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To develop a risk-stratification tool to help identify medical child abuse (MCA) in children evaluated for failure to thrive (FTT).In this case-control study, the control group consisted of children who were seen in the pediatric gastroenterology department and diagnosed with FTT before the age of 5 years between 2000 and 2010. Cases were distinguished by having also been referred to the Child Advocacy Committee at the Cleveland Clinic Foundation (CCF) and/or reported to the Department of Child and Family Services by the CCF as a possible case of MCA. We used retrospective chart review to compare 17 cases of MCA with 68 controls. Classification-tree analysis was used to generate the risk-stratification tool.A risk-stratification tool, in the form of a classification tree, was developed and incorporated the following individual risk indicators: (1) ≥ 5 organ systems involved; (2) absence of serious congenital anomaly or confirmed genetic disorder; (3) ≥ 5 reported allergies; and (4) refusal of services from a multidisciplinary feeding team. Overall, the classification tree had a sensitivity of 100% and a specificity of 96%.The results of this study suggest that a diagnosis of MCA may be suspected in children with FTT on the basis of features in the initial presentation and clinical course. Using the proposed risk-stratification tool that incorporates these features might assist in earlier identification of medically abused children and reduce morbidity and mortality.