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Failure to thrive (undernutrition) in children younger than two years: Etiology and evaluation

Kathleen J Motil, MD, PhD
Teresa K Duryea, MD
Section Editors
Jan E Drutz, MD
Craig Jensen, MD
Carolyn Bridgemohan, MD
Deputy Editor
Mary M Torchia, MD


Failure to thrive (FTT), also called "weight faltering" or "faltering growth," refers to failure to gain weight appropriately; in more severe cases, linear growth and head circumference also may be affected. FTT is a sign that describes a particular problem rather than a diagnosis. The underlying cause of FTT is "always insufficient usable nutrition," although a wide variety of medical and psychosocial stressors can contribute (table 1) [1].

Severe malnutrition can cause persistent short stature, secondary immune deficiency, and permanent damage to the brain and central nervous system [1]. Early identification and expeditious treatment may help to prevent long-term developmental deficits [2]. (See "Failure to thrive (undernutrition) in children younger than two years: Management", section on 'Prognosis' and "Secondary immunodeficiency due to underlying disease states, environmental exposures, and miscellaneous causes", section on 'Malnutrition'.)

The etiology of FTT and the initial evaluation of children younger than two years with FTT will be described here. The management of FTT in children younger than two years and poor weight gain in children older than two years are discussed separately. (See "Failure to thrive (undernutrition) in children younger than two years: Management" and "Poor weight gain in children older than two years of age".)


Failure to thrive — A consensus definition for FTT, including duration of concern about growth, is lacking [3-6]. We use the term FTT to describe children whose weight is less than the 2nd percentile for gestation-corrected age and sex when plotted on an appropriate growth chart (figure 1A-B) (calculator 1) and who have decreased velocity of weight gain that is disproportionate to growth in length (figure 2A-B) (calculator 2) [7]. Weight below the 2nd percentile is approximately equivalent to a Z-score of -2; the Z-score is a value that represents the number of standard deviations from the mean value. (See "Measurement of growth in children", section on 'Z-scores'.)

FTT is not used to describe children growing along a curve with a normal interval growth rate, even if their weight is <2nd percentile [8,9]. FTT is also not used to describe infants and young children with genetic short stature, constitutional growth delay, prematurity, or intrauterine growth restriction who have appropriate weight-for-length and normal growth velocity [10,11]. (See "Normal growth patterns in infants and prepubertal children", section on 'Variants of normal'.)

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Literature review current through: Nov 2017. | This topic last updated: Nov 07, 2017.
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  1. Perrin E, Frank D, Cole C, et al. Criteria for Determining Disability in Infants and Children: Failure to Thrive. Evidence Report/Technology Assessment No. 72. AHRQ Publication NO. 03-E026. Agency for Healthcare Research and Quality, Rockville, MD, March 2003.
  2. Corbett SS, Drewett RF. To what extent is failure to thrive in infancy associated with poorer cognitive development? A review and meta-analysis. J Child Psychol Psychiatry 2004; 45:641.
  3. Peterson KE, Chen LC. Defining undernutrition for public health purposes in the United States. J Nutr 1990; 120:933.
  4. Olsen EM, Petersen J, Skovgaard AM, et al. Failure to thrive: the prevalence and concurrence of anthropometric criteria in a general infant population. Arch Dis Child 2007; 92:109.
  5. Spencer NJ. Failure to think about failure to thrive. Arch Dis Child 2007; 92:95.
  6. Hughes I. Confusing terminology attempts to define the undefinable. Arch Dis Child 2007; 92:97.
  7. Casey PH. Failure to thrive. In: Developmental-Behavioral Pediatrics, 4th ed, Carey WB, Crocker AC, Coleman WL, et al (Eds), Saunders Elsevier, Philadelphia 2009. p.583.
  8. Emond A, Drewett R, Blair P, Emmett P. Postnatal factors associated with failure to thrive in term infants in the Avon Longitudinal Study of Parents and Children. Arch Dis Child 2007; 92:115.
  9. Maggioni A, Lifshitz F. Nutritional management of failure to thrive. Pediatr Clin North Am 1995; 42:791.
  10. Bithoney WG, Dubowitz H, Egan H. Failure to thrive/growth deficiency. Pediatr Rev 1992; 13:453.
  11. Zenel JA Jr. Failure to thrive: a general pediatrician's perspective. Pediatr Rev 1997; 18:371.
  12. Frank D. Failure to thrive. In: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 3rd ed, Augustyn M, Zuckerman B, Caronna EB (Eds), Lippincott Williams & Wilkins, Philadelphia 2011. p.204.
  13. Wright JA, Ashenburg CA, Whitaker RC. Comparison of methods to categorize undernutrition in children. J Pediatr 1994; 124:944.
  14. Wright CM. Identification and management of failure to thrive: a community perspective. Arch Dis Child 2000; 82:5.
  15. Edwards AG, Halse PC, Parkin JM, Waterston AJ. Recognising failure to thrive in early childhood. Arch Dis Child 1990; 65:1263.
  16. Waterlow JC. Classification and definition of protein-calorie malnutrition. Br Med J 1972; 3:566.
  17. Waterlow JC. Note on the assessment and classification of protein-energy malnutrition in children. Lancet 1973; 2:87.
  18. Waterlow JC. Some aspects of childhood malnutrition as a public health problem. Br Med J 1974; 4:88.
  19. Gomez F. Mortality in third degree malnutrition. J Trop Pediatr 1956; 2:77.
  20. McLaren DS, Read WW. Weight/length classification of nutritional status. Lancet 1975; 2:219.
  21. Raynor P, Rudolf MC. Anthropometric indices of failure to thrive. Arch Dis Child 2000; 82:364.
  22. Daniel M, Kleis L, Cemeroglu AP. Etiology of failure to thrive in infants and toddlers referred to a pediatric endocrinology outpatient clinic. Clin Pediatr (Phila) 2008; 47:762.
  23. Schwartz ID. Failure to thrive: an old nemesis in the new millennium. Pediatr Rev 2000; 21:257.
  24. Krugman SD, Dubowitz H. Failure to thrive. Am Fam Physician 2003; 68:879.
  25. Bithoney WG. Elevated lead levels in children with nonorganic failure to thrive. Pediatrics 1986; 78:891.
  26. Markowitz R, Duggan C. Failure to thrive: Malnutrition in the pediatric outpatient setting. In: Nutrition in Pediatrics Basic Science and Clinical Applications, 3rd, Walker WA, Watkins JB, Duggan C (Eds), BC Decker Inc, Hamilton, Ontario 2003. p.897.
  27. Sills RH. Failure to thrive. The role of clinical and laboratory evaluation. Am J Dis Child 1978; 132:967.
  28. Frank DA, Zeisel SH. Failure to thrive. Pediatr Clin North Am 1988; 35:1187.
  29. Pugliese MT, Weyman-Daum M, Moses N, Lifshitz F. Parental health beliefs as a cause of nonorganic failure to thrive. Pediatrics 1987; 80:175.
  30. Weston JA, Stage AF, Hathaway P, et al. Prolonged breast-feeding and nonorganic failure to thrive. Am J Dis Child 1987; 141:242.
  31. Bithoney WG, Newberger EH. Child and family attributes of failure-to-thrive. J Dev Behav Pediatr 1987; 8:32.
  32. Homer C, Ludwig S. Categorization of etiology of failure to thrive. Am J Dis Child 1981; 135:848.
  33. Casey PH. Failure to thrive: a reconceptualization. J Dev Behav Pediatr 1983; 4:63.
  34. Cook JT, Frank DA, Berkowitz C, et al. Food insecurity is associated with adverse health outcomes among human infants and toddlers. J Nutr 2004; 134:1432.
  35. National Institute for Health and Care Excellence. Faltering growth: Recognition and management of faltering growth in children. NICE guideline (NG75). September 2017. Available at: https://www.nice.org.uk/guidance/ng75 (Accessed on October 02, 2017).
  36. Frank D, Silva M, Needlman R. Failure to thrive: Mystery, myth and method. Contemp Pediatr 1993; 10:114.
  37. McDougall P, Drewett RF, Hungin AP, Wright CM. The detection of early weight faltering at the 6-8-week check and its association with family factors, feeding and behavioural development. Arch Dis Child 2009; 94:549.
  38. Olsen EM, Skovgaard AM, Weile B, et al. Risk factors for weight faltering in infancy according to age at onset. Paediatr Perinat Epidemiol 2010; 24:370.
  39. American Academy of Pediatrics Committee on Nutrition. Failure to thrive. In: Pediatric Nutrition, 7th ed, Kleinman RE, Greer FR (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2014. p.663.
  40. Mash C, Frazier T, Nowacki A, et al. Development of a risk-stratification tool for medical child abuse in failure to thrive. Pediatrics 2011; 128:e1467.
  41. Blair PS, Drewett RF, Emmett PM, et al. Family, socioeconomic and prenatal factors associated with failure to thrive in the Avon Longitudinal Study of Parents and Children (ALSPAC). Int J Epidemiol 2004; 33:839.
  42. Cardona Cano S, Hoek HW, Bryant-Waugh R. Picky eating: the current state of research. Curr Opin Psychiatry 2015; 28:448.
  43. Ashenburg CA. Failure to thrive: Newer concepts in treatment (Twenty-eighth Ross Roundtable Report). In: Pediatric Nutritional Challenges From Undernutrition to Overnutrition, Ambulatory Pediatric Association (Ed), Abbott Laboratories, Columbus, OH 1997. p.14.
  44. Parkinson KN, Wright CM, Drewett RF. Mealtime energy intake and feeding behaviour in children who fail to thrive: a population-based case-control study. J Child Psychol Psychiatry 2004; 45:1030.
  45. Levy Y, Levy A, Zangen T, et al. Diagnostic clues for identification of nonorganic vs organic causes of food refusal and poor feeding. J Pediatr Gastroenterol Nutr 2009; 48:355.
  46. Alvares M, Kao L, Mittal V, et al. Misdiagnosed food allergy resulting in severe malnutrition in an infant. Pediatrics 2013; 132:e229.
  47. Goldbloom RB. Growth failure in infancy. Pediatr Rev 1987; 9:57.
  48. Robb AS. Eating disorders in children. Diagnosis and age-specific treatment. Psychiatr Clin North Am 2001; 24:259.
  49. Chatoor I, Ganiban J, Hirsch R, et al. Maternal characteristics and toddler temperament in infantile anorexia. J Am Acad Child Adolesc Psychiatry 2000; 39:743.
  50. Black MM, Cureton PL, Berenson-Howard J. Behavior problems in feeding: individual, family, and cultural influences. In: Failure to thrive and pediatric undernutrition: a transdisciplinary approach, Kessler DB, Dawson P (Eds), Paul H. Brooks, Baltimore 1999. p.151.
  51. Wojcicki JM, Holbrook K, Lustig RH, et al. Chronic maternal depression is associated with reduced weight gain in latino infants from birth to 2 years of age. PLoS One 2011; 6:e16737.
  52. COUNCIL ON COMMUNITY PEDIATRICS, COMMITTEE ON NUTRITION. Promoting Food Security for All Children. Pediatrics 2015; 136:e1431.
  53. Kleinman RE, Murphy JM, Wieneke KM, et al. Use of a single-question screening tool to detect hunger in families attending a neighborhood health center. Ambul Pediatr 2007; 7:278.
  54. Hager ER, Quigg AM, Black MM, et al. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics 2010; 126:e26.
  55. O'Brien LM, Heycock EG, Hanna M, et al. Postnatal depression and faltering growth: a community study. Pediatrics 2004; 113:1242.
  56. Weston JA, Colloton M, Halsey S, et al. A legacy of violence in nonorganic failure to thrive. Child Abuse Negl 1993; 17:709.
  57. O'Connor ME, Szekely LJ. Frequent breastfeeding and food refusal associated with failure to thrive. A manifestation of the vulnerable child syndrome. Clin Pediatr (Phila) 2001; 40:27.
  58. Wright C, Birks E. Risk factors for failure to thrive: a population-based survey. Child Care Health Dev 2000; 26:5.
  59. Bureau of Family and Community Health. The Massachusetts Growth and Nutrition Program Summary Report FY 2003. Available at: www.mass.gov/eohhs/docs/dph/com-health/nutrition/report-2003.pdf (Accessed on January 23, 2012).
  60. Skuse DH, Gill D, Reilly S, et al. Failure to thrive and the risk of child abuse: a prospective population survey. J Med Screen 1995; 2:145.
  61. Black MM, Dubowitz H, Casey PH, et al. Failure to thrive as distinct from child neglect. Pediatrics 2006; 117:1456.
  62. Block RW, Krebs NF, American Academy of Pediatrics Committee on Child Abuse and Neglect, American Academy of Pediatrics Committee on Nutrition. Failure to thrive as a manifestation of child neglect. Pediatrics 2005; 116:1234.
  63. Gahagan S, Holmes R. A stepwise approach to evaluation of undernutrition and failure to thrive. Pediatr Clin North Am 1998; 45:169.
  64. Centers for Disease Control and Prevention (CDC). "Choking game" awareness and participation among 8th graders--Oregon, 2008. MMWR Morb Mortal Wkly Rep 2010; 59:1.
  65. Casey PH. Growth of low birth weight preterm children. Semin Perinatol 2008; 32:20.
  66. Wright CM, Williams AF, Elliman D, et al. Using the new UK-WHO growth charts. BMJ 2010; 340:c1140.
  67. Pollitt E, Eichler A. Behavioral disturbances among failure-to-thrive children. Am J Dis Child 1976; 130:24.
  68. Berwick DM, Levy JC, Kleinerman R. Failure to thrive: diagnostic yield of hospitalisation. Arch Dis Child 1982; 57:347.
  69. Hardin DS, Rice J, Ahn C, et al. Growth hormone treatment enhances nutrition and growth in children with cystic fibrosis receiving enteral nutrition. J Pediatr 2005; 146:324.
  70. Moy L, Levine J. Capsule endoscopy in the evaluation of patients with unexplained growth failure. J Pediatr Gastroenterol Nutr 2009; 48:647.