Last updated:
April 1, 2026
Table Of Contents
Overview
Failure to thrive is characterized by insufficient weight gain or inappropriate growth at the expected rate given a child’s age. It is currently defined as a weight-for-age below the fifth percentile on a standardized age-based growth chart, a decrease in weight percentile of more than 2 major percentile lines on the growth chart, or less than the 80th percentile of median weight-for-height or weight-for-length ratio.
It is divided into organic and non-organic (environmental) causes.
Organic causes of failure to thrive
| Category | Causes |
|---|---|
| Inadequate caloric intake | Cleft Lip/Palate; Dysphagia or other oral-motor dysfunction; Esophageal Strictures/Achalasia; Gastroesophageal Reflux Disease (GERD); Hypotonia or other developmental delays leading to difficulty feeding; Pyloric Stenosis; Psychiatric conditions such as bulimia or anorexia |
| Excessive caloric loss or malabsorption | Celiac Disease; Chronic Diarrhea; Cystic Fibrosis or other exocrine pancreatic dysfunction; Eosinophilic Esophagitis/Colitis; Inflammatory Bowel Disease such as Crohn’s disease or ulcerative colitis; Milk-protein or other food allergies; Laxative Abuse; Protein-Losing Enteropathies; Short Gut Syndrome |
| Increased systemic caloric requirements | Anemia; Chronic Lung, Kidney, or Liver Disease; Chronic Infections such as HIV, tuberculosis, hepatitis, urinary tract infections, enteric pathogens, TORCH infections; Congenital Heart Disease; Endocrinopathies such as hyperthyroidism; Inborn Errors of Metabolism; Malignancy; Prematurity; Rheumatologic Condition |
Psychosocial practices that can cause failure to thrive (inorganic causes of failure to thrive)
| Practice | Why is it a concern for FTT |
|---|---|
| Worries whether food will run out before there is money to buy more | Food insecurity is a high risk for all the practices listed below |
| Overdilution of a standard formula | Reduces caloric concentration |
| Using condensed milk to make formula | Condensed milk has inadequate protein, fat and calories to sustain growth |
| A former premature infant on a standard formula before one year of age | Premature infants should be on a 22- calorie per ounce formula for a year |
| Cereal in a bottle | Dilutes caloric density, may increase the work of feeding, and can decrease reflux |
| No vitamin/mineral preparation in a former preterm who is also receiving cow’s milk | Lack of effective counselling. Preemies are prone to Vitamin D and iron deficiency. |
| Infrequent feeding | Lack of effective counselling. Inadequate caloric intake is common. |
- Inorganic causes of failure to thrive
- Breastfeeding-related challenges
- Inadequate milk supply
- Not feeding frequently enough
- Formula-feeding challenges
- Mixing incorrectly, too small a feeding volume, or not frequent enough
- Challenges transitioning to solid foods
- Infant refusing dense calorie options
- Restrictive dietary choices
- Lack of knowledge about nutritional requirements
- Maladaptive feeding behaviours
- Food insecurity
- Psychosocial/family stressors, such as parents returning to work or single parents with multiple children in the home
- Child abuse/neglect
- Breastfeeding-related challenges
- Signs and symptoms of a neglected child
- Poor hygiene
- Malnourished
- Bruises
- Treatment of mild FTT
- Manage the underlying cause
- Educate the parents regarding proper feeding practice and the amount of nutrition required based on the child’s age
- Children with FTT require 150% of their daily needs until normal
- One-week food diary
- Follow up in one week
- Consult with a nutritionist or specialist in complicated cases
- Treatment of moderate-to-severe FTT
- Observed feeding over 3-7 days
- 100-200 kcal/kg/d
- Labs and consults as necessary
- Parent education (if non-organic)
- Mandatory social services/child protective services if neglect/abuse is suspected
- Frequent follow-up
- Observed feeding over 3-7 days
Misconceptions about FTT
- “Failure to thrive is most commonly due to neglect and malnutrition.”
- While partly true worldwide, FTT is more commonly due to illness, parental misconception, or difficulty regarding proper feeding.
- “Failure to thrive can be diagnosed whenever a child falls below percentiles.”
- Not always. An estimated 25% of children younger than 2 will change percentiles. Most clinicians consider crossing 2 major percentile lines to be indicative of FTT.
- “A diagnosis of failure to thrive necessitates admission for observation.”
- Not always. Severe FTT and suspected cases of neglect should be admitted. Some mild cases where the cause can be identified can be sent home with proper instructions and follow-up
Assessment of Failure to Thrive
- History
- Nutrition History
- Frequency of feedings/meals
- Diet and types of food given
- Amount of food given
- Formula used and proper mixing techniques (if applicable)
- Breastfeeding practice (if applicable) – determine the duration of feeds, maternal estimates of milk supply and infant’s ability to transfer milk at the breast, breast pumping history, and volumes of expressed breast milk if applicable
- If bottle-fed, inquire about the type of bottle and nipple flow rate
- Any other particular diet practices (for social, religious, cultural or economic reasons)
- Elimination history
- Stool output
- Frequency and consistency should be noted
- Note any dietary factors that cause a change in stool patterns
- Red flags include: bloody or mucoid stool, and large and bulky stool
- Urine output
- Can be used to assess hydration status, hence ask for frequency and colour
- Any signs of infection, such as dysuria, urgency or discharge, should be documented
- Past Medical History of the child
- History of congenital abnormalities
- History of atopy – suggests food allergies
- Previous history of poor weight gain and interventions
- History of infections
- Current or recent medications
- Stool output
- Obstetric History
- Gravida/para/abortus status of the mother (particularly at the time of birth of the patient)
- Course of pregnancy, including any general complications
- Infections
- Substance use – alcohol and cigarettes
- Therapeutic medications taken
- Neonatal History
- Gestational age at birth
- Birth weight
- APGAR score
- Birth percentiles
- Neonatal course – any complications, e.g., resuscitation, or hospitalization in the newborn unit
- Review of Newborn Screening Tests
- Developmental History
- Fine motor skills
- Gross motor skills
- Social skills
- Social, economic and family History
- Poverty
- Family dynamics
- Other caregivers besides the primary caregiver
- Daycare use
- Known medical conditions in the family, such as FTT in older siblings
- Parental food allergies and food preferences should be documented
- Review of Systems
- Nutrition History
- Physical examination
- Vitals
- Temperature
- Pulse
- Respiration rate
- Color
- Skin and hair
- Hair texture
- Nails
- Birth marks
- Rashes
- Hygeine
- Trauma or burns
- Head
- Circumference and size
- Fontanelles
- Frontal bossing
- Facies/dysmorphia
- Eye
- Conjunctiva
- Fundoscopic exam
- Pupils
- Ears
- Size
- Shape
- Position
- Otoscopy
- Mouth/pharynx
- Tongue
- Teeth/caries
- Gums
- Palate
- Breath odour
- Oral candidiasis
- Neck
- Shape
- Webs/redundant skin
- Massess
- Thyroid
- Trunk
- Bowel sounds
- Shape
- Liver and spleen
- Umbilicus
- Genitalia
- General appearance
- Pelvic exam if abuse is suspected
- Extremities and musculoskeletal
- Edema
- Digits
- Joints
- Spinal alignment
- Neurological
- Cranial Nerves
- Deep Tendon Reflexes
- Tone
- Suck/swallow response
- Psychiatric (Mental State Exam)
- Appearance
- Activity
- Affect
- Behaviour towards the caregiver
- Vitals
- Investigations
- Comprehensive metabolic panel
- Thyroid function tests
- Liver function tests
- Renal function tests
- Electrolytes
- Blood glucose
- Complete blood count
- Urinalysis
- Serum proteins
- Stool O&C (Ova and Cysts)
- Sweat Chloride
- Karyotype if Turner’s is suspected
- Serology for celiac disease
- Comprehensive metabolic panel