Article growth and development

Failure to Thrive: A Consequence of

Undernutrition
Sheila Gahagan, MD,
Objectives After completing this article, readers should be able to:
MPH*
1. Recognize three common presentations in the physician’s office of failure to thrive.
2. Identify three principal mechanisms that lead to a mismatch between caloric intake
Author Disclosure and caloric expenditure.
Dr Gahagan did not 3. Understand the complex interaction between psychosocial and biomedical risks that
disclose any financial may lead to failure to thrive.
relationships relevant 4. Review the diagnostic approach based on three different growth presentations.
to this article. 5. Discuss the role of the physician in identifying psychosocial factors in failure to thrive
and in referring families to mental health professionals.

Introduction
Failure to thrive (FTT) is not a disease, but a sign that is better thought of as a final
common pathway of many medical, psychosocial, and environmental processes that lead to
poor growth in a young child. Although FTT once was conceptualized as either organic or
nonorganic, it now is understood to be the result of interaction between the environment
and the child’s health, development, and behavior. The evaluation of a young infant who
is growing slowly, or not at all, is truly the ultimate test of the pediatrician’s ability to
evaluate simultaneously biomedical and psychosocial information obtained from the
medical history and the physical examination. The stakes are high during the diagnostic
phase because the child could have a life-threatening disease or be in a life-threatening
psychosocial environment. Fortunately, these dire scenarios are exceedingly rare. Most
cases of FTT are due to inadequate nutrition that results from biologic and environmental
factors that intersect in such a way as to preclude adequate nourishment of the child. It is
essential to take a developmental approach to poor growth because the causes of this
condition change with development.

Case Histories
Two case histories are presented to illustrate examples of medical and psychosocial
conditions leading to inadequate growth. Management must be tailored to the child,
taking into account medical, psychological, family interaction, and economic problems.

Case 1
AB, a 15-month-old girl, was referred by her primary care pediatrician for evaluation of
poor growth. She had grown adequately for the first 6 postnatal months, but her growth
began to plateau after 6 months of age. She had experienced nine ear infections over 9
months, several bouts of “pneumonia,” and loose bowel movements and “diarrhea”
almost constantly.
Her nutritional history included breastfeeding for 2 months, followed by weaning to
formula. She was started on rice cereal at 4 months of age and gradually was introduced to
a variety of pureed foods. She had been eating some table food for many months. The
family history was noncontributory. The parents were very concerned. The maternal
grandmother, who had lived with the family, had cancer and was in hospice care. The
mother reported depression because of her own mother’s illness. The parents had

*Clinical Professor, Department of Pediatrics and Communicable Diseases; Assistant Research Scientist, Center for Human
Growth & Development, University of Michigan, Ann Arbor, Mich.

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growth and development failure to thrive

addition, the history of chronic diarrhea,

her protuberant abdomen, and the sever-
ity of her wasting in the face of a normal
dietary history raised concerns. A limited
laboratory evaluation was undertaken,
looking specifically for malabsorptive dis-
eases, including cystic fibrosis and celiac
disease. The chronic infections suggested
the possibility of immunologic disease,
which would be considered if she did not
have malabsorptive disease.
Laboratory studies were ordered and a
sweat test scheduled. The family was
asked to feed her three meals and three
nutritious snacks on a set daily schedule.
The importance of social support for the
family dealing with a sick child, a fragile
marriage, and a dying grandmother was
discussed, and the family was helped to
contact community mental health ser-
vices. Telephone contact was maintained.
Laboratory studies showed anemia, a
low serum albumin, and positive tests for
immunoglobulin A antiendomysial anti-
body and antigliadin antibody. These
positive tests were confirmed by an intes-
tinal biopsy diagnostic for celiac disease.
Her sweat test was negative. She re-
sponded to a gluten-free diet with excel-
lent weight gain.
In this case, the important psychoso-
cial problems were not the cause of the
child’s FTT. These issues may have de-
layed her diagnosis by distracting the fam-
ily from her symptoms or biasing her pe-
diatricians against a medical cause for her
Figure 1. Growth chart for AB.
poor growth. On the other hand, she was
diagnosed at a young age, and she made
separated for several months during the last year because
of marital discord, but were back together and doing Triceps Skinfold Thickness
Table 1.
well.
Notable findings on the child’s physical examination Norms Within 2 Standard
included thin, wispy hair; bilateral serous otitis media; Deviations Based on Preliminary
transmitted upper airway rhonchi; and a protuberant
abdomen. She was normocephalic, her length was at the NHANES Data (1971–1972)
10th percentile, and her weight was below the 3rd per- Age Boys Girls
centile (Fig. 1). She had very thin extremities, with a
triceps skinfold thickness of 6 mm (⬍5th percentile) 1 year 9.8 to 11.6 9.8 to 11.4
2 year 9.6 to 10.8 9.9 to 11.1
(Table 1).
3 year 9.7 to 11.1 11.1 to 12.5
The differential diagnosis included multifactorial FTT 4 year 9.1 to 10.5 10.1 to 11.3
due to recurrent ear infections and psychosocial stress. In

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 growth and development failure to thrive

an excellent recovery after the proper diet

was instituted. The important clues for an
underlying medical condition included
the history of recurrent infections, physi-
cal findings consistent with severe malnu-
trition, and a height percentile decreasing
nearly simultaneously with the decreasing
weight percentile.

Case 2
CD was referred for evaluation of FTT at
8 months of age by his primary care pedi-
atrician. He was born to a 31-year-old,
primiparous mother from Taiwan, whose
husband was working in the United
States as an engineer. She was university-
educated, but did not speak English. The
baby was born at term, weighing 3.4 kg
and delivered by cesarean section for fail-
ure to progress. The mother was readmit-
ted to the hospital on the 11th postoper-
ative day for fever and endometritis. She
was discharged on oral antibiotics after
4 days.
Over the first 2 postnatal months, the
infant was breastfed and grew well, dou-
bling his birthweight by the 2-month visit
(6.8 kg, ⬎95th percentile). Between 2
and 8 months of age, he gained only
500 g (average of 2 g/d). He refused to
eat and often vomited during feedings
when upset; his mother wondered aloud
whether he might be “evil.” He nursed at
night approximately every 2 hours for
5 minutes each time. During the day, he
received 24-kcal/oz formula fortified
Figure 2. Growth chart for CD.
with cereal. They had tried many different
types of pureed foods. Both parents had
been thin as children. The mother was isolated in their measurements were within normal limits. Later, the child
apartment and did not drive. She did not know any was evaluated for gastroesophageal reflux by pH probe
neighbors, and their only friends lived more than because of his ongoing vomiting. The study result was
30 miles away. They sometimes visited with friends on normal.
the weekend, but not every weekend. The maternal An ideal intervention should have included mental
grandmother had come from Taiwan to help for the first health services and a significant change in living situation
2 months of the infant’s life. The mother had no history to allow social interaction for the mother. A visiting
of depression and did not believe that she was depressed. nurse to help with feeding and early child development
The physical findings were normal except for cachexia services were warranted. However, the family did not
and fussiness. The child’s head circumference was at the accept recommended interventions, and they were un-
50th percentile, length at the 25th percentile, and weight able to organize more social interaction and support for
at less than the 5th percentile (Fig. 2). the mother. A behavioral plan for negative reinforcement
Results of a complete blood count and electrolyte of the child’s vomiting was developed collaboratively

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growth and development failure to thrive

with the family. This plan involved giving only necessary alternative labels to FTT. Although most inadequate
and casual attention to vomiting, while providing more growth is related to undernutrition, growth failure can
spirited interaction for good eating behavior. Concrete result from unusual medical conditions that involve
feeding goals were set, and the parents were educated to other factors. The term FTT may have pejorative conno-
avoid force-feeding. The pediatrician, who was their tations to some families and social service agencies. Wast-
primary source of support, praised and supported even ing is decreased weight for height and signals acute
small improvements in the child’s behavior, feeding, and malnutrition. It also is defined by decreased subcutane-
weight gain. The child’s feeding and weight gradually ous fat, as measured by triceps skinfold thickness (Table
improved, until he was growing below and parallel to the 1). Stunting is decreased height for age and can be a sign
5th percentile for weight, where he remained until age 5 of chronic undernutrition. It is important to take into
years.
account family stature (genetic potential).
At 5 years of age, his height had reached the 50th
Organic FTT (OFTT) describes an infant or toddler
percentile. Between ages 5 and 6 years, CD gained
who has grown poorly and has a medical disorder known
considerable weight to the 95th percentile. His height
to interfere with growth, including malabsorptive dis-
reached the 90th percentile, and body mass index in-
eases, genetic syndromes, endocrine disorders, and neu-
creased to the 85th percentile. At 8 years of age, he is at
risk for being overweight, but otherwise in good physical rologic dysfunction. Almost any chronic medical condi-
health. His primary pediatrician notes that his mother tion in a young child may manifest as poor growth.
continues to show considerable anxiety about his health Nonorganic FTT (NOFTT) often has been used as a
and does not allow him to use public rest rooms. Her fear diagnosis of exclusion to describe the child who has
is so extreme that she requires him to wear a pull-up grown poorly and has no identified medical condition.
diaper if they are going to be away from home for more This framework suggests that NOFTT is caused by envi-
than a few hours. ronmental conditions, rather than intrinsic biologic dis-
This is a complicated case of a mother who is ex- ease. Multifactorial FTT (or “mixed FTT”) describes the
tremely isolated and probably has an anxiety disorder. It common situation in which both organic and nonor-
is possible that she also was depressed during his infancy. ganic factors are identified as contributing to a child’s
The child began life fully able to consume adequate poor growth. Just as “layering of risk” or multiple risks
amounts of milk, but he developed an infant feeding can result in developmental delay, multiple predisposing
disorder, characterized by aversion, refusal, and vomit- conditions can interact to cause growth failure in an
ing. Current evidence suggests vulnerable child syn- infant who might have grown normally having only a
drome. Although his inadequate weight gain has re- single disease or a single psychosocial risk factor. Condi-
solved, he is now at risk for obesity and perhaps mental tions contributing to FTT often are of high prevalence,
health problems of his own. Although the pediatricians such as chronic otitis media and reactive airway disease in
recognized the importance of mental health care, includ- the child and depression in the mother.
ing infant mental health services, the family did not Current standards of care encourage more descriptive
accept those recommendations. The pediatricians in-
diagnoses for children who have environmental contrib-
stead provided frequent pediatric visits, counseling, and
utors to their poor growth. Children who previously
monitoring. If the child had not responded, it might
would have been described as having NOFTT now are
have become necessary to involve child protective ser-
identified more commonly as having specific develop-
vices, place a gastrostomy tube, or both. It is impossible
mental or psychological problems, including oromotor
to say how mandated social service involvement or gas-
trostomy tube feeding might have changed the outcome dyspraxia, sensory-motor disorder, feeding disorder of
for better or for worse. infancy, a family relationship problem, a “quality of
nurture problem,” child neglect, or mental disorder of a
Definitions and Diagnostic Classifications parent. The Diagnostic and Statistical Manual for Pri-
FTT is defined, for the purposes of this article, as failing mary Care (DSM-PC) Child and Adolescent Version con-
to grow at a rate consistent with expected standards for tains descriptive diagnoses for these conditions. (1) An-
infants and toddlers younger than 3 years of age. FTT is other helpful manual is the Diagnostic Classification of
a clinical syndrome that has multiple possible causes, Mental Health and Developmental Disorders of Infancy
often occurring in combination. The terms “undernutri- and Early Childhood (Diagnostic Classification: 0 to 3).
tion” and “inadequate growth” have been proposed as (2)

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 growth and development failure to thrive

Epidemiology creased caloric expenditure (such as occurs in

Inadequate growth is a common concern in the pediatric hyperthyroidism, congenital heart disease, and chronic
office. The prevalence of underweight is highest in young pulmonary disease); and, most frequently, 3) inadequate
infants. Interpreting prevalence data is difficult because intake of calories.
many studies do not exclude low-birthweight infants. In some cases, low intake is associated with poor
Low-birthweight infants account for 20% to 40% of the strength or neurologic ability to suck, chew, or swallow
children who have low height for age in studies of adequate amounts of food. In addition, some children
low-income children. (3) The prevalence of low weight have minor neurologic or psychological differences that
for age has dropped over the past 30 years from 5.5% to lead to oral aversion or an inability to enjoy eating some
4.1% in children 2 to 6 years old. (4) The prevalence of or all foods. These children often are characterized as
low weight for height has remained at approximately having “sensory food aversions.”(7) Some specific di-
2.5% during the same period. Although few affected etary factors have been associated with FTT, including
children have serious organic disease, all require skilled breastfeeding difficulties, poor transition to food be-
pediatric care to uncover the cause of their growth failure tween 6 and 12 months of age, improper formula mix-
and to implement a successful plan for nutritional reha- ing, avoidance of high-calorie foods, and excessive fruit
bilitation. Poor growth is more common in lower- juice consumption (Table 2). Family conditions that put
income communities because of the prevalence of risk a child at risk for decreased nutritional intake include
conditions, including lack of knowledge about good inadequate knowledge about infant nutritional needs,
child nutrition, financial hardship, and social problems mental health disorders (including depression and anxi-
that include substance abuse and child maltreatment. ety), family chaos, and rarely, outright child neglect. It is
However, FTT exists in all socioeconomic groups. not uncommon to find more than one medical and social
Conditions that put children at risk for poor growth factor contributing to the condition.
include poverty and food insecurity. Currently, 20% of If clinicians do not reference the weight-for-height
United States children younger than 4 years of age are curve, infants and toddlers from families who are of short
living below the federal poverty line ($18,850 for a stature more likely will be labeled as having “FTT” than
family of four in 2004). (5) Food insecurity has been those whose families are tall. Short stature syndromes,
documented in 21% of households having children including genetic, teratologic, and endocrine conditions,
younger than 3 years of age in five United States urban initially may come to medical attention because of poor
medical centers. (6) Food insecurity occurs when the growth. Psychosocial dwarfism is an interesting short
availability of adequate food is limited or uncertain and stature syndrome, sometimes associated with measurable
often is associated with intermittent hunger. Other doc- growth hormone deficiency, that occurs in environments
umented risk factors include larger family size and a characterized by emotional deprivation.
history of child abuse.
Clinical Aspects
Pathogenesis Presentation (Symptoms and Signs)
The pathogenesis of poor growth in young infants is Infants and toddlers who have FTT present to the phy-
related to inadequate caloric intake to meet caloric ex- sician because: 1) the family is concerned that their child
penditure. Three principal mechanisms lead to this mis- is not growing as well as other children of the same age,
match: 1) loss of calories through malabsorption; 2) in- 2) the family reports that the child is feeding poorly, or
3) the physician notices on physical examination or by
scrutiny of the growth charts that the child is growing
Dietary Associations With
Table 2. poorly. An a priori diagnosis of FTT by a physician who
has had no concern expressed by the family is common. If
Poor Growth in Young the family does not understand the physician’s concern
Children about the child’s growth or if they feel criticized by the
identification of poor growth in their child, it is more
• Breastfeeding difficulties difficult to build the necessary collaborative therapeutic
• Improper formula mixing partnership.
• Poor transition to food (6 to 12 months of age)
The evaluation of a child who has FTT requires a
• Excessive juice consumption
• Avoidance of high-calorie foods complete history, including a review of systems. The
clinician must remember that almost any medical condi-

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growth and development failure to thrive

Table 3. Developmental Approach to Possible Causes of Failure to Thrive

0 to 6 Months 6 to 12 Months
Maternal psychological (depression or attachment Maternal psychological (anxiety disorder or separation/individuation
disorder) disorder)
Poor breast milk supply Inadequate knowledge about nutrition needs
Economic problem Infant needs poorly ascertained
Poor feeding (sucking, swallowing) Genetic problem: short stature syndrome
Feeding refusal (aversion) Infant difficulty with transition to solid food
Medical problem (eg, malabsorption) New-onset illness (eg, celiac disease, human immunodeficiency
virus infection)

tion can present with poor growth in a young child, or other medical interventions occurring soon after birth.
including very rare diseases. However, more than 80% of Affected infants may associate the new experience of
children who are of inadequate growth do not have any feeding with discomfort from another source, resulting
underlying medical disorder. A nutritional history, a in refusal to feed. This behavior may be the earliest
feeding behavior history, and documentation of parent- manifestation of “posttraumatic feeding disorder.”(7)
child patterns of interaction are essential components of This association is confounded by the increased likeli-
the evaluation, along with the presenting complaint, hood of developmental problems in sick newborns,
medical history, family history, social history, and history which could result in feeding disorders related to a
of height and weight trajectories of parents and siblings. medical condition or neurologic disability. Enteral feed-
The nutritional history should include exact mixing tech- ing may be needed to support these infants nutritionally.
niques for infant formula. Documentation of who cares Weaning from tube feedings and learning how to eat
for and feeds the child throughout the day is part of the later may be extremely problematic and require intensive
feeding behavior history. occupational and speech therapy, as well as psychological
When growth failure is based on a feeding disorder, support.
the timing of the onset of the feeding and growth prob-
lem reveals important information about the psychody-
namic status of the infants and families (Table 3). Infants Growth Chart
who do not grow in the first 6 months after birth may be The growth chart is the most important tool used to
poorly attached to their caregivers. Infants who develop evaluate a child who has FTT and is the basis for the
eating problems in the second 6 months after birth are approach to the differential diagnosis. Plotting weight,
more likely to have overinvolved mothers who interfere length/height, and head circumference serially is criti-
with development toward a more independent feeding cally important. Attention to growth velocity for all three
style. It is very unusual for poor growth to start later in measurements provides a dynamic picture of changes in
the second year after birth. weight, length, and head circumference over time. Nor-
Some early-onset feeding disorders are believed to mal growth velocity tracks along a percentile curve at an
result from uncomfortable processes such as intubation expected rate. Average expected weight gain by age is
listed in Table 4. The time of onset of growth deficiency
Growth Velocity at the
Table 4.
can be determined by examining the growth curve. It
often is possible to find an illness or a psychosocial event
50th Percentile National Center that coincides with the onset of poor growth.
for Health Statistics Growth
Charts Physical Examination
Age (mo) Average Weight Gain/d (g) A complete physical examination emphasizing neurode-
velopmental status, evaluation of skin for neurocutane-
0 to 3 25 to 30 ous markings, dysmorphic features, and assessment of
3 to 6 20
nutritional status is performed, remembering that very
6 to 12 12
12 to 18 8 rare conditions may present as inadequate growth (Fig.
3) Signs of acute medical problems such as dehydration

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 growth and development failure to thrive

Figure 3. Approach to the differential diagnosis of failure to thrive.

may prompt hospitalization for further evaluation and feeding, may result in refusal by the child. Furthermore,
treatment. parents who cannot tolerate the messiness of toddler
When a feeding disorder or family problem is in the eating inadvertently may create unpleasant associations
differential diagnosis, a feeding observation is helpful. with meal times for the child. Parenting practices that
Feeding can be observed in the examination room, by enhance intake include creating a social feeding environ-
videotape, or by home visit. Observation of breastfeed- ment in which the child receives familiar food that is
ing can reveal physical difficulties with latch on, suck, let developmentally appropriate in texture and portion size.
down, and mother-infant interaction. Observing bottle
feeding may uncover a poor suck or a lack of coordina- Laboratory Tests
tion of suck and swallow. Improper feeding techniques Few routine laboratory tests are recommended. A shot-
such as prolonged attempts at burping or discontinuing gun approach to laboratory testing for FTT is not cost-
feeding when the infant is still hungry often are apparent effective. Rather, tests are performed based on positive
only by observation. Observation of spoon-feeding and findings from history and physical examination (Fig. 3).
self-feeding ideally includes observation of other family Additional laboratory and radiologic tests are completed
members to assess factors that enhance or interfere with for children who do not respond to dietary intervention.
developmentally appropriate feeding. Examples of inter- It is wise to review the newborn metabolic screening tests
actions that interfere with feeding include the extremes for a young infant who is not growing adequately. Hy-
of force feeding and neglect. More subtle parent-child pothyroidism and inborn errors of metabolism can cause
interaction problems, such as parental anxiety about feeding problems as well as poor growth. Routine labo-

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growth and development failure to thrive

ratory tests in children between 6 and 18 months of age

include screening for iron deficiency, lead poisoning, Examples of Short
Table 5.
tuberculosis, and chronic urinary tract infection. All
other laboratory testing should be based on findings
Stature Syndromes That May
from the history, physical examination, or specific diag- Cause Failure to Thrive
nostic hypothesis. Some children will be evaluated for
malabsorption and others for chromosomal problems; Genetic Short Stature Syndromes
still others will require brain imaging. However, there is • Russell-Silver syndrome
no uniform “FTT evaluation.” An evaluation that is • Turner syndrome
• Down syndrome
guided by findings from the history and physical exami- Endocrine Conditions
nation will have good predictive value.
• Hypothyroidism
• Hypophosphatemic rickets
Psychosocial Evaluation • Growth hormone deficiency
When psychosocial contributors to the child’s problem Teratologic Conditions
are suggested, further evaluation of family economic, • Fetal alcohol syndrome
organizational, and mental health is warranted. During
this phase of the evaluation, identifying resources as well
as problems can aid in the development of an interven- infections, teratologic and genetic conditions, and brain
tion plan. For example, if the mother is suffering from a injury.
grief reaction and is not attached to her infant, a strongly Those who have no microcephaly but are of short
attached father might be able to provide enough nurtur- stature are evaluated initially to see if the short stature is
ing to both infant and mother to reverse the inadequate primary or if it has developed because of poor weight
nutritional intake. A skilled primary care physician often gain. Those having primary short stature are evaluated
can understand the factors that lead to an infant feeding for genetic syndromes associated with short stature as
poorly. However, in some cases, a referral to a social well as teratologic and endocrinologic conditions (Table
worker or a public health nurse provides more in-depth 5).
information about the family, home, resources, and in- Most children who have FTT do not have significant
terpersonal interactions. Sometimes it is necessary to microcephaly or short stature. The evaluation then be-
involve child protective services for neglect or purposeful gins with assessing the adequacy of calories offered.
starvation. Any possible signs of physical abuse are cause When adequate calories are not being offered, the phy-
for concern because children who have physical trauma sician must determine if this situation is inadvertent or
and FTT may be at increased risk for death from child intentional.
abuse. It is not uncommon to find a child who is unable or
unwilling to accept the food that is offered. In these
Differential Diagnosis cases, the child may have poor appetite, oral aversion
The child’s growth parameters are the basis for a system- (resistance to tasting, licking, sucking, and swallowing),
atic approach to the differential diagnosis. Figure 3 is a food aversion (more specific difficulties with particular
diagnostic schema outlining this strategy, although no foods or textures), or oromotor dysfunction (neurologic
attempt has been made to itemize all possible diagnoses. impairment related to sucking, chewing, or swallowing).
Three categories of growth patterns are used to help the These findings may be linked to physical illness. Poor
clinician think through the broad differential diagnosis: appetite may be habitual in a child who has been sick or
1) FTT with microcephaly, 2) FTT with short stature, otherwise undernourished. These children simply are
and 3) FTT characterized by adequate height for age and used to their low caloric intake.
normal head circumference. Children who have micro- Other conditions to consider in a child who manifests
cephaly are subdivided further into those who have and low weight but normal height and head circumference
those who do not have prominent neurologic signs. include those caused by caloric loss through vomiting or
Children who have microcephaly but no neurologic signs malabsorption or a hypermetabolic state. A rare but
are evaluated for the possibility that head growth has dramatic condition, Russell diencephalic syndrome can
been impaired by malnutrition, which happens only in present with severe emaciation and normal head circum-
very severe cases. Those having microcephaly and prom- ference caused by a space-occupying lesion of the hypo-
inent neurologic symptoms are evaluated for TORCH thalamic optic chiasm. A pseudohydrocephalic appear-

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 growth and development failure to thrive

to chew more textured foods. Between 6 and 12 months

Feeding Interventions for
Table 6. of age, milk (human milk or formula) continues to supply
most of the calories. During this period, the infant
Infants and Toddlers should eat pureed food several times each day in a pleas-
Breastfeeding in Young Infant ant and social setting, preferably at a family meal. By the
middle of the second postnatal year, nonmilk foods
• Assist with latch-on technique
• Ensure proper feeding timing should provide at least 50% of the toddler’s calories.
▪ Newborn (minimum of 8 times in 24 hours) During this period, the frequency of meals increases to
▪ Feed at least 5 minutes on each breast three meals and two nutritious snacks.
• Let down When the infant who has grown poorly is breastfeed-
▪ Treat maternal exhaustion, stress, hunger, thirst
ing, the feeding problem can be a maternal factor such as
• Milk supply
▪ Use breast pump to increase supply deficient supply or an infant problem such as poor suck.
▪ Use medications such as metoclopramide In either instance, there is value in intervening to increase
Breastfeeding in Toddler the mother’s milk supply through the following ap-
• Assure adequate supplemental food proaches: 1) breast pumping to stimulate the positive
• Decrease non-nutritive sucking feedback loop of human milk production; 2) giving
• Choose weaning or increase milk supply metoclopramide to increase oxytocin; 3) advising rest,
Bottle Feeding fluids, and nutrition for the mother; 4) developing strat-
• Verify proper formula mixing egies to decrease maternal and family stress; and 5) mak-
• Verify minimum: 5.5 oz/kg (110 kcal/kg) formula ing other modifications in the home and workplace to
Toddler Feeding
support breastfeeding. The use of metoclopramide
• 3 meals ⴙ 2 nutritious snacks per day 10 mg tid orally has been documented to be safe and
• 16 to 32 oz of milk per day
• Discontinue juice, punch, soda pop until weight gain effective in stimulating the initiation and maintenance of
• Stop forcing and food battles lactation. (8) If the infant has a poor suck due to neuro-
• Feed in a social environment logic or anatomic problems, expressed human milk can
be fed by bottle or tube.
The decision to supplement with formula should be
made with care. Such a decision may be vested with
ance has been described in association with the meaning by the mother. She may consciously see this
diencephalic syndrome. decision as an indictment of incompetence or she may
subconsciously allow her “failure to feed” to influence
Management her self-concept negatively. The pediatrician must ensure
Management of FTT must begin before the evaluation is that the infant receives adequate calories, but walk a fine
complete. As the physician is gathering information from line in the care of the mother, who may feel incompetent
a lengthy medical history; complete physical examina- and even discarded if she cannot breastfeed. Addressing
tion; and further laboratory, radiologic, or psychosocial the psychodynamic meaning of breastfeeding may lessen
evaluations, education about adequate nutrition is pro- maternal guilt or feelings of failure for breastfeeding
vided. Nutritional and feeding intervention begins at the difficulties. When formula supplementation is started,
first visit, at which time feeding and growth responses are the mother can begin to increase her milk supply in
monitored. All medical conditions are treated as part of anticipation of providing more of the infant’s nutritional
the management of a child who has grown poorly, in- needs in the future.
cluding minor problems such as reactive airway disease Intervention for the formula-fed baby also requires
and recurrent ear infections. More serious medical prob- good communication with the parents. Understanding
lems, such as electrolyte disturbances and dehydration, the factors that contribute to FTT is important for over-
often require hospitalization. coming the barriers to adequate feeding. If the infant
Feeding management includes attention to nutrition sleeps most of the time, a schedule that involves waking
and to feeding behavior, both of which change with for feedings at least every 3 hours is beneficial. If the
development (Table 6). The normal infant initially re- infant falls asleep before finishing feedings, techniques
quires 110 kcal/kg, decreasing to 100 kcal/kg at 6 for keeping the baby awake may help. Some families
months of age. Feeding begins with sucking and swal- discontinue feeding, even when the infant is hungry, for
lowing milk, followed by gradually developing the ability a variety of reasons, including misreading of the baby’s

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growth and development failure to thrive

cues or adherence to a predetermined quantity. Less physicians also can help the family identify other sources
commonly, such underfeeding happens for financial or of support, including family members, friends, and com-
serious psychiatric reasons. Pediatrician permission for munity agencies. Just as the parents may need help with
larger feedings may allow some families to respond more feeding the child, infants and toddlers who are difficult to
appropriately to their infant’s needs. If catch-up growth feed benefit from additional caretakers who can do an
is desired, 120 kcal/kg are given. occasional feeding.
Parents who want complete control of their infant’s Positive reinforcement and encouragement from the
feeding may have more trouble when the child is be- primary care physician can be therapeutic. The pediatri-
tween 12 and 18 months of age. For children, this is a cian can incorporate supportive language into every visit:
period of increasing independence and ability. They of- “This is very challenging.” “Having a baby who will not
ten have a strong desire to self-feed. If there are problems eat makes many mothers feel as if they are not doing a
in this transitional period, the physician can explore good enough job.” “You’re doing a good job with her
issues about mess, control, and the loss associated with sleeping, and she does not cry excessively. Now, let me
the baby growing up. Children who feel that they are help you with her eating.” It is essential to keep in mind
being force-fed often go hungry rather than submit. that the mother may feel very vulnerable during the first
These children have been described by Chatoor as having postpartum months, a state of mind that is compounded
“infantile anorexia,” a condition characterized by issues by a child who will not eat. In all cases, long-term
of autonomy and dependency. (8) Some self-feeding is monitoring of the child’s growth and development is
important, even for a toddler who is not growing well. warranted because children who have experienced FTT
However, young children usually are not yet skilled are at increased risk for future undernutrition, overnutri-
enough to attain adequate calories without assistance. tion, eating disorders, and developmental and school
A two-spoon strategy can work well, allowing the child problems. Ironically, some children who experienced
to use his or her own spoon while the parent feeds him or poor growth as infants may be at risk for childhood
her. Finger feeding is encouraged and is enjoyed by the obesity later in life, as described in Case 2.
toddler, who can handle eating soft pieces of cheese, Hospitalization can be beneficial in the management
small pieces of soft fruits and cooked vegetables, and of some children who are not gaining weight. In cases of
small chunks of bread. This is an important time for frank neglect, feeding in the hospital can demonstrate
developing taste preferences. Most children refuse new that the child can gain weight when given adequate
tastes and textures at the first exposure. However, with calories. There are several potential problems with this
repeated exposures, familiar food becomes acceptable. approach, the most important being poor appetite in
Families must understand that they are shaping the children who have been taking too little food. Another
child’s food preferences during this period. We strongly problem is the current standard of short hospital stay.
recommend that families emphasize nutritious foods, Hospitalization also can be useful when feeding cannot
including vegetables, fruits, lean meats, potatoes, rice, be observed in the outpatient setting. The clinician must
noodles, and dairy products. Dairy products, oils, butter, remember that hospitalization adds new variables that
and margarine are high in fat and, therefore, very helpful may affect the child’s feeding behavior positively or neg-
in attaining adequate calories for children who do not eat atively. Hospitalization or treatment in a long-term day
well. It is more important that children accept a small treatment setting is necessary for many infants and tod-
number of nutritious foods than that they eat a great dlers who have severe eating disorders. This type of
variety of foods. Helping families to set realistic goals can intensive, multimodal therapy is available at few medical
prevent many feeding battles. centers. The duration of inpatient treatment for infant or
Addressing nonmedical problems, including mental toddler eating disorders typically is several months. The
health disorders, child maltreatment, and feeding disor- cost of this type of intervention may seem excessive until
ders, may be necessary even in children who have medical one considers the risk and the cost of life-long gastros-
conditions associated with their poor growth. When a tomy tube feeding.
parental mental health disorder is identified, the pedia-
trician should refer the parent to appropriate care. Par- Prognosis
ents who are unwilling or unable to get mental health Almost all children who have poor growth show ade-
care can receive support and monitoring from the pedi- quate improvement in their dietary intake with interven-
atrician. A weekly phone call or weight check visit for the tion. Many manifest improved growth even without
child can provide support for the parent. Primary care intervention as they move into a more independent phase

e10 Pediatrics in Review Vol.27 No.1 January 2006

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 growth and development failure to thrive

of feeding and become more competent at attaining their velopmental effects provides motivation to aim for
own food when hungry. Some children who have had preventing FTT.
eating disorders when infants continue to be “picky
eaters” for most of their childhood. A small percent of
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 Failure to Thrive: A Consequence of Undernutrition
Sheila Gahagan
Pediatrics in Review 2006;27;e1
DOI: 10.1542/pir.27-1-e1

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References This article cites 6 articles, 1 of which you can access for free at:
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1
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ewborn_infant_sub
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 Failure to Thrive: A Consequence of Undernutrition
Sheila Gahagan
Pediatrics in Review 2006;27;e1
DOI: 10.1542/pir.27-1-e1

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Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca,
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