Last reviewed: March 2026
Contents
MDM Templates
FTT — Admit for Evaluation
Infant/child presents with documented poor weight gain and weight currently below the 3rd percentile (or crossing two or more major percentile lines on WHO growth chart). Parents describe poor oral intake. No acute illness to explain the growth failure.
Differential includes inadequate caloric intake, malabsorption (celiac, CF, milk protein allergy), cardiac disease, metabolic/endocrine disorder, chronic infection, and neglect. Given severity of weight loss and inability to identify a clear reversible cause in the ED, inpatient evaluation is warranted to observe feeding, document caloric intake, and complete a systematic workup.[1]
Plan: Admit for supervised oral challenge with documented intake and output. Social work consulted. Basic labs and further workup directed by inpatient team.
FTT — Discharge with Close Follow-up
Infant/child presents with poor weight gain noted on growth chart but is well appearing, well hydrated, developmentally appropriate, and tolerating oral intake in the ED. No signs of dehydration, hypothermia, or hypoglycemia. Social situation assessed and reassuring.
History and exam not consistent with cardiac disease, malabsorption, metabolic disorder, or neglect. Growth trajectory suggests early or mild failure to thrive, likely related to inadequate caloric intake or feeding technique issues.[1]
Plan: Discharge with PCP follow-up within 48-72 hours for weight recheck. Family counseled on caloric supplementation and feeding strategies. Return for poor feeding, lethargy, dehydration, or vomiting.
Clinical Education
Definition and Growth Criteria
FTT is a sign, not a diagnosis. Defined as weight below the 3rd percentile for age on WHO growth charts, or a deceleration in weight crossing two or more major percentile lines. Use WHO charts for children <2 years and CDC charts for ages 2 and older.[1]
Weight is affected first, then length, then head circumference. If head circumference is affected, think chronic or severe malnutrition or an underlying genetic/neurologic condition. Isolated short stature with normal weight-for-height is more likely constitutional or familial.
Organic vs Non-Organic Causes
Non-organic (psychosocial) causes account for the majority of FTT cases. Inadequate caloric intake from poverty, caregiver knowledge gaps, improper formula preparation, food insecurity, or neglect. These children typically gain weight rapidly once adequate calories are provided in the hospital.[2]
Organic causes to consider: cardiac (CHF from undiagnosed CHD), GI (celiac disease, GERD, milk protein allergy, CF), endocrine (hypothyroidism, growth hormone deficiency), metabolic (IEM), chronic infection (HIV, TB, recurrent UTI), and neurologic (cerebral palsy affecting swallowing).
Red Flags in the ED
Dehydration, hypothermia, bradycardia, or hypoglycemia indicate severe malnutrition and warrant immediate admission. Refeeding syndrome is a concern in severely malnourished children — start calories slowly and monitor phosphorus, potassium, and magnesium.
Developmental regression or loss of milestones suggests an underlying neurologic or metabolic condition rather than simple caloric insufficiency.
ED Workup
The most valuable ED test is a supervised oral challenge. Document exactly how much the child eats and how they feed. If the child takes in adequate calories without choking or emesis, that itself is reassuring and informative.[1]
Basic labs if organic cause suspected: glucose, BMP, CBC, UA, TFTs. Consider celiac serologies (tTG-IgA) if >6 months and eating gluten. Sweat chloride for CF if recurrent respiratory infections or steatorrhea. These are generally inpatient workup items unless the child is acutely ill.
When to Suspect Abuse or Neglect
Social work should be involved early in all FTT admissions. Neglect is the most common form of child maltreatment and FTT may be its presenting sign. Concerning features: caregiver disengagement, inconsistent history, missed well-child visits, multiple ED visits without PCP follow-up, sibling with similar history, and evidence of physical abuse.[2]
Mandatory reporting applies when neglect is suspected — you do not need to prove it, only suspect it.
Disposition
Admit: Weight <3rd percentile with no clear explanation. Dehydration, hypothermia, hypoglycemia, or bradycardia. Concern for organic etiology requiring inpatient workup. Concern for neglect or unsafe home. Child not tolerating oral feeds.
Discharge with close follow-up: Mild FTT with weight still on the growth curve. Well-appearing, tolerating PO, developmentally normal. Reassuring social situation. PCP follow-up within 48-72 hours for weight recheck.
tydotphrase.com 