CPS Statement: Failure to Thrive in the Toddler

CPS Statement: Failure to Thrive in the Toddler

The following was adapted from the Canadian Paediatric Society's statement on "The toddler who is falling off the growth chart."  Please see the full statement for the full recommendations from the Canadian Paediatric Society. For more information, please see our PedsCases podcast on "Failure to Thrive."


Problems in a child's health or nutrition almost always affect growth.  A significant decrease in growth velocity outside of normal variations is termed failure to thrive and warrants evaluation. If detected early and treated appropriately, growth failure may be reversible.  If not, the child's ultimate height may be affected. Therefore it is important for physicians to closely monitor the weight, length/height and head circumference of developing children to detect changes in growth pattern. The WHO growth charts are now the standard for monitoring growth in children. 

Most children follow the same percentile for weight and height throughout childhood, however birth weight and height does not always reflect a child's genetic potential. Intrauterine growth is affected by a number of factors including maternal nutrition, smoking, placental insufficiency or gestational diabetes. After the birth the child may have "catch-up" or "catch-down growth towards their genetic potential in the first 2-3 years of life.  Nutrition can also affect early growth patterns with breastfed infants showing faster growth in the first six months of life than formula-fed infants. After the age of three, there should be no more changes in growth percentile until puberty.


The CPS lists the following as the leading causes of growth failure:

  • Inadequate caloric intake - Either because the child is eating poorly (most common), anorexia associated with chronic disease, or lacking oral and/r eating skills.
  • Increased energy losses - Either due to emesis or malabsorption from pancreatic disease (eg. Cystic fibrosis), cholestatic liver disease or intestinal disease (eg. Celiac disease, Crohn's  disease).
  • Increased energy needs - Either due to an underlying chronic condition or chronic or recurrent infections (ie. Primary immune deficiencies).
  • Endocrine problem - Including hypothyroidism or a growth hormone deficiency.
  • Other (rare) - Diencephalic tumours or renal tubular acidosis.


First, ensure that growth has been measured accurately and in the same conditions. For example the child should be undressed, on the same scale and using a height gauge.

Mid-parental height can be used to estimate a child's genetic potential:

  • Boys = (Father's height + Mother's height)/2 + 6.5 cm +/- 8.5 cm
  • Girls = (Father's height + Mother's height)/2 - 6.5 cm +/- 8.5 cm

A complete history and physical should be completed, including a detailed nutrition and diet history:

  • Assess the eating environment including distractions.
  • Is the child easy to feed?
  • Have there been any negative experiences with food, including reflux or allergies?
  • Has there been difficulty introducing new foods including solids, textures or weaning from breastmilk?

Healthcare providers should be sensitive to questioning around parenting skills and approaches to food, as this can be a very stressful situation for parents.

With the help of a nutritionist, caloric intake can be estimated from a 72-hour food diary and compared to requirements.  Malabsorption should be suspected in a child who has growth failure despite having a higher caloric intake than would be need.

Investigations should be ordered in a step-wise manner, and should be guided by a differential diagnosis. For a detailed list of suggested investigations please see the complete statement.


After completing assessment, if no disease is detected, it is important to reassure that their child is healthy and to continue to monitor growth as you would any other child. If a disease is diagnosed treat the underlying cause.

If the child has inadequate caloric intake, assess caloric needs (cal/kg/day) using the formula:

  • Caloric needs =  Caloric needs for weight age x (ideal weight/actual weight)

A nutritionist can suggest changes to the child's diet to increase calorie density, including adding high-calorie formulas to supplement after meals.

Pharmacologic intervention including cyproheptadine should only be used in consultation with an expert in the field, but may help make the child feel hunger and feel happier to eat.

Tube feeding should be considered only when the underlying disease is made worse by poor nutritional status, oral feeding is unsafe and all other options have been exhausted.  Insertion of a nasogastric tube can be traumatic for a child and family and can lead to oral aversion in the future.

Psychosocial interventions can work to reduce parental and child anxiety around feeding, return control of feeding to the child and work to make mealtimes a positive family experience.


Last updated by PedsCases: May 1, 2015

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