Nutritional Considerations in Failure to Thrive Workup

Updated: Feb 22, 2021
  • Author: Simon S Rabinowitz, MD, PhD, FAAP; Chief Editor: Jatinder Bhatia, MBBS, FAAP  more...
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Laboratory Studies

Because many instances of failure to thrive are nonorganic, a history and physical examination are normally all that are required. Laboratory assessment has a limited value in diagnosing a previously unknown clinical disease or demonstrating inadequate treatment (ie, improper regiments or more commonly noncompliance). [62, 63]  

Children diagnosed with failure to thrive usually undergo certain screening tests that are more helpful in determining their physical status rather than elucidating the etiology. These often including the following:

  • Complete blood cell (CBC) count

  • Urinalysis

  • Urine culture

  • Electrolytes, including creatinine and blood urea nitrogen (BUN)

  • Liver function tests, including total protein and albumin

  • Prealbumin (may be used as a nutritional marker)

More specific tests may be indicated, depending on findings from the history and physical examination, including the following:

  • Erythrocyte sedimentation rate (ESR) to establish objective inflammation

  • HIV testing

  • Sweat chloride test

  • Thyroid function tests

  • Stool studies for parasites or malabsorption

  • Immunoglobulins and other immune studies

  • Purified protein derivative (PPD) skin test

  • Radiological studies

  • Tissue transglutaminase antibody (TTG-IgA), a screen for celiac disease (prevalence now appreciated to be 1 case per 133 population)

If concern surrounds possible growth hormone deficiency, the following may be obtained:

  • Serum insulinlike growth factor I (IGF-I)

  • Insulinlike growth factor binding protein (IGF-BP3)

Note that in patients with failure to thrive, the growth hormone axis may be secondarily affected, a condition referred to as deprivational dwarfism.


Imaging Studies

Bone age may be helpful in distinguishing genetic short stature from constitutional delay of growth. Chest radiography is helpful in assessing cardiopulmonary disease.

For a child with suspected dysphagia, which may present as coughing, choking, difficulty with certain consistencies of food, or food refusal, video cinefluoroscopy can be an extremely valuable study. Also called a modified barium swallow, the infant is given liquids and solids of varying consistency under the direction of a feeding therapist who collaborates with the radiologist to film the swallows. Subsequently, the film can be slowed down to evaluate the various phases of swallowing and document penetration and aspiration.



Other diagnostic procedures may be appropriate and are performed as indicated.

A recent retrospective study on the indications for diagnostic upper endoscopy found that failure to thrive was among the top 3 conditions prompting this invasive investigation. The majority of children were found to have normal findings. The yield of identifying previously unrecognized problems that could have contributed to the failure to thrive was low and included gastritis (22%), esophagitis (14%), and celiac disease (2.6%). [64] Frequently, physical findings and or a history are characteristic for acid peptic disease (gastritis, esophagitis, duodenitis, peptic ulcer) and can be treated empirically. Celiac disease can be suggested by positive tissue transglutaminase IgA, but present guidelines recommend biopsy to confirm the diagnosis. An article from a medical school based feeding program found that virtually the only successful applications of endoscopic procedures were for children with medical diagnoses that were responsible for the FTT. [63]