Specific research questions are:

What is the best definition of failure to thrive? 1) What criteria for failure to thrive have been proposed, and what are the test characteristics of these proposed criteria for identifying a) children with underlying illnesses and other causes of poor growth that require intervention (e.g. neglect) and b) children who would benefit from intervention with respect to long-term growth or other outcomes.

What routine and specialized diagnostic testing is appropriate in failure to thrive? 2) What are the yield, benefits, and harms of specific routine diagnostic tests in children with failure to thrive? 3) What are the yield, benefits, and harms of directed diagnostic testing in specific populations of children with failure to thrive (e.g. specific symptoms, severe failure to thrive)?

What is the appropriate management for failure to thrive? 4) What is the natural history of failure to thrive with regard to growth, intellectual development, and other outcomes (e.g. removal from home due to neglect) in populations comparable to modern U.S. populations? What are risk factors for worse outcomes? 5) What is known about the comparative effectiveness and harms of a) behavioral feeding interventions; b) oral supplemental feeding; c) enteral tube feeding; and d) other interventions for failure to thrive with regard to growth, intellectual development, and other outcomes. 6) What is known about the effectiveness and harms of hospitalization for evaluation and management of failure to thrive?

What patients or group(s) of patients does your question apply to? Children 2 months to three years of age without previously recognized underlying cause for poor growth

Are there subgroups of patients that your question might apply to? Children with severe failure to thrive

Benefits 1) Optimization of physical growth 2) Optimization of development 3) Diagnosis of underlying pathology causing of failure to thrive, with treatment when possible 4) Identification and intervention in abuse and neglect associated with failure to thrive 5) Improvement in behavior and psychosocial problems

Harms 1) Discomfort and adverse events from supplemental feeding (e.g. aspiration of nasogastric feeds leading to pneumonitis or death, overnutrition) 2) Discomfort, adverse events, and overdiagnosis of underlying pathology from diagnostic testing (e.g. risks of anesthesia and risk of perforation with endoscopy) 3) Stress for child and caregivers 4) Inappropriate disruption of family 5) Harm to family-physician relationship

Failure to thrive is a common condition in a vulnerable population with potentially lifelong consequences.1,4 6 Diagnosis of failure to thrive represents an opportunity to improve growth and development and to identify treatable underlying conditions at an earlier stage. However, there are also considerable potential harms and costs of evaluation and management for failure to thrive.

The answers to our questions will support a clinical practice guideline and identify priorities for future research. A clinical guideline and evidence-based approach is needed within the year.

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Professional Society

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American Academy of Pediatrics

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