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Failure to Thrive

Study guide:


  • A descriptive term used to describe the malnourished infants who fail to meet the appropriate growth parameters for the their age (growth failure).

    • Weight below the 5th percentile for age and sex. 

    • Weight for age curve falls across two major percentile lines.

    • Weight <80% of the expected weight for age.



  • It occurs in 5-10% of the children who are treated in the primary healthcare centers.

  • It occurs in 3-5% of the children who are found in the referral system.

Causes & Types: 


  • History & physical examination: 

    • Feeding behavior and frequency.

    • Signs of malabsorption (distended abdomen, thin buttocks, etc.).

    • Signs of chronic lung disease or heart failure.

    • Focus on the growth chart parameters:

      • Firstly failure to gain weight But in severe cases length and head circumference will be affected afterward

    • Check for signs of abuse.

    • Inappropriate behavior.

  • Investigations:

    • Initial work up:

      • CBC with differential

      • ESR

      • Electrolyte profile

      • Urine analysis

      • Stool analysis

      • Bone profile

    • Specific investigations for the specific cause (e.g. IgA tissue transglutaminase antibodies for celiac disease).



  • Correct the acute problems:

    • Electrolytes

    • Infections

    • Dehydration

  • Nutritional Rehabilitation:


    • Goal is catch-up weight and growth parameters with the appropriate age.

    • Most cases can be managed with nutrition intervention and feeding behavior modification.


    • High Calorie Diet with close Follow-up.

  • Parental Behavior Modification.

      • Extensive work-up for organic causes. 

      • Hemodynamically unstable: hypotension, bradycardia, hypothermia etc.

      • Signs of physical abuse.

      • Failure of outpatient therapy/management.

      • Weight below the birth weight at the age of 6 weeks.


    Hospitalization: ​​​​​​

Figure 1: Failure to Thrive


  1. Cvetnic W, Pino E, Koerner C. USMLE step 2 CK pediatrics. [New York]: Kaplan; 2011.

  2. Shah S, Ronan J, Alverson B. Step-up to pediatrics.

  3. Kliegman R. Nelson textbook of pediatrics.

  4. Lissauer T, Clayden G, Craft A. Illustrated textbook of paediatrics. Edinburgh: Mosby; 2012.

  5. Failure to thrive (undernutrition) in children younger than two years: Etiology and evaluation [Internet]. 2016 [cited 2 March 2016]. Available from:

  6. S. H. Psychiatric and social factors of failure to thrive. Family Medical Center [Internet]. 2016 [cited 2 March 2016]. Available from:


Written by:         Asmaa Salem


Reviewed by:      Roaa Amer
                           Lama Al Luhidan


Format editor:   Roaa Amer


Web publisher:  Bayan Alzomaili

Audio recording:

Read by: Bayan Alzomaili
Directed by: Rana Alzahrani
Audio production: Bayan Alzomaili

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