Falling Off the Growth Curve: An Underrecognized Risk of Automated Formula Machines

Growth faltering, falling off the growth curve, or failure to thrive are all common terms used to describe a frequent but clinically important scenario routinely seen in pediatrics, often identified during infancy and other periods of rapid growth. Inadequate intake is the most common cause identified, especially in the neonatal period. This can lead to lasting consequences for cognitive potential and final adult height. We present the case of a four-month-old female infant who experienced a sudden decline from the 13.6th to the 4.6th percentile in weight for age between six weeks of age and her four-month well visit. Parents reported an adequate intake volume of 32 oz/day prepared with an automated formula machine and age-appropriate elimination. A careful nutrition history regarding formula preparation revealed that the machine was set to a concentration significantly lower than recommended for her specific formula. This meant the prepared formula provided substantially fewer than the recommended 20 kcal/oz. After two weeks of manual formula fortification, the patient demonstrated improved weight gain and returned to the 14.72nd percentile in weight for age. While growth faltering is common, this report highlights a less frequently recognized cause of inadequate intake, namely, improperly concentrated formula prepared by an automated mixing machine. This underscores the importance of a thorough pediatric nutrition history, including a detailed assessment of formula mixing methods. Physicians must be prepared to counsel caregivers on correct formula preparation, whether using manual or automated mixing methods. With automated machines, providers should consider verifying that the settings are appropriate for the specific formula. When patients present with inadequate growth, it is important to consider incorrect formula preparation as a potential etiology and to investigate further.