Failure to thrive differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akash Daswaney, M.B.B.S[2]


It is important to differentiate failure to thrive into organic and non-organic causes. Furthermore, using the concepts of bone age, chronological age, catch up growth and catch down growth, conditions such as constitutional growth delay and familial short stature should also be considered.

Differentiating failure to thrive from other diseases

  • The differential diagnoses of failure to thrive ranges from gastro-esophageal reflux disease to pediatric HIV infections.
  • Measuring bone age and comparing it with chronological age can help the physician differentiate between syndromes like constitutional growth delay and familial short stature. [1]
    • Constitutional growth delay- patients have a low weight for age, low height for age and bone age < chronological age early on in their lives. This is followed by a growth spurt during adolescence where catch up takes place. Infants have a more severe catch down growth. [2]
    • Familial short stature- parents have a positive family history and their bone age matches their chronological age. Children have a projected adult height that is within their anticipated adult height, based on their mid parental height.


    • Chromosomal disorders- special considerations should be made when measuring infants with disorders such as trisomy 13, trisomy 21, Turner syndrome or premature infant with a history of intrauterine growth restriction.
    • Catch down growth – A sudden drop over two major percentiles may be noted after an initial high rate of growth. The infant may simply be adjusting it’s growth rate to match it’s genetic potential.
  • A thorough history and physical examination will help the physician to differentiate between organic and non- organic causes.
  • Non-organic causes include[4][5][6]:
  1. Social, psychological, and environmental factors
  2. Non accidental trauma – subdural hematoma
  3. Low socioeconomic status
  4. Child neglect, abuse, and poor parent-child interaction
  5. Poverty
  6. Poorly educated parents
  • Organic causes can further be subdivided into;
    1. Inadequate caloric intake
    2. Excessive calorie expenditure
    3. Inadequate calorie absorption
Inadequate calorie intake Excessive calorie expenditure Inadequate calorie absorption
  1. Poverty and inadequate food storage
  2. Feeding difficulties- poor infant feeding technique, improperly reconstituted formula, uninhibited access to high calorie food, behavioral problems related to feeding
  3. Inadequate breast milk production, breastfeeding failure, errors in artificial feeding, poor latch/suck strength
  4. Mechanical or structural problems with swallowing; cleft lip, cleft palate, neuromuscular disease, motor neuron disease
  5. Prenatal insult – worsening of prematurity or intrauterine growth restriction
  6. Erratic diets – unorthodox beliefs, Munchausen syndrome by proxy
  7. Systemic diseases causing decreased appetite, anorexia, and food refusal.
  1. Chromosomal conditions – trisomy 13,trisomy 18, trisomy 21, Turner’s syndrome
  2. Congenital heart disease – cyanotic and non-cyanotic heart diseases.
  3. Teratogenic exposures – anti-epileptics, tetracyclines
  4. Endocrine dysfunction – growth hormone deficiency, type 1 Diabetes mellitus
  5. Cirrhosis of liver
  6. Chronic respiratory illness, intrauterine infections
  7. Malignancy
  8. Thyroid dysfunction
  9. Renal tubular acidosis, Renal failure
  10. Increased Intracranial pressure
  11. Immunodficiency syndrome causing recurrent infections, e.g. HIV
  1. Bowel obstruction - Ladd bands, paralytic ileus, small intestinal bowel obstruction
  2. Necrotizing enterocolitis /Short bowel syndrome
  3. Pyloric stenosis
  4. Gastro-esophagal reflux disease
  5. Cystic fibrosis
  6. Pancreatic insufficiency


  1. Pancreatic insufficiency,
  2. Celiac disease
  3. Giardiasis
  4. Inflammatory bowel disease
  5. Inborn errors of metabolism – amino acid disorders, lysosomal storage diseases
  6. Enzyme deficiencies
  7. Biliary atresia
  8. Cow’s milk protein allergy


  1. Goh LH, How CH, Ng KH (2016). "Failure to thrive in babies and toddlers". Singapore Med J. 57 (6): 287–91. doi:10.11622/smedj.2016102. PMC 4971446. PMID 27353148.
  2. Jeong SJ (2011). "Nutritional approach to failure to thrive". Korean J Pediatr. 54 (7): 277–81. doi:10.3345/kjp.2011.54.7.277. PMC 3195791. PMID 22025919.
  3. Krugman SD, Dubowitz H (2003). "Failure to thrive". Am Fam Physician. 68 (5): 879–84. PMID 13678136.
  4. Larson-Nath C, Biank VF (2016). "Clinical Review of Failure to Thrive in Pediatric Patients". Pediatr Ann. 45 (2): e46–9. doi:10.3928/00904481-20160114-01. PMID 26878182.
  5. Nangia S, Tiwari S (2013). "Failure to thrive". Indian J Pediatr. 80 (7): 585–9. doi:10.1007/s12098-013-1003-1. PMID 23604606.
  6. Berwick DM, Levy JC, Kleinerman R (1982). "Failure to thrive: diagnostic yield of hospitalisation". Arch Dis Child. 57 (5): 347–51. doi:10.1136/adc.57.5.347. PMC 1627558. PMID 6807215.

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