In the first few years of life most kids gain weight and grow much more quickly than they will later on. Sometimes, however, kids don't meet expected standards of growth. Most still follow growth patterns that are variations of normal, but others are considered to have "failure to thrive."

This is a general diagnosis, with many possible causes. Common to all cases, though, is the failure to gain weight as expected, often accompanied by poor height growth.

Diagnosing and treating a child who fails to thrive focuses on identifying any underlying problem. From there, doctors and the family work together to get the child back into a healthy growth pattern.

About Failure to Thrive

Although it's been recognized for more than a century, failure to thrive lacks a precise definition, in part because it describes a condition rather than a specific disease. Kids who fail to thrive don't receive or are unable to take in, retain, or utilize the calories needed to gain weight and grow as expected.

Most diagnoses of failure to thrive are made in infants and toddlers in the first few years of life — a crucial period of physical and mental development. After birth, a child's brain grows as much in the first year as it will grow during the rest of life. Poor nutrition during this period can have permanent negative effects on mental development.

Most babies double their birth weight by 4 months and triple it by age 1, but kids with failure to thrive often don't meet those milestones. Sometimes, a child who starts out "plump" and who shows signs of growing well can begin to fall off in weight gain. After a while, linear (height) growth may slow as well.

If the condition progresses, undernourished kids may:

• become disinterested in their surroundings
• avoid eye contact
• become irritable
• not reach developmental milestones like sitting up, walking, and talking at the usual age

Causes

Failure to thrive can result from a variety of underlying causes, such as:

• Social factors. In some cases, doctors may not identify a medical problem, but may find that the parents are actually causing the failure to thrive. For example, some parents inappropriately restrict the amount of calories they give their infants. They may fear the child will get fat or enforce a limited diet similar to one they follow. Or, they might not feed the child enough either because of a lack of interest or because of too many distractions in the household, leading to neglect of the child. Living in poverty also can lead to an inability to provide kids with proper nutrition.
• Conditions involving the gastrointestinal system. These include gastroesophageal reflux disease (GERD), chronic diarrhea, cystic fibrosis, chronic liver disease, and celiac disease. With GERD, the esophagus may become so irritated that a child refuses to eat because it hurts. Persistent diarrhea can interfere with the body's ability to hold on to the nutrients and calories from food.

  Cystic fibrosis, chronic liver disease, and celiac disease are malabsorptive disorders that limit the body's ability to absorb nutrients. An infant may eat a lot, but the body doesn't absorb and retain enough of that food. Celiac disease is a sensitivity to a dietary protein found in wheat and certain other grains. The immune system's abnormal response to this protein causes damage to the lining of the intestine, interfering with its ability to absorb nutrients.

• A chronic illness or medical disorder. A child who has trouble eating — because of prematurity or a cleft lip or palate, for example — may not take in enough calories to support normal growth. Other conditions that can lead to failure to thrive include cardiac, endocrinologic, and respiratory disorders, which can increase a child's caloric needs so that it becomes difficult to meet them.
• An intolerance of milk protein. This can cause difficulty with absorbing nutrients until it's diagnosed. It can also put an entire class of food out of reach, restricting the child's diet and occasionally leading to failure to thrive.
• Infections. Parasites, urinary tract infections, tuberculosis, etc., can put great energy demands on the body and force it to use nutrients rapidly (and can diminish appetite), sometimes bringing about short- or long-term failure to thrive.
• Metabolic disorders. These can limit the body's capacity to make the most of calories consumed. They might make it difficult for the body to break down, process, or derive energy from food, or cause a buildup of toxins during the breakdown process that can make a child feed poorly or vomit.

In some cases, doctors are unable to pinpoint a specific cause.

In the past, doctors tended to categorize cases of failure to thrive as either organic (caused by an underlying medical disorder) or inorganic (caused by caregivers' or parents' actions), but are less likely to make a distinction today because medical and behavioral causes often appear together.

For instance, if a baby has severe reflux and is reluctant to eat, feeding times can be stressful. The baby may become upset and frustrated, and the caregiver might be unable to feed the child adequate amounts of food.

Diagnosis

Many babies go through brief periods when their weight gain plateaus or they even lose a little weight. However, if a baby doesn't gain weight for 3 consecutive months during the first year of life, doctors usually become concerned.

Doctors diagnose failure to thrive by using standard growth charts to plot weight, length, and head circumference, which are measured at each well-baby exam. Children who fall below a certain weight range for their age or who are failing to gain weight at the expected rate will be evaluated further to determine if there's a problem.

Along with obtaining a thorough medical and feeding history and performing a detailed physical exam, the doctor may order a complete blood count, urine test, and various blood chemical and electrolyte tests to search for underlying medical problems. If a particular disease or disorder is suspected, the doctor might perform additional tests specific to that condition.

To determine whether a child is receiving enough food, the doctor (sometimes with the help of a dietitian) will do a calorie count after asking the parents what the child eats every day. And talking to the parents can help a doctor identify any problems at home, such as neglect, poverty, household stress, or feeding difficulties.

Treatment

Children with failure to thrive need the help of their parents and a doctor. Sometimes, an entire medical team will work on the case.

In addition to the primary doctor, the team might include a nutritionist to evaluate the child's dietary needs, and an occupational or speech therapist to help the caregiver and child develop successful feeding behaviors and address any sucking or swallowing problems. Occupational and speech therapists are often helpful because of their expertise in the muscular control that's involved in eating.

Because treatment of failure to thrive involves treating any disease or disorder causing the problem, specialists such as a cardiologist, neurologist, or gastroenterologist may also be part of the care team.

Particularly in cases of failure to thrive that are thought to be caused by caregivers' or parents' actions, a social worker and a psychologist or other mental health professional may help address problems in the home environment and provide any needed support.

In cases of poor nutrition, treatment often can be carried out at home with frequent follow-up visits to the doctor's office or clinic. The doctor will recommend high-calorie foods and place an infant on a high-calorie formula.

More severe cases may call for tube feedings in which a tube is put in that runs from the nose into the stomach. Liquid nutrition is provided at a steady rate through the tube. Once the tube is in place, the child is usually fed at night to avoid interference with daily activities or limiting the child's desire to eat during the day. (About half of a child's caloric needs can be delivered at night through a continuous drip.) Once more adequately nourished, the child will feel better and will probably start to eat more on his or her own. At that point, the tube can be removed.

A child with extreme failure to thrive may need to be hospitalized to be fed and monitored continuously. During this time, any possible underlying causes of the condition can be evaluated and treated appropriately. This also lets the doctors see the caregiver's feeding technique and the interaction between caregiver and child during feedings and at other times.

How long treatment lasts varies from case to case. Weight gain takes time, so several months may pass before a child is back in the normal range. Kids who require hospitalization may stay for 10 to 14 days or more to establish satisfactory weight gain, but it can be many months until the symptoms of severe malnutrition are gone.

Failure to thrive caused by a chronic illness or disorder may have to be monitored periodically and treated for even longer, perhaps for a lifetime.

Does My Child Have Failure to Thrive?

If you're worried that your child is failing to thrive, remember that many things can cause slower weight gain. For instance, breastfed babies and bottle-fed babies often gain weight at different rates in the early newborn period.

Genetics also play a big role in weight gain, so if you and your spouse are slim, your baby may not put on pounds quickly. However, infants should still gain weight steadily and it can be difficult to monitor this from home. So it's important to see your child's doctor regularly.

As a guideline, babies usually eat eight to 12 times in a 24-hour period (a couple of ounces [60 milliliters] every few hours) in the first weeks after birth. By the time they're 2 to 3 months old, the number of feedings has dropped to six to eight, but the amount they eat each time has increased. At 4 months, about 30 ounces (890 milliliters) a day provides sufficient nutrition for most infants.

Your doctor will have many opportunities to identify a problem at regular well-baby checkups. You can also periodically check your baby's weight at home, if you want the reassurance.

When to Call the Doctor

If you notice a drop in weight gain or your baby doesn't seem to have a normal appetite, call your doctor. Any major change in eating pattern also warrants a call. Toddlers and older kids may have days and sometimes weeks when they show little interest in eating, but that shouldn't happen in infants.

If you have trouble feeding your baby, your doctor can help. When a child doesn't readily eat, parents can become frustrated and feel they're doing something wrong. That can magnify the problem and increase the stress for you and your baby. Instead, get help for both of you by consulting the doctor.

Reviewed by: Steven Dowshen, MD
Date reviewed: August 2011

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