Eva had an uncomplicated start to life. She was the third child of a fit and well 30-year-old mother, born by spontaneous vaginal delivery at 38 weeks with a birth weight of 2.77 kg (ninth centile). Exclusively breast fed, Eva’s growth was initially within normal range; however, at 5.5 months concern arose regarding her weight gain and after GP consultation, she was weaned in an attempt to increase her calorie intake. This made no difference and at 7 months of age, a specialist paediatric review was undertaken at her local hospital for ongoing faltering growth (fig 1).

COMMENT 1: FAILURE TO THRIVE

• A common reason for referral, estimated to account for up to 5% of hospital admissions.1

• A term of problematic definition and measure,2 however, a drop of two centiles3 on the standard Child Growth Foundation 1990 growth chart or weights falling below the 5th3 or more rigorously the 0.4th centile4 are suggested thresholds for action.

• Physiological adjustment of weight and length can occur in the first months of life,5 so crossing centiles early may be appropriate.

• Growth arrest is often significant and indicative of underlying pathology.

• Myriad causes, of which non-organic aetiologies underlie approximately 95% of cases.6

At Eva’s first review, history was unremarkable with direct questioning revealing no recurrent infections, diarrhoea, vomiting or cough. There were no neurodevelopmental concerns and her mother reported that she was feeding well. There was a family history only of eczema in her otherwise well older siblings. Initial investigations for failure to thrive, which are shown in table 1, showed a mildly elevated alkaline phosphatase (ALP).

Continued breast feeding, in addition to energy rich formula and solids, was encouraged in an attempt to increase Eva’s energy intake. Despite this, she continued to drop off the weight centiles (fig 1 …