A. Hospitalization. Admit patients with severe malnutrition or when infant or child is at risk for harm, follow-up is not reliable, caregiver is neither competent nor compliant, or outpatient management fails.

B. Parental Education and Training. Key component of treatment, regardless of cause. Avoid placing blame. Parents may require referral to nutritional, occupational therapy, physical therapy, psychiatric, and social services.

C. Psychosocial Causes. Ensure that home environment is safe, caregiver is competent and compliant, and follow-up is reliable.

1. Infants. Observe feeding techniques.

2. Toddlers. Institute routine mealtimes, offer solids before liquids, and limit juice or water.

D. Organic Causes. Treat underlying condition. Institute slow introduction of high-calorie foods, with close monitoring.

E. Caloric Supplementation. Depends on specific diagnoses and severity. Patients often require 50% increase in caloric requirements.

F. Follow-up. Frequent follow-up and close monitoring of growth and development are important because patients are at risk for cognitive and developmental delays.

VI. Problem Case Diagnosis. Exam findings in the 4-month-old infant were normal except for loss of subcutaneous fat, and interaction with family was appropriate. Mother reported that she had been mixing 2 cans of water to every can of formula concentrate, "trying to make ends meet."This provided two thirds of infant's required caloric intake per day (13.3 cal/oz rather than 20 cal/oz). Diagnosis is FTT caused by environmental factors.

VII. Teaching Pearl: Question. If a healthy thriving infant shows a decline over two or more major percentiles late in infancy, is this cause for concern?

■ VIII. Teaching Pearl: Answer. Normal changes in linear growth occur in infants. Studies show that healthy thriving infants channel to higher or lower percentiles over the first 18 months of life, at times crossing over two or more major percentiles, then staying within that new channel of growth.

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