Failure to Thrive (FTT)

Definition

• Poor growth defined as weight below the 3rd centile or crossing two centile lines downward

• Adjust growth charts for prematurity (infants <37 weeks) until 2 years of age

• Use condition-specific growth charts for syndromic conditions such as Down syndrome

Red Flags

• Child-related signs: Dehydration, malnutrition, lethargy, recurrent infections, persistent fever

• Caregiver-related concerns: Indicators of neglect or abuse, poor attachment behaviours, mental health issues

• Social factors: Domestic violence, parental substance misuse, social isolation, frequent missed appointments

Causes

• Inadequate intake: Breastfeeding difficulties (poor latch), incorrect formula preparation, restricted diet, delayed introduction of solids

• Malabsorption: Coeliac disease, cystic fibrosis, chronic liver disease, cow’s milk protein allergy

• Excessive caloric use: Congenital heart disease, diabetes, hyperthyroidism, chronic infections

• Other causes: Genetic syndromes (e.g., Prader-Willi, Turner syndrome), inborn errors of metabolism (e.g., phenylketonuria)

History

• Feeding history: Evaluate frequency of feeds, vomiting, food refusal, introduction of solids, and formula preparation errors

• Family history: Document parental height, socioeconomic status, refugee status, and food insecurity

• Medical history: Look for diarrhoea, fatty stools, chronic illness signs, and developmental milestones

• Social history: Assess for factors that may impact nutritional intake and healthcare access

Investigations

• Blood tests: Full blood count, urea, electrolytes and creatinine, comprehensive metabolic panel, liver function tests, ESR, iron studies, thyroid function tests, and blood glucose

• Urine and stool tests: Urine MCS for infection; stool microscopy and fat globules evaluation for malabsorption

• Special tests: Coeliac serology (anti-TTG and total IgA); consider vitamin D levels if indicated

Management

• Weight monitoring: Weekly weight checks to track progress

• Parental support: Provide detailed feeding guidance, correct formula preparation, and encourage appropriate complementary feeding

• Nutritional rehabilitation: Refer to a dietitian or paediatric nutrition service if growth remains suboptimal

• Referrals: Refer to a paediatrician for complex or persistent growth failure; involve a lactation consultant for breastfeeding difficulties

• Multidisciplinary approach: Involve social services and child protection if neglect or significant psychosocial issues are identified

Notes

• Early intervention improves outcomes and prevents long-term developmental impacts

• Treating the underlying cause usually restores normal growth trajectory

• Regular follow-up is essential to monitor progress and adjust management as needed