Growth and weight faltering (formerly known as failure to thrive) is defined as a height or weight for length or body mass index below the expected measurement or height/weight that crosses 2 percentile lines on age- and sex-specific growth charts after previous typical growth. The cause may be a medical condition or may be related to environmental factors. All types of weight faltering are related to inadequate nutrition. Treatment is aimed at restoring proper nutrition.
Failure to thrive is outdated terminology. It has been replaced with growth and weight faltering (1).
General reference
1. Tang MN, Adolphe S, Rogers SR, Frank DA. Failure to Thrive or Growth Faltering: Medical, Developmental/Behavioral, Nutritional, and Social Dimensions. Pediatr Rev. 2021;42(11):590-603. doi:10.1542/pir.2020-001883
Etiology of Growth and Weight Faltering in Children
The physiologic basis for growth and weight faltering is inadequate nutrition and is divided into 3 categories: organic, nonorganic, and mixed. Most cases of growth and weight faltering are mixed (1).
Organic growth and weight faltering
Organic growth and weight faltering is due to an acute or chronic disorder that interferes with nutrient intake, absorption, metabolism, or excretion or that increases energy requirements (see table Some Causes of Organic Growth and Weight Faltering). Illness of any organ system can be a cause.
Children with organic growth and weight faltering may present at any age depending on the underlying disorder.
Some Causes of Organic Growth and Weight Faltering
Mechanism | Disorder |
|---|---|
Decreased nutrient intake | Central nervous system (eg, cerebral palsy) Gastroesophageal reflux disease Parasites |
Disaccharidase (eg, lactase) deficiency Short gut syndrome | |
Impaired metabolism | Chromosomal abnormality (eg, Down syndrome, Turner syndrome) Galactose-1-phosphate uridyl transferase deficiency (classic galactosemia) |
Increased excretion | |
Increased energy requirements | Cystic fibrosis Infection |
Nonorganic growth and weight faltering
Nonorganic growth and weight faltering is due to insufficient calorie intake. It usually manifests first as failure to gain weight. Growth in length and head circumference remain normal for a period of time until they too become impacted by poor calorie intake. This is the most common pattern of nonorganic growth and weight faltering.
When nonorganic growth and weight faltering is caused by psychologic factors, growth failure accompanies or precedes poor weight gain. This is thought to occur because mental stress in the child may cause increased levels of counter-regulatory hormones (eg, corticosteroids, catecholamines), which oppose the effects of growth hormone.
Up to 80% of children with growth failure do not have an apparent growth-inhibiting (organic) disorder; growth failure occurs because of environmental neglect (eg, lack of food), stimulus deprivation, or both.
Lack of food may be due to
Poverty
Poor understanding of feeding techniques
Improperly prepared formula (eg, overdiluting formula to stretch it because of financial difficulties)
Inadequate supply of breast milk (eg, because the mother is under stress, exhausted, or poorly nourished)
Nonorganic growth and weight faltering is often due to disordered interactions between a child and caregiver. An unstimulated child becomes apathetic and ultimately anorexic. Stimulation may be lacking because the caregiver
Is depressed or apathetic
Needs assistance with parenting skills
Is anxious about or unfulfilled by the caregiver role
Feels hostile toward the child
Is responding to real or perceived external stresses (eg, demands of other children in large or chaotic families, marital dysfunction, a significant loss, financial difficulties)
Difficulties with caregiving do not fully account for all cases of nonorganic growth and weight faltering. The child’s temperament, capacities, and responses help shape caregiver nurturance patterns. Some scenarios involve caregiver-child mismatches, in which the child’s demands (eg, a difficult feeder), although not pathologic, cannot be adequately met by the caregiver, who might, however, do well with a child who has different needs or even with the same child under different circumstances. Investigating what makes a child a difficult feeder may uncover a problem with caregiver–child interaction that would have remained hidden if the child were an easy feeder.
Mixed growth and weight faltering
In mixed growth and weight faltering, organic and nonorganic causes can overlap. For example, children with organic disorders also have disturbed environments and/or dysfunctional caregiver interactions. Likewise, children with severe undernutrition caused by nonorganic growth and weight faltering can develop organic medical problems.
Etiology reference
1. Peterson Lu E, Bowen J, Foglia M, et al. Etiologies of Poor Weight Gain and Ultimate Diagnosis in Children Admitted for Growth Faltering. Hosp Pediatr. 2023;13(5):394-402. doi:10.1542/hpeds.2022-007038
Diagnosis of Growth and Weight Faltering in Children
Frequent weight monitoring
Thorough medical, family, and social history
Diet history
Laboratory testing
Weight, height or length, and head circumference should be plotted against age on growth charts, such as those recommended by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC). (For children 0 to 2 years, see WHO Growth Charts; for children 2 years and older, see CDC Growth Charts.) Until premature infants reach 2 years of age, age should be corrected for gestation.
Weight is the most sensitive indicator of nutritional status. Another useful measure of undernutrition includes a body mass index (BMI) Z-score of less than -2 (ie, 2 standard deviations below the mean BMI for age and sex). When growth and weight faltering is due to inadequate caloric intake, weight falls from the baseline percentile before length does.
Reduced linear growth usually indicates severe, prolonged undernutrition. Simultaneous fall off of length or height and weight suggests a primary disorder of growth or a prolonged inflammatory state.
Because the brain is preferentially spared in protein-energy undernutrition, reduced growth in head circumference occurs late and indicates very severe or long-standing undernutrition.
Children who are underweight may be smaller and shorter than their peers and may present with fussiness or crying, lethargy or sleepiness, and constipation. Growth and weight faltering is associated with physical delays (eg, sitting, walking), social delays (eg, interacting, learning), and, if occurring in older children, delayed puberty.
Usually, when growth failure is noted, a history, including diet history (see table Essentials of the History for Growth and Weight Faltering), is obtained, diet counseling is provided, and the child’s weight is monitored frequently.
Careful examination of the growth chart can lend clues to the diagnosis. For example, if the weight and height fall off simultaneously, a diagnosis of an organic cause is likely. However, without historic or physical evidence of a specific underlying etiology for growth failure, no single clinical feature or test can reliably distinguish organic from nonorganic growth and weight faltering. Because children may have both organic and nonorganic growth and weight faltering, the physician should search simultaneously for an underlying physical problem and for personal, family, and child-family characteristics that support a psychosocial etiology.
Optimally, evaluation is multidisciplinary, involving a physician, a nurse, a social worker, a nutritionist, an expert in child development, and often a psychiatrist or psychologist. The child’s feeding behaviors with health care professionals and with the caregivers must be observed, whether the setting is an inpatient or outpatient. A child who does not gain weight satisfactorily in spite of outpatient assessment and intervention usually is admitted to a hospital so that all necessary observations can be made and diagnostic tests can be done quickly.
During hospitalization, the child’s interaction with people in the environment is closely observed, and evidence of self-stimulatory behaviors (eg, rocking, head banging) can be noted. Some children with nonorganic growth and weight faltering have been described as hypervigilant and wary of close contact with people, preferring interactions with inanimate objects if they interact at all. Although nonorganic growth and weight faltering is more consistent with neglectful rather than abusive parenting, the child should be examined closely for evidence of abuse. A screening test of developmental level should be done and, if indicated, followed with more sophisticated assessment. Hospitalized children who begin gaining weight well with proper feeding techniques, formula preparation, and amount of calories are more likely to have nonorganic growth and weight faltering.
Engaging the caregivers as co-investigators is essential. It helps foster their self-efficacy and avoids blaming caregivers who may already feel frustrated or guilty because of a perceived inability to nurture their child. For hospitalized children, the family should be encouraged to visit as often and as long as possible unless otherwise contraindicated. Staff members should make them feel welcome, support their attempts to feed the child, and provide toys and ideas that promote caregiver-child play and other interactions.
Caregiver adequacy and sense of responsibility should be evaluated. Suspected neglect or abuse must be reported to social services, but, in many instances, referral for preventive services that are targeted to meet the family’s needs for support and education (eg, additional food stamps, more accessible child care, parenting classes) is more appropriate as a first step.
Essentials of the History for Growth and Weight Faltering
Item | Comments |
|---|---|
Growth charts | Measurements, including those taken at birth if possible, should be examined to determine the trend in growth rate. Because of wide normal variations, diagnosis of growth and weight faltering should not be based on a single measurement, except when undernutrition is obvious. |
Diet history (3 days) | Diet history should be detailed, including eating or feeding schedule, and, in infants, techniques for the preparation and feeding of formula (including volumes) or adequacy of breast milk supply. Plastic nipple type and flow should be evaluated. As soon as possible, caregivers should be observed feeding the infant to evaluate their technique and the infant’s vigor of sucking. An infant who tires easily during feeding may have underlying cardiac or pulmonary disease. Enthusiastic burping or rapid rocking of the infant during feeding may result in excessive regurgitation or even vomiting. Bottle propping, if identified, should be addressed because this method of feeding is not advised. A disinterested caregiver may be depressed or apathetic, suggesting a psychosocial environment that is lacking stimulation for and interaction with the child. In older children, additional history should be obtained including a food log, food allergies/intolerances, symptoms of dysphagia or aspiration, perceived appetite, food or texture selectivity, and medications that may suppress appetite. |
Assessment of the child’s elimination pattern | Abnormalities of urine or stool and frequent emesis should trigger an investigation to detect underlying renal disease, malabsorption syndrome, pyloric stenosis, or gastroesophageal reflux. |
Medical history and birth history | Of concern is any evidence of intrauterine growth restriction or prematurity with growth delay that has not been compensated; developmental delay; trauma; unusual, prolonged, or chronic infections (eg, tuberculosis, parasitic, HIV); neurologic, cardiac, pulmonary, or renal disease; illness or hospitalization; and possible food intolerance. A mental health history may be warranted in older children and adolescents to screen for anxiety, depression, or eating disorders. |
Family history | Included is information about familial growth patterns, especially in parents and siblings; the occurrence of diseases known to affect growth (eg, cystic fibrosis); and a caregiver’s recent physical or psychiatric illness resulting in inability to provide consistent stimulation and nurturance. |
Social history | Attention is focused on family composition; housing stability and access to refrigeration, cooking facilities, and running water; food insecurity; desire for pregnancy with and acceptance of the child; and stresses (eg, job changes, family moves, separation, divorce, deaths, other losses). Assessment of culturally based or alternative dietary practices should also be assessed. |
Testing
Extensive laboratory testing is usually nonproductive. If a thorough history or physical examination does not indicate a particular cause, most experts recommend limiting screening tests to
Complete blood count with differential
Erythrocyte sedimentation rate
Blood urea nitrogen and serum creatinine and electrolyte levels
Urinalysis (including ability to concentrate and acidify) and culture
Stool for pH, reducing substances, odor, color, consistency, and fat content
Depending on prevalence of specific disorders in the community, blood lead level, HIV, or tuberculosis testing may be warranted.
Newborn screening test results should be reviewed for indications of other genetic diseases. Additionally, even though newborn screening tests now assess newborns for cystic fibrosis, a sweat test should be done if the child has a history of recurrent upper or lower respiratory tract disease, a ravenous appetite, foul-smelling bulky stools, hepatomegaly, or a family history of cystic fibrosis.
Testing for endocrine disorders that can impact growth is sometimes appropriate. Hyperthyroidism may result in weight loss. Testing includes determining levels of thyroxine (T4) and thyroid-stimulating hormone (TSH). Growth hormone deficiency screening (done by measuring blood levels of insulin-like growth factor 1 [IGF-1] and IGF binding protein type 3 [IGFBP-3]) is appropriate when growth in height is more severely affected than growth in weight or when height/length and weight fall off simultaneously.
Testing for celiac disease may be done as part of the initial evaluation. Testing may include the serologic marker anti-tissue transglutaminase antibody (tTG) and the anti-endomysial antibody (EMA) and sometimes small-bowel biopsy.
Investigation for infectious diseases should be reserved for children with evidence of infection (eg, fever, vomiting, cough, diarrhea); however, a urine culture may be helpful because some children with growth and weight faltering due to urinary tract infection lack other symptoms and signs.
Radiologic investigation should be reserved for children with history or examination findings suggestive of anatomic or functional pathology (eg, pyloric stenosis, gastroesophageal reflux). However, if an endocrine cause is suspected, bone age is sometimes determined.
Treatment of Growth and Weight Faltering in Children
Sufficient nutrition
Treatment of any underlying disorder
Long-term social support
Treatment of growth and weight faltering is aimed at providing sufficient health and environmental resources to promote satisfactory growth.
A nutritious diet containing adequate calories for catch-up growth (about 150% of normal caloric requirement) and individualized medical and social supports are usually necessary.
Ability to gain weight in the hospital does not always differentiate children with nonorganic growth and weight faltering from those with organic growth and weight faltering; all children grow when given sufficient nutrition. However, occasionally children with nonorganic growth and weight faltering lose weight in the hospital, highlighting the complexity of this condition.
For children with organic or mixed growth and weight faltering, the underlying disorder should be treated quickly.
For children with apparent nonorganic growth and weight faltering or mixed growth and weight faltering, management includes provision of education and emotional support. Because long-term social support or psychiatric treatment is often required, the evaluation team may be able only to define the family’s needs, provide initial instruction and support, and institute appropriate referrals to community agencies. The caregivers should understand why the referrals are being made and, if options exist, should participate in decisions concerning which agencies will be involved. If the child is hospitalized in a tertiary care center, the referring physician should be consulted regarding local agencies and the level of expertise available in the community.
A predischarge planning conference involving hospital-based personnel, representatives from the community agencies that will provide follow-up services, and the child’s primary physician is ideal. Areas of responsibility and lines of accountability must be clearly defined, preferably in writing, and distributed to everyone involved. The caregivers should be invited to a summary session after the conference so that they can meet the community workers, ask questions, and arrange follow-up appointments.
In some cases, the child must be placed in foster care. Most children are expected to eventually return to their biologic parents, and therefore parenting skill training and psychologic counseling must be provided for them. The child’s progress must be monitored scrupulously. Return to the biologic parents should be based on their demonstrated ability to care for the child adequately, not only on the passage of time.
Prognosis for Growth and Weight Faltering in Children
Prognosis for organic growth and weight faltering depends on the cause.
With nonorganic growth and weight faltering, the majority of children age > 1 year achieve a stable weight above the third percentile with appropriate management.
Children who develop any type of growth and weight faltering before age 1 year are at high risk of cognitive delay, especially verbal and math skills. Children diagnosed at age < 6 months, when the rate of postnatal brain growth is maximal, are at highest risk.
Key Points
Growth and weight faltering is defined as a height or weight for length or BMI below the expected measurement or height/weight that crosses 2 percentile lines on age- and sex-specific growth charts after previous typical growth.
Organic growth and weight faltering is due to a medical disorder (eg, malabsorption, inborn error of metabolism).
Nonorganic growth and weight faltering is due to psychosocial problems (eg, neglect, poverty, difficult caregiver–child interactions).
In addition to taking a thorough medical, social, and dietary history, health care professionals should observe parents/caregivers feeding the child.
Hospitalization may be necessary to evaluate the child, to observe the child's response to appropriate feeding, and to involve a feeding team if needed.
More Information
The following English-language resources may be useful. Please note that The Manual is not responsible for the content of these resources.
World Health Organization: Growth charts for children 0 to 2 years
Centers for Disease Control and Prevention: Growth charts for children 2 years and older
