One of the main purposes of well child visits is to make sure that babies and young children are gaining weight, height and head circumference appropriately. Babies who do not gain enough are diagnosed with Failure to Thrive. The Failure to Thrive diagnosis may be made when a baby or child drops below the 2nd percentile more than once, or when their growth drops over more than 2 major percentile lines (90th, 75th, 50th, 25th, 10th, 5th). For example, a baby that goes from 75th percentile to 25th percentile, or a baby that goes from 25th percentile to under the 5th percentile.
I hear this one a lot:
“So my baby is on the small side, why is that such a big deal?”
Well, it may not be a big deal! A baby who is trucking away at the 5th percentile with steady weight gains may truly just be a “small baby.” Or a baby who dips to the 2nd percentile but comes right back up may have just had a little growth hiccup.
BUT – babies who truly meet the criteria for “Failure to Thrive” – this IS a big deal. The infant brain develops rapidly within the first year of life. Babies whose brains are deprived of nutrients may never get the chance to catch up. This is why Failure to Thrive babies often have lower IQ than “normal” babies later in life. Failure to Thrive can also lead to immunodeficiency (low immune system function), which makes babies and children at risk for infections.
What is normal?
- Babies 0-3 months should gain approximately 1 ounce (30 g) per day.
- Babies 3-6 months should gain approximately 1/2 ounce (17-18 g) per day.
- Babies 6-9 months should gain a little less than 1/2 ounce (12-13 g) per day.
- Babies 9-12 months should gain approximately 1/3 ounce (9 g) per day.
- Toddlers 12 – 36 months should gain approximately 1/3 ounce (9 g) per day.
Remember that this is an average over time, and that children very frequently gain weight in growth spurts. This is why we usually check growth weekly or monthly (daily when babies are first born).
Remember – it doesn’t matter if your child is at the 5th percentile or 95th percentile – but that they stay consistent (at least relatively consistent).
What are common causes of Failure to Thrive?
By far the most common cause of Failure to Thrive is inadequate intake of nutrients. In other words – they aren’t getting enough breastmilk, formula or solid foods!
- Most often weight will drop on the growth curve before length and then head circumference. This usually indicates a nutritional problem.
- When length drops on the growth curve before weight this is usually due to an endocrine problem. “Endocrine” refers to a hormonal problem.
- When head circumference drops as much or more than weight or length this is often from a genetic problem or problem during pregnancy.
“My baby/toddler was diagnosed with Failure To Thrive, what do I do?”
- First – ask for a copy of your child’s growth chart. This is very important: make sure that your physician is using the World Health Organization (WHO) growth chart. Often breastfed babies will appear to “drop” on the CDC growth chart that is commonly used in the United States, but will be completely normal on the WHO growth chart. If your child was born prematurely or has a genetic abnormality that affects growth your physician should use special growth charts appropriate for their condition.
- Second – if your baby has dropped on head circumference or length please ask them to remeasure. 1/4” can make a huge difference, and if your child was measured 1/4” large for her last visit, and 1/4” small at this visit it can appear that she has completely dropped off the growth curve. Recheck!
- Third – follow your physician’s advice for scheduling regular weight/length checks. Please make sure that your child gets checked regularly until he catches back up on the growth chart.
Babies or toddlers eating solid foods:
Check out the Naturopathic Pediatrics article on Failure to Thrive in Babies/Toddlers Eating Solid Foods
Check out the Naturopathic Pediatrics article on Failure to Thrive in a Breastfed Baby.
Formula Fed babies and Pumped Breastmilk babies:
Aim for at least 25-30+ ounces of breastmilk or formula per day. (Most babies consume on average 19-30 ounces per day, but babies who are failure to thrive will need extra to catch up.) Follow your physician’s advice, some babies will need many more calories to catch up, and may even need additional calories from formula. If your baby is getting pumped breastmilk some physicians will even recommend adding one-half teaspoon of regular formula powder to 3 ounces (~90 mL) of pumped milk. If your baby has been consistently taking 25-30 ounces of breastmilk per day and still continues to have failure to thrive then see the section below.
What if my child is eating enough but still has failure to thrive?
When we know for sure that a baby or child is getting enough food but they still aren’t gaining weight we will look for other causes. One of the first things us doctors typically do is order blood work (I know, I know, blood draws on babies are NOT fun). We will check for anemia (iron deficiency), lead poisoning, diabetes (blood sugar) and thyroid problems. I usually check vitamin D levels at the same time, since most children in my area are vitamin D deficient. Other things we may check for, depending on our suspicions:
- Genetic abnormalities that were missed previously
- Cow’s milk protein allergy (especially in breastfed babies)
- Intestinal parasites (uncommon in the city folk, but somewhat common if the family lives on a farm, and very common in the developing world)
- Celiac disease
- Cystic fibrosis
- Developmental delays, signs of vision or hearing impairment, or signs of autism spectrum disorder
- Signs of other gastrointestinal problems – frequent vomiting, diarrhea, bloody diapers, etc. We will probably send your child to be evaluated by a gastroenterologist.
- Us physicians are also checking for child neglect and asking whether the child was exposed to medications or alcohol while Mom was pregnant. (Don’t be offended if we ask those questions, you know we have to!)
Have a team of experts
Many times your child’s primary care doctor will refer to additional experts. The best approach to failure to thrive is to have a team working with you. This may include an occupational therapist, a speech language pathologist (to work on tongue movement), home-visit nurses, and sometimes a physical therapist and endocrinologist.
Frank DA. Failure to thrive. In: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 3rd ed, Augustyn M, Zuckerman B, Caronna EB (Eds), Lippincott Williams & Wilkins, Philadelphia 2011. p.204.
Corbett SS, Drewett RF. To what extent is failure to thrive in infancy associated with poorer cognitive development? A review and meta-analysis. J Child Psychol Psychiatry 2004; 45:641.
Kirkland R, Motil K. Failure to thrive (undernutrition) in children younger than two years: Etiology and evaluation. UpToDate. 12 March 2014. Web. 30 August 2015.
Kirkland R, Motil K.Failure to thrive (undernutrition) in children younger than two years: Management. UpToDate. 12 March 2014. Web. 30 August 2015.
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