What is the treatment approach for a patient with failure to thrive (FTT)?

Treatment of Failure to Thrive

The cornerstone of treating failure to thrive is aggressive nutritional intervention with increased caloric density (150% of expected caloric needs for weight) combined with treatment of any underlying medical conditions, using a multidisciplinary team approach when initial interventions fail. 1

Immediate Nutritional Management

All children with FTT require additional calories for catch-up growth—specifically 150% of the caloric requirement for their expected weight, not their actual weight. 2 This is the single most critical intervention regardless of etiology.

Caloric Enhancement Strategies

• Increase caloric density of existing diet by fortifying foods with extra oil or fat, rather than simply increasing volume, as this is better tolerated and more effective 1
• For breastfed infants with poor weight gain, provide more frequent feedings 1
• For formula-fed infants, use high-energy/protein infant formulas or carefully supervised concentrated feeds 1
• Add oral nutritional supplements (ONS) to normal food intake, as nutritional counseling alone is insufficient to improve nutritional status 1—this is a critical pitfall to avoid

Specialized Feeding Support

• For breastfed infants who fail to gain weight despite optimization, fortify expressed breast milk 1
• Initiate feeding therapy at the first sign of oral aversion to prevent long-term feeding difficulties 1
• Consider assisted feeding (nasogastric or gastrostomy tube) when oral intake remains inadequate despite interventions 3
• Do not delay tube feeding in children with severe oral aversion, as prolonged malnutrition causes permanent neurodevelopmental consequences 1

Treatment of Underlying Medical Conditions

Gastrointestinal Issues

• Optimize pancreatic enzyme replacement therapy (PERT) if malabsorption is present, as inadequate enzyme dosing is a common reversible cause 1
• Treat gastroesophageal reflux with proton pump inhibitors, particularly when oral aversion or feeding difficulties are present 3, 1
• Manage constipation and intestinal dysmotility with appropriate bowel regimens, as this significantly impacts nutritional intake 1

Micronutrient Deficiencies

• Correct specific micronutrient deficiencies (trace elements, vitamins) through targeted supplementation 1
• Address linoleic acid deficiency, which may eliminate the need to increase overall energy intake 1

Endocrine Abnormalities

• Treat hypothyroidism if identified on thyroid function testing 4
• Consider growth hormone therapy if growth hormone deficiency is documented 3

Monitoring and Follow-Up

Growth monitoring frequency is critical and should be standardized: 1

• Every clinic visit for infants
• Every 3 months for older children and adolescents
• Every 6 months for adults

Assess serial measurements over time rather than single evaluations to signal treatment failure 1

When to Escalate Care

Indications for Specialist Referral

• Refer to gastroenterology for persistent feeding difficulties, reflux, or poor growth despite initial interventions 3, 1
• Consider specialized referrals to endocrinology, genetics, or neurology when initial evaluation does not identify a cause or when specific abnormalities are detected 5, 1
• Feeding therapy evaluation is indicated when feeding difficulties are present 3

Indications for Hospitalization

Hospitalization is rarely required 2 but is indicated for:

• Severe failure to thrive 2
• Safety concerns or suspicion of abuse/neglect 6
• Failure of outpatient management 6
• Severe psychosocial impairment of the caregiver 6

Outpatient vs. Inpatient Management

Most children with FTT can be safely and more economically managed as outpatients 7 if:

• The degree of FTT is mild to moderate 7
• Mother-child interaction is positive 7
• The mother is not severely disturbed 7
• The baby has no inflicted injuries or deprivational behavior 7

Outpatient management should include new feeding instructions, a stimulation program, social work intervention, home visits by a public health nurse, and weekly weight checks 7

Critical Pitfalls to Avoid

• Do not rely on nutritional counseling alone—multiple studies demonstrate it is insufficient to improve nutritional status in FTT 1
• Do not delay tube feeding in severe cases with oral aversion—the neurodevelopmental consequences of prolonged malnutrition are permanent 1
• Do not perform routine laboratory testing unless there are clear symptoms of organic disease or failure to respond to nutritional interventions 8
• Do not diagnose FTT when normal infants shift to a lower growth percentile in the first two years of life and then follow that percentile consistently 2

Adjunctive Pharmacotherapy

Oxandrolone is FDA-approved as adjunctive therapy to promote weight gain in patients who fail to gain or maintain normal weight without definite pathophysiologic reasons, though this is typically reserved for specific clinical scenarios after other interventions 9

Long-Term Approach

A multidisciplinary approach with home nursing visits and nutritional counseling improves weight gain, parent-child relationships, and cognitive development 6. Long-term follow-up is often required to address multiple psychosocial issues even after normal weight is attained 7.