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Why “Failure to Thrive”?

November 5, 2021

“Failure to thrive is an archaic term…” So starts the review article “Failure to Thrive or Growth Faltering: Medical, Developmental/Behavioral, Nutritional, and Social Dimensions” by authors Tang, Adolphe, and Frank in this month’s issue of Pediatrics in Review (10.1542/pir.2020-001883). “Failure to thrive,” or “FTT” as we called it over 40 years ago in medical school, was also embellished with the terms “organic” and “non-organic.” Diagnosis seemed simple back then. If an infant in your clinic was not gaining weight as she or he should, you would admit the patient to the hospital, do a few screening labs, and feed the child. If the child did not gain weight and there was an unusual laboratory finding, the child had “organic FTT” and you had to find that medical cause. However, if the child gained weight and the laboratory exam was normal, then the child had “non-organic FTT” and the fault lay with the caretaker, ie, the mother.

Now that was archaic thinking.

Since the journal’s inception, there have been seven review articles on “Failure to Thrive” published by Pediatrics in Review. Common themes in all seven reviews are the definition of “failure to thrive”; a plea for readers to recognize that the term refers to a sign, not a diagnosis; and that the underlying issue of “failure to thrive” is undernutrition. In their article, Tang, Adolphe, and Frank add to these themes by discussing social determinants of health. The article highlights that there are many intertwining reasons why an infant or child may have growth faltering.

I find “failure to thrive” to be an intriguing phrase. To me it implies that, despite having what appears to be the best of circumstances, a person is not happy, succeeding, or staying healthy. To find what circumstances are missing, Tang, Adolphe, and Frank suggest starting with a thorough prenatal and perinatal history which “…includes complete medical history, family history, nutritional and feeding history, developmental history, and social history.” In my experience, there is invariably something unexpected to be found when one encounters a child who is faltering in growth for unexplained reasons.

One final comment. “Failure to thrive” may be an archaic term, but there is something about that phrase that we inherently understand and cannot stop using, much like other words and phrases we use in medicine. In 1977 the American Thoracic Society and the American College of Chest Physicians officially renamed “rales” as “crackles.” To this day, we receive case reports with authors using the term “rales.” “Signs” are physical characteristics that a clinician detects on physical exam whereas “symptoms” are a physical problem that a person experiences that may indicate an underlying disease. To this day, we receive case reports with authors stating, “the patient had symptoms of hepatomegaly…” To this day, we receive and will continue to receive case reports of children with “failure to thrive” because, for a child not to grow, not to be healthy, and not to be happy, we instinctively, and perhaps subconsciously, acknowledge we have failed to find why.

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