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Failure to thrive (undernutrition) in children younger than two years: Management
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Failure to thrive (undernutrition) in children younger than two years: Management
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2016. | This topic last updated: Dec 01, 2015.

INTRODUCTION — Failure to thrive (FTT), also called "weight faltering," 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 'Prognosis' below and "Secondary immunodeficiency due to underlying disease states, environmental exposures, and miscellaneous causes", section on 'Malnutrition'.)

The management of FTT in infants and children younger than two years will be discussed here. The etiology and evaluation 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: Etiology and evaluation" and "Poor weight gain in children older than two years of age".)

TERMINOLOGY — A consensus definition for FTT is lacking. 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) [3]. Weight below the 2nd percentile is approximately equivalent to a Z-score of -2; the Z-scores is a value that represent the number of standard deviations from the mean value. (See "Measurement of growth in children", section on 'Z-scores'.)

Other definitions for FTT are discussed separately. (See "Failure to thrive (undernutrition) in children younger than two years: Etiology and evaluation", section on 'Failure to thrive'.)

SEVERITY ASSESSMENT — For the purpose of this topic, we classify the severity of FTT according to the Waterlow method (ie, the ratio of the child's weight to the median weight-for-height for acute FTT and the ratio of the child's height to the median height-for-age for chronic FTT (table 2)).

INDICATIONS FOR HOSPITALIZATION — Indications for hospitalization include [4-7]:

Severe malnutrition (table 2) or body mass index ≤12 kg/m2

Significant dehydration (table 3)

Serious intercurrent illness or significant medical problems

Psychosocial circumstances that put the child at risk for harm

Failure to respond to several months of outpatient management

Precise documentation of energy intake

Extreme parental impairment or anxiety

Extremely problematic parent-child interaction

Practicality of distance, transportation, or family psychosocial problems preclude outpatient management

Hospitalization may be neither helpful nor necessary unless the child is severely malnourished, seriously ill, or at risk of harm. Separation of the child from the family by hospitalization may promote anxiety and anorexia in the child and cause a delay in feeding and supporting the child within his or her established environment. Contrary to previous teaching, weight gain during hospitalization does not conclusively prove that psychosocial factors are the sole cause of poor growth; nor does failure to gain weight conclusively exclude the role of psychosocial factors.

INITIAL MANAGEMENT — Management of children with FTT is individualized according to severity and chronicity of undernutrition, underlying medical disorders, and the needs of the child and family [6]. Successful management requires a plan to address contributing nutritional, medical, developmental/behavioral, and psychosocial factors [5]. Support of the caregivers is critical. They should be involved as much as possible in the formulation of the treatment plan [2,4]. The involvement of a dietitian, occupational or speech therapist, social worker, and/or developmental and behavioral pediatrician can be helpful in formulating a management plan.

Overview of approach — The pace and aggressiveness of initial management depends upon the severity of malnutrition (table 2) and underlying medical problems.

Mild FTT — Children with mild FTT (table 2) without an underlying medical disorder generally can be managed by the primary care clinician in the outpatient setting. For children with underlying medical conditions (eg, small-for-gestational-age infant, fetal alcohol syndrome, prematurity, etc), multidisciplinary management may be warranted [6,8]. (See 'Adjunctive interventions' below and 'Interdisciplinary team' below.)

Depending upon the contributing factors identified during the evaluation, management may include:

The provision of dietary advice by the primary care clinician or a pediatric dietitian, focusing on ways to increase oral intake [8,9] (see 'Strategies to increase intake' below)

Changes to the feeding environment (table 4) (see 'Feeding environment' below)

Home-based support (eg, visiting nurse or other appropriately trained home visitor) [10-12] (see 'Psychosocial support' below)

Referral to community, state, or federal assistance programs (eg, food pantries, food stamps, Supplemental Nutrition for Women, Infants, and Children [WIC] in the United States) (see 'Psychosocial support' below)

In randomized trials, such simple interventions often are successful for children with mild FTT [10,11,13].

Children with mild FTT should have regular follow-up visits to reinforce the feeding plan and monitor weight gain. (See 'Follow-up' below and 'Response to initial management' below.)

Moderate FTT — For children with moderate FTT (table 2), we suggest interdisciplinary management in the outpatient setting [6,14,15]. The interdisciplinary team may be part of a specialized program at a referral center or, if such a program is not available, assembled by the primary care provider. (See 'Interdisciplinary team' below.)

Involvement of a dietitian is helpful in formulating the nutrition plan and strategies to increase intake. For children with moderate FTT, the target energy and protein intake should be achieved over 7 to 10 days to avoid complications associated with rapid refeeding [7,16]. (See 'Nutritional therapy' below and 'Nutritional recovery syndrome (refeeding syndrome)' below.)

Adjunctive interventions to address developmental and behavioral issues and provide psychosocial support should also be provided as necessary. (See 'Adjunctive interventions' below.)

Children with moderate FTT should have regular follow-up visits to reinforce the feeding plan and monitor weight gain. (See 'Follow-up' below and 'Response to initial management' below.)

Severe FTT — For children with severe FTT (table 2) or body mass index (BMI) <12 kg/m2, we suggest hospitalization for initial management by an interdisciplinary team [6]. Hospitalization permits safe implementation of a feeding regimen that will ensure catch-up growth. Hospitalization also may permit recurrent opportunities for education of the caregivers about appropriate diet and feeding styles [4]. Hospital volunteers, when available, may provide valuable role modeling, support, and aid in feeding.

Although we prefer to initiate feeding orally for most children with FTT, we generally initiate feeds via a nasogastric tube for children with BMI <12 kg/m2. Nasogastric tube feeds also may be necessary for children who cannot or will not feed orally.

For children with severe FTT (table 2), the target energy and protein intake should be achieved over 7 to 10 days, with feedings every two to four hours [7,16,17]. (See 'Energy requirements for catch-up growth' below.)

Gradual refeeding is necessary for several reasons:

Severe malnutrition is almost always accompanied by anorexia [18]; during early refeeding, frequent small volume feeding may be better tolerated (see "Malnutrition in children in resource-limited countries: Clinical assessment", section on 'Kwashiorkor')

Feedings with increased caloric density are usually hyperosmolar and can cause diarrhea and/or malabsorption if advanced too quickly [16,18,19]

Refeeding may be complicated by a nutritional recovery syndrome ("refeeding syndrome") (see 'Nutritional recovery syndrome (refeeding syndrome)' below)

During hospitalization, the child's daily food consumption is recorded, daily energy intake estimated, and daily weight gain monitored. Although there is no standardized approach, we monitor potassium and phosphate daily for the first three to five days of refeeding; the frequency thereafter is determined by the trend and response to supplementation (if necessary).

The approach to feeding should be the same as the anticipated treatment at home after discharge. The caregivers should be involved as much as possible in the formulation of the treatment plan [2,4]. Caregivers of children with growth failure often feel a sense of failure that may be exacerbated by the success of the hospital staff in feeding the child and achieving weight gain.

Criteria for discharge include a safe home environment and demonstration by the caregivers that they understand and can carry out the management plan [16]. Weight gain is not necessary before discharge. Discharge planning should include provision of necessary support and follow-up [4]. (See 'Psychosocial support' below.)

After discharge, children with severe FTT should continue to be followed by an interdisciplinary team. (See 'Follow-up' below and 'Response to initial management' below.)

Interdisciplinary team — Most children with FTT benefit from interdisciplinary management and/or home visiting programs [4,10,14,20-22]. In addition to the pediatric health care provider, the interdisciplinary team may include dietitians, occupational or speech therapists, social workers, nurses, developmental specialists, child-life workers, psychiatrists, and workers from social and educational services in the community [4,23]. The healthcare provider and multidisciplinary team should work with the strengths of the family to encourage the development of a nurturing environment and to determine which of the potential interventions are most feasible and acceptable [8].

Nutritional therapy — Nutritional therapy is the mainstay of management of FTT. The goal of nutritional therapy is to enable "catch-up" weight gain to overcome the weight deficit [7]. Catch-up weight gain typically is two to three times the expected weight gain for age (table 5), or approximately 45 to 60 g/day.

Consultation with a dietitian is helpful in assessing the severity of undernutrition, estimating energy intake and requirements for catch-up growth, and helping the caregivers plan menus tailored to the child's preferences that will provide enough dietary energy and nutrients for catch-up growth.

Energy requirements for catch-up growth — Children with FTT require a diet high in energy and other nutrients for catch-up growth [6,7,23].

Catch-up growth will not occur unless energy intake is greater than the Estimated Energy Requirement (EER) for age [7,24-26]:

0 through 2 months – 100 to 110 kcal/kg per day

3 through five months – 85 to 95 kcal/kg per day

6 through 8 months – 80 to 85 kcal/kg per day

9 through 11 months – 80 kcal/kg per day

12 through 24 months – 80 to 83 kcal/kg per day

To estimate the daily energy requirement for catch-up growth, we usually multiply the EER for age by the median weight for the child's current length and divide by the child's actual weight [6,27,28]. As an example, in a 15-month-old boy whose weight is 9 kg and length is 78 cm, the median weight for length is 10.4 kg (figure 3), and estimated energy intake for catch-up growth is 96 kcal/kg per day ((83 kcal/kg per day x 10.4 kg) ÷ 9 kg).

The sufficiency of intake is proven by subsequent weight and, eventually, height gain [7,23]. Infants with severe FTT may require >200 kcal/kg for catch-up growth [29]. (See 'Response to initial management' below.)

Vitamin and mineral supplementation — During the catch-up growth phase, existing stores of vitamins and minerals may not be sufficient. We recommend a multivitamin preparation that includes iron and zinc for children who are being treated for FTT [6,30,31]. The need for additional iron supplementation is determined by laboratory evaluation [7]. (See "Iron deficiency in infants and young children: Screening, prevention, clinical manifestations, and diagnosis".)

Strategies to increase intake — Strategies to achieve adequate intake of energy and protein intake depend upon the age and dietary preferences of the child. Consultation with a dietitian may help the caregivers plan menus tailored to the child's preferences that will provide enough dietary energy and nutrients for catch-up growth.

Young infants – The feeding schedule for infants depends upon the infant's nutritional needs and hunger cues. Infants younger than four months require frequent feedings, typically 8 to 12 per day; infants older than four months typically require between four and six feedings per day. Strategies to increase the caloric density of human milk and infant formula are provided below.

Human milk – In the inpatient setting, the caloric density of human milk is generally increased with human milk fortifiers. In the outpatient setting, the caloric density of human milk for term infants can be increased by adding infant formula powder to pumped breast milk [32].

-For breast milk with 22 kcal per ounce (30 mL), add one-half teaspoon (2.5 mL) of infant formula powder to 3 ounces (89 mL) of pumped breast milk.

-For breast milk with 24 kcal per ounce (30 mL), add one teaspoon (5 mL) of regular formula powder to 3 ounces (90 mL) of pumped breast milk.

The caloric density of human milk should not be increased by the addition of carbohydrate (eg, maltodextrin) or fat (eg, medium chain triglyceride) because the protein concentrate of such a mixture is inadequate for optimum growth [32].

The fortification of human milk for premature infants is discussed separately. (See "Human milk feeding and fortification of human milk for premature infants", section on 'Fortification of human milk'.)

Infant formula – The caloric density of infant formula can be increased by adding less water to powder or concentrated formula or by adding modular supplements such as glucose polymers (eg, maltodextrin) or fat (eg, medium chain triglycerides, corn oil) (table 6) [5].

Increasing the caloric density of commercial infant formula through concentration or the addition of glucose polymers and medium chain triglycerides increases the osmolality of the formula, which can cause diarrhea or malabsorption [19,30,32]. For this reason, formulas usually are not concentrated beyond 24 kcal per ounce (30 mL) unless fluid restriction is necessary (eg, for infants with congenital heart disease) [30]. Increases in the caloric density beyond 24 kcal/ounce (30 mL) should be made gradually (eg, in increments of 3 kcal per ounce [30 mL]) with modular supplements (glucose polymers, medium chain triglycerides) to a maximum of 30 kcal per ounce (30 mL).

The addition of carbohydrate or fat to standard infant formulas alters the nutrient ratio of the formula by providing nonprotein calories [32,33]. Providing more than 60 percent of energy from fat may induce ketosis and should be avoided. Consultation with a dietitian may be warranted to avoid excessive intake of individual nutrients.

Older infants and children – For infants and young children who have started solid foods, energy intake can be increased by increasing the caloric density of foods that the child likes to eat (eg, by adding rice cereal or formula powder to pureed foods; using high-calorie milk drinks instead of milk; adding cheese, butter, or sour cream to vegetables (table 7)) [5,8]. During catch-up growth, total energy and protein intake is more important than variety.

Older infants and children should eat often (every two to three hours, but not constantly). They should have three meals and three snacks on a consistent schedule; "grazing" on low-nutrient snack foods throughout the day and constant sipping on low-calorie liquid, fruit juice, or carbonated drinks should be avoided. Snacks should be timed so that the child's appetite for meals will not be spoiled (eg, snack time should not occur within one hour of mealtime; snacks should be avoided immediately after an unfinished meal) [4]. At meal and snack time, solid foods should be offered before liquids [6]. Excessive fluid consumption reduced intake of solid foods. Juice consumption should be limited to 4 to 8 ounces (120 to 240 mL) per day.

Appetite stimulants – Appetite stimulants, such as cyproheptadine, may be helpful in selected circumstances, but have no proven long-term benefit [34]. One author of this topic review (KM) begins cyproheptadine 0.12 mg/kg twice per day in children who have failed to achieve adequate catch-up weight gain (ie, a rate of weight gain that is two to three times the normal rate for age (table 5)) after three to six months of fortification of formula or food. Cyproheptadine is discontinued if weight gain is not improved after two to three months or the caregivers complain of significant drowsiness.

Feeding environment — Changes to the feeding environment may help to ensure adequate energy intake for catch-up growth. It is helpful to meet with all caregivers to ensure that the feeding program is consistent.

General guidelines for optimizing the feeding environment include [5,8,30,35]:

The child should be positioned so that the head is up and the child is comfortable. Children should be allowed to feed themselves.

Mealtime distractions should be minimized.

Mealtime should be relaxed and social; eating with other family members and pleasant conversation not related to food should be encouraged.

Mealtime should be free of battles over eating; caregivers should encourage, but not force, the child to eat; food should not be withheld as punishment.

The child should be praised when he or she eats well, but not punished when he or she does not.

Additional tips for caregivers are provided in the table (table 4).

Nutritional recovery syndrome (refeeding syndrome) — In severely malnourished children, refeeding may be complicated by a nutritional recovery syndrome ("refeeding syndrome"). Symptoms and signs include sweatiness, increased body temperature, hepatomegaly (caused by increased deposition in the liver), widening of the sutures (the brain growth is greater than the growth of the skull in infants with open sutures), increased periods of sleep, and fidgetiness or mild hyperactivity [5,17].

Rapid changes in tissue mineral content during the first week of refeeding may cause hypophosphatemia and hypokalemia [36]. Hypophosphatemia or hypokalemia can be treated orally with sodium phosphate or potassium phosphate in two divided doses to correct deficits. The estimated daily requirement for phosphorous approximates the dietary reference intake for age (ie, 100 mg/day [3.2 mmol/day] for infants 0 to 6 months, 275 mg/day for infants 6 to 12 months, and 460 mg/day for children 1 to 2 years [37]). Conversion from mg to mmol varies with the source of the supplement; consultation with a pharmacist is recommended. The estimated daily requirement for potassium is 1 to 2 meq/kg. Phosphate and potassium supplements should be discontinued once serum levels have returned to normal.

Adjunctive interventions — General measures in the management of FTT include interventions to address underlying medical, developmental, and behavioral, factors contributing to undernutrition and anticipation and prevention of consequences of malnutrition [6].

Medical — Medical conditions that contribute to undernutrition should be addressed as indicated (eg, referral to allergist for management of food allergies, to a gastroenterologist for management of gastroesophageal reflux). (See "Management of food allergy: Avoidance" and "Gastroesophageal reflux in infants" and "Management of gastroesophageal reflux disease in children and adolescents".)

Medical consequences of undernutrition should be anticipated and prevented as much as possible. As an example, children with undernutrition are at increased risk for recurrent infections; such infections should be treated promptly to prevent prolonged periods of decreased intake or increased losses associated with intercurrent illness. Immunizations should be administered according to the standard schedule and updated in children who have fallen behind. (See "Standard immunizations for children and adolescents".)

Developmental and behavioral — Developmental and behavioral problems may contribute to inadequate intake (eg, oral motor dysfunction) or increased losses (eg, rumination). Such problems must be addressed in the overall management plan. (See "Sucking and swallowing disorders in the newborn" and "Aspiration due to swallowing dysfunction in infants and children" and "Failure to thrive (undernutrition) in children younger than two years: Etiology and evaluation", section on 'Development and behavior'.)

In the United States, early intervention programs may be helpful in addressing these problems by providing developmental stimulation and physical and occupational therapy as indicated. Referral to a developmental behavioral pediatrician or behavioral psychologist may be helpful for such children.

Undernutrition in infancy may be associated with severe, irreversible developmental deficits and behavior problems [38]. The provision of early psychosocial stimulation may help to mitigate these problems [39,40]. In long-term follow-up of 129 children (9 to 24 months) with growth retardation who were randomly assigned to two years of nutritional supplementation with or without weekly psychosocial stimulation, early psychosocial stimulation was associated with increased adult IQ, higher educational attainment, and less involvement in violent behavior [39]. The developmental and behavioral status of children with FTT during the first two years of life should be closely monitored and early childhood services provided as soon as possible when indicated. (See 'Prognosis' below and "Developmental-behavioral surveillance and screening in primary care", section on 'When to perform developmental-behavioral screening'.)

Psychosocial support — Psychosocial difficulties must be addressed in concert with improved nutrition. Effective treatment, whether in inpatient or outpatient setting, requires involvement and support of the caregivers.

Psychosocial interventions should be provided to enhance the quality of caretaking and to address environmental effects on the caregiver's ability to provide adequate nutrition to the child [4,5]. Potential psychosocial interventions include:

Home visitation by professional or appropriately trained lay personnel, which may be helpful in providing guidance, support, and monitoring [4,10,21,41,42]

Facilitation of access to WIC, food stamps, and Temporary Assistance for Needy Families (formerly Aid to Families with Dependent Children) in the United States, and similar programs in other countries; resources in the United States include [43]:

2-1-1 – Provides information about school lunch programs, summer food programs, soup kitchens, community gardens, and government-sponsored food programs

Healthy Food Bank Hub – Provides a food bank locator and other resources households without enough food

MyPlate – Provides tip sheets and recipes for healthy eating at low cost

Provision of additional guidance and support to caregivers (eg, housing advocacy, job training, substance abuse treatment, respite care)

Child neglect accounts for a minority of children with FTT, but Child Protective Services should be involved if there is a history of intentional withholding of food from the child, strong beliefs in health and/or nutrition regimes that jeopardize a child's well-being, and/or a family that is resistant to recommended interventions despite a multidisciplinary team approach. (See "Child neglect and emotional maltreatment", section on 'Mandated reporting'.)

FOLLOW-UP — Close follow-up and frequent contact with the healthcare team are essential for reinforcing nutritional recommendations and psychosocial support [44]. The frequency of follow-up depends upon the child's age and severity of undernutrition, but usually ranges from weekly to monthly [30]. Frequent follow-up should continue until catch-up growth is demonstrated and a positive trend is maintained [35]. Developmental and behavioral surveillance should occur at each of these visits and throughout childhood. (See "Developmental-behavioral surveillance and screening in primary care", section on 'When to perform developmental-behavioral screening'.)

Community social service workers, visiting nurses, and dietitians can facilitate monitoring between visits and help to ensure a nurturing environment [44]. (See 'Psychosocial support' above.)

RESPONSE TO INITIAL MANAGEMENT — Successful response to initial therapy is defined by achievement of catch-up growth (ie, a rate of weight gain that is two to three times the normal rate for age) (table 5). With adequate nutritional intake, catch-up growth is generally initiated within two days to two weeks, depending upon the severity of the initial deficit [28,29,45].

Four to nine months of accelerated growth rates must be maintained to restore a child's weight for height [29]. As the deficits are replenished, intake and rates of growth spontaneously decelerate toward normal levels [29]. Catch-up growth in height/length lags several months behind that in weight, but will occur if dietary treatment is continued appropriately [28,29].

Guidelines for discharge from FTT follow-up are lacking. We extend the interval between visits when the child is consuming a normal diet for age and has demonstrated normal rate of weight gain for age and maintenance of weight-for-height above the 10th percentile for age and sex on at least two assessments one month apart. However, we continue to monitor growth at approximately six month intervals for at least one year to ensure that normal growth rates are maintained and that catch-up height has been achieved.

MANAGEMENT OF TREATMENT FAILURE — The management of treatment failure depends upon previous interventions. For children with FTT who have been followed by the primary care clinician for two to three months and have failed to achieve catch-up growth, outpatient management should be optimized. This may include involvement of, or referral to, a multidisciplinary team (if not already undertaken) [4,30]. Quantitative assessment of intake (eg, 24-hour food recall, three-day food record) also may be helpful. (See "Dietary history and recommended dietary intake in children", section on 'Dietary diary'.)

For children followed by the primary care clinician or a multidisciplinary team who do not achieve catch-up growth despite adequate energy and protein intake for catch-up growth and improved or appropriate feeding technique, additional evaluation of medical, nutritional, and social factors is indicated [6,16,30]. This may include investigation for malabsorption, increased metabolic demands, or decreased ability to utilize nutrients (table 1)[6]. Assessment of feeding and feeding interventions by an occupational therapist may be needed to improve sucking, chewing, and/or swallowing. (See "Sucking and swallowing disorders in the newborn".)

Supplementation of oral feedings with daytime or nighttime nasogastric feedings may be necessary in children who fail to achieve adequate catch-up growth despite four to six weeks of adequate oral intake [5]. Such children usually require the expertise of a multidisciplinary team. For children with mild or moderate malnutrition, nasogastric tube feedings may be initiated in the outpatient setting if adequate parental instructions for refeeding and periodic monitoring can be provided by home care personnel. For children with severe malnutrition, nasogastric tube feedings should be instituted in the hospital setting, where monitoring for the refeeding syndrome can be performed. Nasogastric feedings can be discontinued after consistent weight gain has been demonstrated for four to six months. If weight gain remains inadequate after three to four months of nasogastric tube feeding, gastrostomy tube placement may be appropriate. (See "Overview of enteral nutrition in infants and children".)

PROGNOSIS — The ultimate growth potential of a child with FTT is determined by genetic potential, the timing of malnutrition (eg, intrauterine versus neonatal versus later infancy; FTT with prenatal onset may be difficult to overcome, even with adequate postnatal nutrition), the severity of malnutrition, underlying medical problems, and whether underlying medical problems can be successfully managed [23,46].

Although the prognosis with respect to weight gain and growth is good, between 25 and 60 percent of infants with FTT remain small for age (weight or height <20th percentile for age and sex) [1,21,47-49].

Children with FTT are at risk for cognitive deficits [5,38,44]. FTT has also been associated with behavior problems and learning problems [5,44]. Whether these findings are a direct result of FTT or the result of continued adverse social circumstances is not clear [47,50].

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Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Poor weight gain in babies and children (The Basics)")

Beyond the Basics topic (see "Patient education: Poor weight gain in infants and children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Failure to thrive (FTT) is a term used to describe failure to gain weight appropriately during the first two years of life. We define FTT by weight less than the 2nd percentile for gestation-corrected age and sex when plotted on an appropriate growth chart (figure 1A-B) (calculator 1) and decreased velocity of weight gain that is disproportionate to growth in length (figure 2A-B) (calculator 2). However, a consensus definition is lacking. (See 'Terminology' above.)

We classify the severity of FTT according to the Waterlow method (ie, the ratio of the child's weight to the median weight-for-height for acute FTT and the ratio of the child's height to the median height-for-age for chronic FTT (table 2)). (See 'Severity assessment' above.)

Indications for hospitalization of infants and young children with FTT include (see 'Indications for hospitalization' above):

Severe malnutrition (table 2) or body mass index <12 kg/m2

Significant dehydration (table 3)

Serious intercurrent illness or significant medical problems

Psychosocial circumstances that put the child at risk for harm

Failure to respond to several months of outpatient management

Precise documentation of energy intake

Extreme parental impairment or anxiety

Extremely problematic parent-child interaction

Practicality of distance, transportation, or family psychosocial problems preclude outpatient management

Management of FTT is individualized according to severity and chronicity of undernutrition, underlying medical disorders, and the needs of the child and family. Successful management requires a plan to address contributing nutritional, medical, developmental/behavioral, and psychosocial factors. Support of the caregivers is critical. The involvement of a dietitian, occupational or speech therapist, social worker, and/or developmental and behavioral pediatrician can be helpful in formulating a management plan. (See 'Initial management' above and 'Interdisciplinary team' above.)

Nutritional therapy is the mainstay of management. Catch-up growth requires energy intake greater than the Estimated Energy Requirement for age. We estimate the daily energy requirement for catch-up growth by multiplying the average energy requirement for age by the median weight for the child's current length (figure 3) and dividing by the child's actual weight. (See 'Energy requirements for catch-up growth' above.)

We recommend that a multivitamin preparation including iron and zinc be provided during the catch-up phase of growth (Grade 1C). (See 'Vitamin and mineral supplementation' above.)

Strategies to achieve adequate intake of dietary energy and protein vary depending upon the age and dietary preferences of the child (table 6 and table 7). Changes to the feeding environment also may be necessary (table 4). (See 'Strategies to increase intake' above.)

Adjunctive interventions include intervention as indicated for medical and developmental/behavioral conditions contributing to undernutrition and anticipation and prevention of medical, developmental, and behavioral consequences. Psychosocial support of the caregivers is critical. (See 'Adjunctive interventions' above.)

The frequency of follow-up depends upon the child's age and the severity of undernutrition, but usually ranges from weekly to monthly. Frequent follow-up should continue until catch-up growth is demonstrated and a positive trend is maintained. (See 'Follow-up' above.)

Response to therapy is defined by achievement of catch-up growth (ie, a rate of weight gain that is two to three times the normal rate for age) (table 5). With adequate nutritional intake, catch-up growth is generally initiated within two days to two weeks, depending upon the severity of the initial deficit. (See 'Response to initial management' above.)

Between 25 and 60 percent of infants with FTT remain small for age (weight or height <20th percentile for age and sex). Cognitive function is below normal in one-half of the children with FTT, and behavior and learning problems are common. Whether these findings are a direct result of FTT or are the result of continued adverse social circumstances is not known. (See 'Prognosis' above.)

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REFERENCES

  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. 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.
  4. Bithoney WG, Dubowitz H, Egan H. Failure to thrive/growth deficiency. Pediatr Rev 1992; 13:453.
  5. Zenel JA Jr. Failure to thrive: a general pediatrician's perspective. Pediatr Rev 1997; 18:371.
  6. Frank D, Silva M, Needlman R. Failure to thrive: Mystery, myth and method. Contemp Pediatr 1993; 10:114.
  7. 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.
  8. Wright CM. Identification and management of failure to thrive: a community perspective. Arch Dis Child 2000; 82:5.
  9. Khoshoo V, Reifen R. Use of energy-dense formula for treating infants with non-organic failure to thrive. Eur J Clin Nutr 2002; 56:921.
  10. Black MM, Dubowitz H, Hutcheson J, et al. A randomized clinical trial of home intervention for children with failure to thrive. Pediatrics 1995; 95:807.
  11. Raynor P, Rudolf MC, Cooper K, et al. A randomised controlled trial of specialist health visitor intervention for failure to thrive. Arch Dis Child 1999; 80:500.
  12. Reifsnider E. Reversing growth deficiency in children: the effect of a community-based intervention. J Pediatr Health Care 1998; 12:305.
  13. Haynes CF, Cutler C, Gray J, Kempe RS. Hospitalized cases of nonorganic failure to thrive: the scope of the problem and short-term lay health visitor intervention. Child Abuse Negl 1984; 8:229.
  14. Bithoney WG, McJunkin J, Michalek J, et al. Prospective evaluation of weight gain in both nonorganic and organic failure-to-thrive children: an outpatient trial of a multidisciplinary team intervention strategy. J Dev Behav Pediatr 1989; 10:27.
  15. Hobbs C, Hanks HG. A multidisciplinary approach for the treatment of children with failure to thrive. Child Care Health Dev 1996; 22:273.
  16. Olsson JM. Failure to thrive. In: Pediatric Hospital Medicine. Textbook of Inpatient Management, Perkin RM, Swift JD, Newton DA (Eds), Lippincott Williams & Wilkins, Philadelphia 2003. p.130.
  17. World Health Organization. Management of severe malnutrition: a manual for physicians and other senior health workers. 1999 www.who.int/nutrition/publications/severemalnutrition/9241545119/en/ (Accessed on September 18, 2015).
  18. Racine AD. Failure to thrive. In: Primary Pediatric Care, 4th ed, Hoekelman RA (Ed), Mosby, St. Louis 2001. p.1072.
  19. Evans S, Twaissi H, Daly A, et al. Should high-energy infant formula be given at full strength from its first day of usage? J Hum Nutr Diet 2006; 19:191.
  20. Bithoney WG, McJunkin J, Michalek J, et al. The effect of a multidisciplinary team approach on weight gain in nonorganic failure-to-thrive children. J Dev Behav Pediatr 1991; 12:254.
  21. Wright CM, Callum J, Birks E, Jarvis S. Effect of community based management in failure to thrive: randomised controlled trial. BMJ 1998; 317:571.
  22. Black MM, Dubowitz H, Krishnakumar A, Starr RH Jr. Early intervention and recovery among children with failure to thrive: follow-up at age 8. Pediatrics 2007; 120:59.
  23. Markowitz R, Duggan C. Failure to thrive: Malnutrition in the pediatric outpatient setting. In: Nutrition in Pediatrics: Basic Science and Clinical Applications, 3rd ed, Walker WA, Watkins JB, Duggan C (Eds), BC Decker Inc, Hamilton, Ontario 2003. p.897.
  24. Food and Agriculture Organization of the United Nations (FAO), World Health Organization (WHO) and United Nations University (UNU): Human Energy Requirements. Chapter 3: Energy requirements of infants from birth to 12 months. Available at: www.fao.org/docrep/007/y5686e/y5686e05.htm (Accessed on January 21, 2013).
  25. Food and Agriculture Organization of the United Nations (FAO), World Health Organization (WHO) and United Nations University (UNU): Human Energy Requirements. Chapter 4: Energy Requirements of Children and Adolescents www.fao.org/docrep/007/y5686e/y5686e06.htm#bm06 (Accessed on October 20, 2015).
  26. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. National Academy of Sciences, 2006. fnic.nal.usda.gov/dietary-guidance/dietary-reference-intakes/dri-nutrient-reports (Accessed on September 18, 2015).
  27. MacLean WC Jr, Lopez de Romaña G, Massa E, Graham GG. Nutritional management of chronic diarrhea and malnutrition: primary reliance on oral feeding. J Pediatr 1980; 97:316.
  28. Frank DA, Zeisel SH. Failure to thrive. Pediatr Clin North Am 1988; 35:1187.
  29. Casey PH, Arnold WC. Compensatory growth in infants with severe failure to thrive. South Med J 1985; 78:1057.
  30. 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.
  31. Walravens PA, Hambidge KM, Koepfer DM. Zinc supplementation in infants with a nutritional pattern of failure to thrive: a double-blind, controlled study. Pediatrics 1989; 83:532.
  32. Singla S, Olsson JM. Enteral nutrition. In: Pediatric Hospital Medicine: Textbook of Inpatient Management, Perkin RM, Swift JD, Newton DA (Eds), Lippincott Williams & Wilkins, Philadelphia 2003. p.812.
  33. Clarke SE, Evans S, Macdonald A, et al. Randomized comparison of a nutrient-dense formula with an energy-supplemented formula for infants with faltering growth. J Hum Nutr Diet 2007; 20:329.
  34. Lemons PK, Dodge NN. Persistent failure-to-thrive: a case study. J Pediatr Health Care 1998; 12:27.
  35. 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.
  36. Solomon SM, Kirby DF. The refeeding syndrome: a review. JPEN J Parenter Enteral Nutr 1990; 14:90.
  37. USDA. Dietary reference intakes: RDA and AI for vitamins and elements. fnic.nal.usda.gov/dietary-guidance/dietary-reference-intakes/dri-tables (Accessed on August 21, 2013).
  38. Emond AM, Blair PS, Emmett PM, Drewett RF. Weight faltering in infancy and IQ levels at 8 years in the Avon Longitudinal Study of Parents and Children. Pediatrics 2007; 120:e1051.
  39. Walker SP, Chang SM, Vera-Hernández M, Grantham-McGregor S. Early childhood stimulation benefits adult competence and reduces violent behavior. Pediatrics 2011; 127:849.
  40. Aboud FE, Akhter S. A cluster-randomized evaluation of a responsive stimulation and feeding intervention in bangladesh. Pediatrics 2011; 127:e1191.
  41. 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.
  42. Wright C, Birks E. Risk factors for failure to thrive: a population-based survey. Child Care Health Dev 2000; 26:5.
  43. COUNCIL ON COMMUNITY PEDIATRICS, COMMITTEE ON NUTRITION. Promoting Food Security for All Children. Pediatrics 2015; 136:e1431.
  44. Goldbloom RB. Growth failure in infancy. Pediatr Rev 1987; 9:57.
  45. Ellerstein NS, Ostrov BE. Growth patterns in children hospitalized because of caloric-deprivation failure to thrive. Am J Dis Child 1985; 139:164.
  46. ud Din Z, Emmett P, Steer C, Emond A. Growth outcomes of weight faltering in infancy in ALSPAC. Pediatrics 2013; 131:e843.
  47. Dykman RA, Casey PH, Ackerman PT, McPherson WB. Behavioral and cognitive status in school-aged children with a history of failure to thrive during early childhood. Clin Pediatr (Phila) 2001; 40:63.
  48. Kristiansson B, Fällström SP. Growth at the age of 4 years subsequent to early failure to thrive. Child Abuse Negl 1987; 11:35.
  49. Drewett RF, Corbett SS, Wright CM. Cognitive and educational attainments at school age of children who failed to thrive in infancy: a population-based study. J Child Psychol Psychiatry 1999; 40:551.
  50. Boddy J, Skuse D, Andrews B. The developmental sequelae of nonorganic failure to thrive. J Child Psychol Psychiatry 2000; 41:1003.
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