creation date: 2026-09-05 20:58
tags: Workups
Faltering Growth
Background
Faltering growth, formerly referred to as failure to thrive, refers to the failure to grow at a rate consistent with expected standards for infants/toddlers younger than 3 years old. This is not a specific disease entity, but rather a clinical sign of inadequate growth.
Clinically, it is defined as crossing two percentile lines on the growth chart.
Pathophysiology
A failure to grow is due to one of the following mechanisms:
- Inadequate caloric intake (ie. not eating enough)
- Malabsorption
- Increased metabolic demand
Differential Diagnosis
Inadequate caloric intake (most common)
- Parental issues
- Lack of food availability
- Feeding issues
- GERD
- Eating disorder
Malabsorption or losses
- Pancreatic insufficiency in cystic fibrosis
- Celiac disease
- Inborn error of metabolism
- Inflammatory bowel disease
Increased metabolic demands
- Thyroid disease
- Chronic infection or immunodeficiency
- Chronic lung disease
- Congenital heart disease
- Malignancy
Initial Evaluation
History
History should include standard pediatric history including:
- Thorough feeding history
- Development and psychosocial history
- History of family member’s growths, development, and medical illnesses
- Mid-parental height calculation
Inquire about feeding behaviours including force feeding, foods the child does not like, and previous attempted interventions.
Physical Exam
General appearance of the child should be noted.
Exams should include:
- Cardiovascular exam
- Abdominal exam
Red Flags
Features that are suggestive of a medical cause include:
- Cardiac findings suggestive of congenital heart disease or heart failure
- Developmental delay
- Dysmorphic features
- Organomegaly or lymphadenopathy
- Recurrent or severe respiratory, mucocutaneous, or urinary infections
- Recurrent vomiting, diarrhea, or dehydration
- Failure to gain weight despite adequate caloric intake
Investigations
As most cases are due to parental issues resulting in inadequate caloric intake, initial management consist of trialing foods child likes, supplementation of higher caloric compliments (eg. adding peanut butter to toast), and feeding clinics.
However, some bloodwork is reasonable:
- CBC
- Electrolytes
- Thyroid
Generally, follow-up is not necessary for another 3-4 months as resolution may take months-years.
If a disease process is suspected (red flags), further testing may be warranted.
- CBC and differential
- Electrolytes and creatinine
- Urinalysis
- Liver function
- ESR
- Anti-tTG
Additionally, guided by history/physical:
- Echocardiogram
- Complement levels
- Immunoglobulin levels
- HIV serology
- Hepatitis serology
- Stool culture for ova & parasites
- Sweat chloride test