Growth faltering (Failure to Thrive – FTT) is a clinical condition in which an infant or child fails to achieve expected growth based on age- and sex-specific standards due to inadequate usable nutrition over time.

A child is considered not growing well when any of the following occur:

• Flattening or downward crossing of growth percentiles on the Road-to-Health (RTH) growth chart

• Weight loss after the neonatal period

• Weight-for-Age or Weight-for-Height Z-score (WHZ) < −2 SD but > −3 SD

• Inadequate rate of weight gain for age

2. Epidemiology & Importance

Growth faltering is one of the earliest warning signs of child illness or social neglect.

Consequences include:

• Impaired brain development

• Reduced immunity

• Increased infection risk

• Delayed cognitive development

• Poor school performance

• Adult chronic disease risk (metabolic syndrome)

3. Pathophysiology

Growth depends on three fundamental processes:

Failure in any leads to negative energy balance → catabolism → weight loss → stunting

Mechanisms

1. ↓ Calorie intake → fat loss

2. Continued deficit → muscle wasting

3. Chronic deficit → impaired height gain

4. Severe → brain growth affected (<2 years critical period)

4. Causes

A. Inadequate Intake (Most common)

B. Malabsorption

• Chronic diarrhoea

• Celiac disease

• Lactose intolerance

• Cystic fibrosis

• Intestinal parasites

C. Increased Metabolic Demand

• Tuberculosis

• HIV infection

• Congenital heart disease

• Chronic lung disease

• Malignancy

• Chronic renal disease

D. Defective Utilization

• Endocrine disorders (hypothyroidism)

• Genetic syndromes

• Metabolic disorders

5. Risk Factors

Child Factors

• Prematurity

• Low birth weight

• Chronic infections

• Developmental delay

• Congenital anomalies

Maternal Factors

• Teenage motherhood

• Maternal illness

• Poor lactation support

• Substance abuse

Environmental Factors

• Poverty

• Food insecurity

• Orphanhood

• Poor sanitation

• Inadequate caregiving

6. Clinical Assessment

A. History (Most important step)

Feeding History

Ask specifically:

• Frequency of feeds

• Duration of breastfeeding

• Formula preparation method

• Night feeding

• Complementary feeding age

• Diet diversity

• Who feeds the child

• Feeding environment

Medical History

• Chronic cough (TB)

• Recurrent diarrhoea

• Vomiting

• HIV exposure

• Congenital heart disease symptoms

• Recurrent infections

Social History

• Caregiver mental health

• Food availability

• Neglect risk

B. Physical Examination

General

• Weight

• Length/height

• MUAC

• Head circumference (<2 yrs)

Look for:

7. Diagnostic Criteria

Child meets FTT if ANY present:

• Crossing down ≥2 growth percentiles

• Weight velocity < expected

• WHZ < −2

• Persistent weight plateau >1 month (<1 yr) or >3 months (>1 yr)

8. Investigations

Investigations are guided by suspected cause — not routine.

Basic Screening

• Full Blood Count (anaemia)

• HIV test

• TB screening

• Stool microscopy

• Urinalysis

If Indicated

9. Management

A. Feeding Management

Birth – 6 Months

• Exclusive breastfeeding ≥8 feeds/day

• Assess latch & positioning

• Manage breastfeeding problems

6 – 12 Months

• Continue breastfeeding first

• Start complementary foods at 6 months

• Begin with iron-rich foods

Examples:

• Mashed beans

• Egg

• Groundnut paste

• Meat puree

• Mashed vegetables

6–8 Months

• 2–3 meals/day

9–11 Months

• 3–4 meals/day + snacks

12 Months

• 5 small meals/day

Add energy density:

1 – 2 Years

• Continue breastfeeding

• If not breastfeeding → 2 cups full cream milk/day

• Daily protein

• Fruits/vegetables twice daily

2 – 5 Years

• 3 family meals + 2 snacks daily

• Encourage self-feeding

10. Non-Pharmacological Management

• Nutrition counselling

• Micronutrient supplementation

• Treat underlying disease

• HIV/TB screening

• Update immunizations

• Monthly follow-up

• Social support referral

• Developmental stimulation

11. Pharmacological Management

Given based on findings:

12. Indications for Hospital Referral

• Severe acute malnutrition

• Oedema

• Persistent vomiting

• Hypoglycaemia

• Severe anaemia

• Suspected abuse

• Developmental regression

13. Prevention

Maternal Education

• Early breastfeeding initiation

• Exclusive breastfeeding 6 months

• Proper complementary feeding

Community Measures

• Food security programs

• Immunization

• Growth monitoring

• Parental counselling

14. Prognosis

15. Key Clinical Message