic rate causes increased energy usage
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|Chronic infections
|Chronic infections such as HIV, tuberculosis, urinary tract infections
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|TORCH infections
|Toxoplasmosis, other (syphilis, varicella zoster, parvovirus B19), rubella, cytomegalovirus, herpes simplex virus
|Infections result in increased energy expenditure
Failure to thrive may be caused by a type of diabetes mellitus called neonatal diabetes mellitus
|Inability to utilize sugars for energy leads to growth difficulties
|Breathing problems may make feeding more difficult
Lack of oxygen to the intestines may cause malabsorption
Overall decreased oxygen delivery to the body and increased energy needs may stunt growth
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|Cancer
|Presentation varies depending on type of cancer, but include pain, swelling, fatigue, fever, headache, night sweats, loss of appetite
|Rapid growth of cancer cells requires high energy usage
|Pediatric cancers are less than 1% of all new cancer diagnoses
Most common pediatric cancers are leukemia, brain and spinal cord tumors, and neuroblastoma
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|Chronic kidney disease
|Dysfunction of the kidneys, the organs that filter blood and produce urine
May be caused by anatomical differences in the kidneys and urinary tract, or by diseases (e.g., infections, diabetes) that cause damage to the kidneys
|Damage to the kidneys leads to dysfunctional activity of growth hormone and other necessary hormones, disruptions to metabolism, inflammation causing increased expenditure, and disturbances in retention and utilization of nutrients Failure to thrive is more prevalent in children of lower socioeconomic status in both rural and urban areas. In 2020, global estimates of malnutrition indicated that 149 million children under 5 were stunted and 45 million were estimated to be wasted. In 2014, approximately 462 millions adults were estimated to be underweight. In comparison, chronic malnutrition is a condition that develops over time and results in growth inadequacy with subsequent developmental, physical and cognitive delays. Around 144 million children worldwide are chronically malnourished. for children younger than two years old or the U.S. Centers for Disease Control and Prevention (CDC) growth charts for patients between the ages of two and twenty years old. This process begins with evaluating the patient's medical history. The medical provider will ask about complications during pregnancy and birth, health during early infancy, previous or current medical conditions of the child, and developmental milestones that have been reached or not reached by the child. Additionally, medical providers will inquire about any medical conditions that other members of the family may have, as well as assess the psychological and social circumstances of the child and family. If indicated, anti-TTG IgA antibodies can be used to assess for celiac disease, and a sweat chloride test can be used to screen for cystic fibrosis. It is potentially fatal, and can occur whether receiving enteral or parenteral nutrition. The most serious and common electrolyte abnormality is hypophosphatemia, although sodium abnormalities are common as well. It can also cause changes in glucose, protein, and fat metabolism. Incidence of refeeding syndrome is high, with one prospective cohort study showing 34% of ICU experienced hypophosphatemia soon after feeding was restarted.
Low-resourced settings
Community-based management of malnutrition (CMAM) has been shown to be effective in many low resourced regions in the past two decades. This method includes providing children with ready-to-use therapeutic food (RUTF) and then following up with their health at home or at local health centers. RUTF is readily-consumed, shelf-stable food that provides all the nutrients required for recovery. It comes in different formulations, is generally a soft, semisolid paste, and can be sourced locally, commercially, or from agencies like UNICEF. In terms of efficacy, clinical experience and systemic reviews have shown higher recovery rates using CMAM than previous methods, such as milk-based formulas. While this is an efficient outpatient method to address FTT, children with underlying pathologies would require further inpatient workup.
RUTF should be treated as prescribed medication to the child experience FTT, and thus should not be shared with others in the family. The recommended feeding protocol is 5-6 servings a day for about 6–8 months, at which time many children will fully recover. Children should have a follow-up every week or two looking at weight and upper arm circumference. Follow-ups can be decreased if there is progress without complications, but if the child is not improving, then further evaluation for underlying issues is recommended. After treatment has ended, the child's caretakers should be counseled on how to continue feeding them and looking for signs of relapse.
Prevention is an effective strategy to address failure to thrive in resource limited regions. Recognition of at-risk populations is an important first step in approaching prevention. Infections such as HIV, tuberculosis and conditions causing diarrhea can be causative factors in failure to thrive. As such, addressing these conditions can greatly improve outcomes. Targeted supplementation strategies such as ready-to-eat foods or legume supplementation are valuable tools for preempting failure to thrive.
Prognosis
Children with failure to thrive are at an increased risk for long-term growth, cognitive, and behavioral complications. Longitudinal studies have also demonstrated slightly lower IQs (3–5 points) and poorer arithmetic performance in children with a history of failure to thrive, compared to peers receiving adequate nutrition as infants and toddlers. Early intervention and restoration of adequate nutrition has been shown to reduce the likelihood of long-term sequelae, however, studies have shown that failure to thrive may cause persistent behavioral problems, despite appropriate treatment. Throughout the 20th century, FTT was expanded to include many different issues related to poor growth, which made it broadly applicable but non-specific. They may struggle with instrumental activities of daily living (e.g., preparing meals for themselves), be at high risk for hospital admission, and need significant discharge planning to support a safe and healthy return home.