Failure to Thrive - FTT: Presentation, Causes, and Management in the ED

Emergency Department Management of Patients With Failure to Thrive

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Table of Contents
 About This Issue

Failure to thrive (FTT) is a relatively common presentation in the emergency department. Up to 90% of cases of FTT have no identifiable cause and are categorized as nonorganic. Before deciding that FTT is nonorganic, it is imperative to consider and rule out organic causes. Identifying the underlying issues surrounding FTT is essential, as it will likely impact the treatment the patient receives. This issue reviews common causes of FTT; provides recommendations for the diagnostic workup, treatment, and disposition of patients with FTT; and offers information to help improve outcomes while minimizing unnecessary testing, decreasing cost, and expediting emergency department care. You will learn:

Criteria that can be used to identify patients with FTT

Common etiologies of organic FTT and nonorganic FTT

Key questions to ask while taking the history, including questions about the pregnancy history, birth history, difficulty with feeding, types of feeds, frequency of feeds, and feeding technique

When diagnostic studies should be ordered, and which diagnostic studies are the most high-yield

Recommendations for managing patients with FTT

How to develop appropriate disposition for patients with FTT

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
    1. Organic Causes of Failure to Thrive
      1. Cardiac Etiologies
      2. Gastrointestinal Etiologies
      3. Endocrine Etiologies
      4. Renal Etiologies
      5. Respiratory Etiologies
      6. Oncologic and Infectious Etiologies
      7. Anatomic and Genetic Abnormalities
    2. Nonorganic Causes of Failure to Thrive
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
  9. Diagnostic Studies
  10. Treatment
  11. Special Populations
  12. Controversies and Cutting Edge
  13. Disposition
  14. Summary
  15. Time- and Cost-Effective Strategies
  16. Risk Management Pitfalls for Patients With Failure to Thrive
  17. Case Conclusions
  18. Clinical Pathway for Management of Patients With Failure to Thrive
  19. Table
    1. Table 1. Calculation of Infant Caloric Need, Feeding Amount, and Frequency
  20. References


Although failure to thrive (FTT) is a relatively common presentation in the emergency department, many emergency clinicians are unsure of how to properly work up a pediatric patient with this condition. Obtaining a thorough history and physical examination will likely reveal the cause of FTT. Although most laboratory testing has low diagnostic yield, they may be indicated in certain circumstances. Radiologic testing is normally not indicated unless the history or physical examination point to a specific etiology. This issue reviews the etiology, pathophysiology, and management of patients with FTT, with the goal of improving outcomes while minimizing unnecessary testing, decreasing cost, and expediting emergency department care.

Case Presentations

Your first patient is a previously healthy, vaccinated 6-month-old boy who presents with poor weight gain. The child has been seen by his primary care provider multiple times within the last several weeks, and the mother is very concerned because he has not shown any improvement. The child was born at term via spontaneous vaginal delivery, did not spend any time in the NICU, and has been well. Despite this, in the past 2 months, the patient has gone from the fiftieth percentile on his growth curve to less than the thirtieth percentile. The patient has not had any vomiting or diarrhea and has been urinating and moving his bowels normally. On physical examination, he is smaller than expected, but otherwise his vital signs are unremarkable, as is the remainder of his physical examination. You inform the family you are going to review his chart, and as you leave the room, you wonder what is going on with this patient. Could it be a metabolic or cardiac abnormality? Is it a problem with the gastrointestinal or respiratory system? What if this is a manifestation of neglect? What tests should you order for the patient? Should you be starting him on IV fluids? Should this patient be admitted to the hospital or discharged home? Do you need to call social work?

Before you can begin to formulate a plan for your first patient, you are presented with another case. The patient is a previously healthy 2-month-old girl who was brought in by her mother, who is in tears. This is the mother's first child. The girl was born full-term via normal spontaneous vaginal delivery without any complications. The mother had limited prenatal care, as she didn’t know she was pregnant. The mother reports that the baby has had all of her regular well-child checks and no issues were noted, but the girl has not gained weight in over a month and she has not been able to get her in to see her PCP. The mother says that bottle feedings are not going as well as they used to, and the baby now takes close to an hour to finish a 3-ounce bottle. The mother is unable to provide any further history, and the examination shows no focal findings. Reviewing the patient’s growth chart, you see that she’s fallen below 2 major percentile lines. You wonder where you should start with your workup… What is the most likely diagnosis? How do you manage and disposition this patient safely?


Failure to thrive (FTT) is a fairly common complaint in emergency medicine, accounting for approximately 1% to 5% of admissions for patients aged < 2 years.1 Total prevalence is likely higher, given that FTT is commonly dealt with by primary care providers in the outpatient setting. Additionally, studies have shown that FTT may often go unrecognized.2 Traditionally, FTT has been considered an ailment that tends to disproportionately affect those in lower socioeconomic classes or in rural communities.3 However, newer research suggests that slow weight gain at an early age is associated with short parental height rather than parental occupation and educational level.4

Although there is not an exact definition for FTT, several criteria are used to identify patients with FTT, with some being more pertinent to the emergency setting than others. Definitions of FTT, such as weight deceleration crossing more than 2 percentile lines, weight for chronological age below the fifth percentile, and length for chronological age below the fifth percentile,5 are definitions that can be applied in the ED setting.

Organic FTT results from an identifiable medical source, whereas nonorganic FTT results from social factors and other unidentifiable medical causes. Up to 90% of cases of FTT have no identifiable cause and are categorized as nonorganic.6 Though less common than nonorganic causes, organic causes of FTT are many, and include cardiovascular, pulmonary, gastrointestinal, and endocrine pathologies.7

Although FTT is an extensive topic, many aspects are not pertinent to the patient’s emergency department (ED) visit; this issue will focus mainly on topics that are high-yield for the emergency clinician. This issue of Pediatric Emergency Medicine Practice reviews the etiologies and diagnostic workup of the most common presentations of FTT in pediatric patients presenting to the ED, with a focus on which relevant diagnostic studies should be obtained and when they are warranted.

Critical Appraisal of the Literature

A literature search was performed using Google Scholar, the Cochrane Database of Systematic Reviews, and PubMed. Search terms included: failure, thrive, growth deficiency, childhood neglect, malnutrition, and growth failure. A total of 277 articles published between 1960 and 2018 were reviewed. There is a general paucity of literature regarding guidelines for patients presenting to the ED with FTT. There has also been little new research on this topic in recent years. There are many models suggesting that the interplay between social and organic factors contributes to FTT in a child. Nonetheless, there are no clear guidelines on the workup or disposition for these patients; most current recommendations are based on traditional dogma. There are several reasons for this. First, FTT has no single universally accepted criterion to make the diagnosis. Second, most publications focus on longitudinal follow-up and risk factors for FTT. When available, current accepted practices will be adapted, based on current consensus.

Risk Management Pitfalls for Patients With Failure to Thrive

1. “I couldn’t find the right growth chart.”

The United States Centers for Disease Control and Prevention growth charts provide information for patients ranging from 2 to 20 years of age; the World Health Organization growth charts provide information for patients ranging from birth to 2 years of age. Awareness of readily available resources can help make an appropriate diagnosis in a shorter period of time.

3. “I didn’t know which tests to order, so I ordered everything to be sure I didn't miss anything.”

There is a dearth of literature supporting the utility of routine laboratory testing in patients with FTT. Overtesting can result in increased time in the ED, increased discomfort to the patient, and increased medical expense. Knowing which laboratory studies are indicated in screening for organic causes of FTT can decrease superfluous testing.

5. “My patient was brought in for poor weight gain; I assumed it was nonorganic FTT.”

Rushing to a diagnosis is a common mistake with FTT. When an infant comes in with poor weight gain, some emergency clinicians may immediately diagnose the patient with FTT without obtaining a proper history and physical examination, or they may assume the poor weight gain is nonorganic and miss an important medical cause for the condition.


Table 1. Calculation of Infant Caloric Need, Feeding Amount, and Frequency


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

  1. Sullivan PB. Commentary: the epidemiology of failure-to-thrive in infants. Int J Epidemiol. 2004;33(4):847-848. (Review article)
  2. Batchelor JA. Has recognition of failure to thrive changed? Child Care Health Dev. 1996;22(4):235-240. (Review article)
  3. Bithoney WG, Dubowitz H, Egan H. Failure to thrive/growth deficiency. Pediatr Rev. 1992;13(12):453-460. (Review article)
  4. 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(4):839-847. (Population cohort study; 11,718 patients)
  5. Olsen EM. Failure to thrive: still a problem of definition. Clin Pediatr (Phila). 2006;45(1):1-6. (Cross-sectional review, 2003-2004)
  6. Hendaus M, Al-Hammadi A. Failure to thrive in infants (review). Georgian Med News. 2013(214):48-54. (Review article)
  7. Homer C, Ludwig S. Categorization of etiology of failure to thrive. Am J Dis Child. 1981;135(9):848-851. (Retrospective chart analysis; 82 patients)
  8. Gahagan S, Holmes R. A stepwise approach to evaluation of undernutrition and failure to thrive. Pediatr Clin North Am. 1998;45(1):169-187. (Review article)
  9. Stephens MB, Gentry BC, Michener MD, et al. Clinical inquiries. What is the clinical workup for failure to thrive? J Fam Pract. 2008;57(4):264-266. (Review article)
  10. Menon G, Poskitt EM. Why does congenital heart disease cause failure to thrive? Arch Dis Child. 1985;60(12):1134-1139. (Prospective study; 30 patients)
  11. Varan B, Tokel K, Yilmaz G. Malnutrition and growth failure in cyanotic and acyanotic congenital heart disease with and without pulmonary hypertension. Arch Dis Child. 1999;81(1):49-52. (Prevalence study; 89 patients)
  12. Poskitt EM. Failure to thrive in congenital heart disease. Arch Dis Child. 1993;68(2):158-160. (Review article)
  13. Marcovitch H. Failure to thrive. BMJ. 1994;308(6920):35-38. (Review article)
  14. van Lieburg AF, Knoers NV, Monnens LA. Clinical presentation and follow-up of 30 patients with congenital nephrogenic diabetes insipidus. J Am Soc Nephrol. 1999;10(9):1958-1964. (Longitudinal study; 30 patients)
  15. Chang CY, Lin CY. Failure to thrive in children with primary distal type renal tubular acidosis. Acta Paediatr Taiwan. 2002;43(6):334-339. (Retrospective study; 28 patients)
  16. Adedoyin O, Gottlieb B, Frank R, et al. Evaluation of failure to thrive: diagnostic yield of testing for renal tubular acidosis. Pediatrics. 2003;112(6 Pt 1):e463. (Retrospective study; 36 patients)
  17. Giglio L, Candusso M, D’Orazio C, et al. Failure to thrive: the earliest feature of cystic fibrosis in infants diagnosed by neonatal screening. Acta Paediatr. 1997;86(11):1162-1165. (Prospective study; 103 patients)
  18. Panetta F, Magazzu D, Sferlazzas C, et al. Diagnosis on a positive fashion of nonorganic failure to thrive. Acta Paediatr. 2008;97(9):1281-1284. (Prospective study; 208 patients)
  19. Samadi DS, Shah UK, Handler SD. Choanal atresia: a twenty-year review of medical comorbidities and surgical outcomes. Laryngoscope. 2003;113(2):254-258. (Retrospective study; 78 patients)
  20. Cole SZ, Lanham JS. Failure to thrive: an update. Am Fam Physician. 2011;83(7):829-834. (Review article)
  21. Schwartz ID. Failure to thrive: an old nemesis in the new millennium. Pediatr Rev. 2000;21(8):257-264. (Review article)
  22. Miller TL, Easley KA, Zhang W, et al. Maternal and infant factors associated with failure to thrive in children with vertically transmitted human immunodeficiency virus-1 infection: the prospective, P2C2 human immunodeficiency virus multicenter study. Pediatrics. 2001;108(6):1287-1296. (Review of cohort study; 92 HIV infected patients and 439 noninfected patients)
  23. Rondanelli M, Caselli D, Trotti R, et al. Endocrine pancreatic dysfunction in HIV-infected children: association with growth alterations. J Infect Dis. 2004;190(5):908-912. (Case control; 30 patients)
  24. Nangia S, Tiwari S. Failure to thrive. Indian J Pediatr. 2013;80(7):585-589. (Review article)
  25. Cronk C, Crocker AC, Pueschel SM, et al. Growth charts for children with Down syndrome: 1 month to 18 years of age. Pediatrics. 1988;81(1):102-110. (Review article)
  26. Ramsay M, Gisel EG, McCusker J, et al. Infant sucking ability, non-organic failure to thrive, maternal characteristics, and feeding practices: a prospective cohort study. Dev Med Child Neurol. 2002;44(6):405-414. (Prospective cohort study; 409 patients)
  27. 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(3):145-149. (Prospective population study; 2609 births)
  28. Block RW, Krebs NF, American Academy of Pediatrics Committee on Child Abuse and Neglect, et al. Failure to thrive as a manifestation of child neglect. Pediatrics. 2005;116(5):1234-1237. (Review article)
  29. Smith MM, Lifshitz F. Excess fruit juice consumption as a contributing factor in nonorganic failure to thrive. Pediatrics. 1994;93(3):438-443. (Retrospective study; 8 patients)
  30. Stanley CA, Anday EK, Baker L, et al. Metabolic fuel and hormone responses to fasting in newborn infants. Pediatrics. 1979;64(5):613-619. (Prospective study; 44 infants)
  31. Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009;37(2):666-688. (Meta-analysis; 30 investigators)
  32. Listernick R. Accurate feeding history key to failure to thrive. Pediatr Ann. 2004;33(3):161-166. (Case report)
  33. Onyiriuka A. Evaluation and management of the child with failure to thrive. Hospital Chronicles. 2011;6(1):9. (Review article)
  34. McCann JB, Stein A, Fairburn CG, et al. Eating habits and attitudes of mothers of children with non-organic failure to thrive. Arch Dis Child. 1994;70(3):234-236. (Prospective study; 26 patients)
  35. 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(3):355-362. (Retrospective study; 226 patients)
  36. Krugman SD, Dubowitz H. Failure to thrive. Am Fam Physician. 2003;68(5):879-884. (Review article)
  37. Nutzenadel W. Failure to thrive in childhood. Dtsch Arztebl Int. 2011;108(38):642-649. (Review article)
  38. Ficicioglu C, An Haack K. Failure to thrive: when to suspect inborn errors of metabolism. Pediatrics. 2009;124(3):972-979. (Review article)
  39. Hannaway PJ. Failure to thrive: a study of 100 infants and children. Clin Pediatr (Phila). 1970;9(2):96-99. (Retrospective review; 100 patients)
  40. Sills RH. Failure to thrive. The role of clinical and laboratory evaluation. Am J Dis Child. 1978;132(10):967-969. (Retrospective review; 185 patients)
  41. Careaga MG, Kerner JA Jr. A gastroenterologist’s approach to failure to thrive. Pediatr Ann. 2000;29(9):558-567. (Review article)
  42. Berwick DM, Levy JC, Kleinerman R. Failure to thrive: diagnostic yield of hospitalisation. Arch Dis Child. 1982;57(5):347-351. (Retrospective review; 122 patients)
  43. Park RW, Frasier SD. Hyperthyroidism under 2 years of age. Am J Dis Child. 1970;120(2):157-159. (Case report)
  44. Bergman P, Graham J. An approach to “failure to thrive”. Aust Fam Physician. 2005;34(9):725-729. (Review article)
  45. Myhre JA, Chadwick EG, Yogev R. Failure to thrive in HIV-infected children: incidence, prevalence, and clinical correlates. Pediatr AIDS HIV Infect. 1996;7(2):83-90. (Retrospective study; 97 patients)
  46. Haller JO, Cohen HL. Hypertrophic pyloric stenosis: diagnosis using US. Radiology. 1986;161(2):335-339. (Review article)
  47. Singer PA, Cooper DS, Levy EG, et al. Treatment guidelines for patients with hyperthyroidism and hypothyroidism. Standards of Care Committee, American Thyroid Association. JAMA. 1995;273(10):808-812. (Review article)
  48. Casey PH, Bradley R, Wortham B. Social and nonsocial home environments of infants with nonorganic failure-to-thrive. Pediatrics. 1984;73(3):348-353. (Prospective study; 23 patients)
  49. Benoit D, Zeanah C, Barton M. Maternal attachment disturbances in failure to thrive. Infant Mental Health J. 1989;10(3):185-202. (Case control; 25 patients)
  50. 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(2):109-114. (Cohort study; 6090 patients)
Publication Information

Vincent Calleo, MD; Ryan Surujdeo, MD, Asalim Thabet, MD

Peer Reviewed By

John W. Harrington, MD; Gretchen Homan, MD, FAAP

Publication Date

March 1, 2020

CME Expiration Date

March 1, 2023   

Pub Med ID: 32115935

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