Failure to ThriveA seemingly normal baby who refuses to eat, doesn’t grow and has been tested for everything with no apparent results may have failure to thrive.

There are many medical and psychosocial reasons for failure to thrive, but there are also many factors that may not be so obvious.

What Is Failure to Thrive?

Failure to thrive is frequently referred to as the failure to gain weight and/or failure to grow within the first three years of life.

Typically, an infant’s or toddler’s weight is much lower than others of the same age and gender.

A more formal definition of failure to thrive is that either:

  • The child’s growth drops below as least two major weight-percentile curves (such as from the 50th percentile to the 5th percentile, and/or
  • The child’s growth drops below the 3rd percentile (known as “falling off the chart”)

Failure to thrive is normally associated with abnormal growth and development.

There may be symptoms of coordination problems and developmental delays in reaching developmental milestones such as:

  • Rolling over
  • Sitting up
  • Crawling
  • Standing
  • Walking
  • Cognitive skills
  • Social skills

Other signs of failure to thrive can include:

  • Lack of weight gain
  • Irritability
  • Listlessness
  • Excessive sleepiness
  • Sleep disturbances
  • Lack of eye contact
  • Disinterest in surroundings
  • Fatigue
  • Hair loss (alopecia)

What Your Doctor May Tell You About Failure to Thrive

Your child’s pediatrician will likely do an assessment with a standard growth chart of your infant or toddler’s age, the length, weight and head circumference, overall health and development as well as your baby’s medical history.

The pediatrician will observe and question the overall extent of your child’s symptoms to see if your child is undernourished and why, or if there is a genetic disorder or disease.

If your baby is bottle-fed, your pediatrician may want a new formula higher in calories and may increase the number of feedings in a day.

If you are breastfeeding, your pediatrician may tell you to supplement your breastfeeding with formula.

If you are breastfeeding your baby, your pediatrician may feel you have an inadequate breastmilk supply or problems with the breastfeeding technique such as with the way your baby latches on to your breast.

Medical tests maybe be required by your pediatrician to rule out any or the possible medical causes of your child’s failure to thrive.

If there is a possible medical cause, your pediatrician may give you a referral to a specialist for your child.

Your child’s pediatrician may give your child medications or suggest specific medical procedures depending on the cause of the condition of your child; however, the focus on eating will be to increase calories.

Severe cases may require a feeding tube for your child.

Your child’s doctor may suggest any of the following:

  • A dietitian
  • A high calorie diet
  • A lactation consultant
  • An occupational therapist for a feeding program
  • A speech therapist for sucking or swallowing problems
  • A social worker for lack of food issues
  • A psychologist or other mental health professional if there is a behavioral problem or challenging social situation

Severe cases of failure to thrive may be treated in the hospital, fed and monitored until symptoms of severe malnutrition are gone.

Another Way to Think About Failure to Thrive

Traditionally, once known underlying medical conditions such as central-nervous-system damage, hormone abnormalities, and metabolic disorders were ruled out, failure to thrive was a condition that was believed to occur most frequently in families where the primary caregiver either could not or would not adequately care for (feed) the child (due to social, economic or psychological factors).

However, failure to thrive is now commonly seen in children without other medical diagnoses who are from affluent, stable, and loving homes–homes in which social, economic or psychological factors are less likely to contribute to growth delays.

In fact, even children who appear to be consuming adequate daily calories and nutrition are receiving this diagnosis. Why is this happening?

If this condition occurs in an infant/child with adequate care/food intake and who otherwise lacks an established medical condition (like cerebral palsy), there may be other underlying and underrecognized medical problems at play.

A child with failure to thrive is not absorbing/assimilating nutrients. Why?

The gastrointestinal health and environmental exposures of a child with failure to thrive must be considered.

Overview

Nutritional deficiencies and malabsorption are two major causation factors that can lead to failure to thrive in babies and young toddlers.

When your baby’s weight drops on the growth curve before the length and the head circumference this usually means a nutritional problem.

When the length drops on the growth curve before the weight, it usually means it’s an endocrine problem (hormonal).

When the head circumference drops as much or more than the weight or length then that usually means there is a genetic problem or a problem from pregnancy.

Remember to take into consideration that some families are just shorter and smaller by genetic inheritance.

Biochemist William Walsh PhD says that southern European Mediterranean countries lacked food with zinc centuries ago and so therefore, the genetics evolved, resulting in people with a shorter stature.

Possible Medical Causes for Failure to Thrive

The following symptoms/diagnoses are commonly seen in children/babies with failure to thrive, and all of these conditions indicate that the child is suffering from gut dysbiosis and/or immune dysregulation and/or mitochondrial dysfunction:

  • Malabsorption: Not absorbing nutrients, caused by factors such as:
    • Damaged gastrointestinal lining
    • Inflammation
    • Food allergy
    • Inadequate probiotic microorganisms
    • Gut dysbiosis
  • Celiac disease, which is caused by an immune response to the consumption of wheat/gluten
  • Inflammatory bowel diseases such as colitis and Crohn’s, which may be due to a variety of causes, including
    • Gut dysbiosis
    • Immune dysregulation
    • Food allergies and/or sensitivities
  • Feeding/swallowing issues, which may be caused by a variety of issues, including:
    • Eosinophilic esophagitis
    • Eosinophilic duodenitis
    • Other allergic-type conditions
    • Gastroesophageal reflux
    • Low muscle tone due to mitochondrial dysfunction
    • Neuromuscular abnormalities
  • Vomiting/reflux disorder (child is unable to keep food down due to one of the above conditions)
  • Chronic diarrhea, which may be caused by:
    • Celiac disease
    • Food allergies and/or sensitivities
    • Inflammatory bowel disease
    • Gut dysbiosis
    • Immune dysregulation
  • Genetic/chromosome abnormalities such as:
    • Down Syndrome
    • Turner Syndrome
  • Defects in major organ systems
  • Ongoing illnesses or disorders
  • Endocrine imbalances such as:
  • Neurological or central nervous system abnormalities causing feeding issues
  • Heart or lung issues that may affect how nutrients are diffused throughout the body
  • Chronic respiratory conditions
  • Malignancies
  • Renal failures
  • Anemia or other blood disorders such as:
    • Fanconi anemia
    • Bone marrow failure
  • Gastrointestinal abnormalities such as:
    • Malabsorption syndrome
    • Lack of digestive enzymes
    • Pancreatic insufficiency
    • Short-gut syndrome
    • Inflammatory bowel disease
  • GastroEsophageal Reflux (GER)
  • Specific vitamin and mineral deficiencies such as:
    • Iron
    • Vitamin D
  • Chronic liver disease
  • Chronic diarrhea
  • Excessive vomiting
  • Long-term gastroenteritis and gastroesophageal reflux (usually temporary)
  • Long-term chronic infections such as:
    • Parasites
    • Urinary Tract Infections (UTIs)
    • Tuberculosis
    • HIV
  • Infections in the mouth and throat that make sucking/eating painful
  • Cerebral palsy
  • Severe allergies and food intolerances such as cow’s milk protein
  • Developmental delays
  • Swallowing difficulties
  • Inadequate breastmilk production
  • Breastfeeding problems
  • Cystic fibrosis
  • Congenital heart disease such as:
    • Tetralogy of Fallot
    • Multifocal atrial tachycardia (increased heart beat)
  • Metabolic disorders
  • Orofacial defects such as cleft palate and lip
  • Suck-swallow incoordination
  • Neuromuscular disorders
  • Inherited disorders such as:
    • Homocystinuria (inability of the body to process methionine)
    • Abetalipoproteinemia (inability to absorb certain dietary fats)
  • Drugs such as anti-epileptic medications
  • Fetal alcohol syndrome
  • Drugs
  • Cigarettes
  • Complications with pregnancy and low birth weight
  • Premature baby
  • Mother’s stress/postpartum depression

Possible Psychosocial Causes for Failure to Thrive

  • Loss of emotional bond between the child and the parent(s)
  • Financial difficulties and poverty
  • Problems with the child- caregiver relationship
  • Poor social support
  • Lack of caregiver knowledge and understanding the infant’s dietary and well-being needs
  • Unlimited access to juice and snacks
  • Inadequate provision of nutrients and calories
  • Inappropriate mealtime environment
  • Food purposefully withheld or erratic eating schedule with little consistency
  • Baby just might not be feeding for long enough or often enough
  • Mom is having trouble weaning baby on to solid foods

Pica

Frequently associated with failure to thrive is pica, a commonly overlooked compulsive-eating disorder of non-food substances caused by nutritional deficiencies and malabsorption issues in the gastrointestinal tract that can lead to failure to thrive very easily among young children.

Pica often precedes diagnoses such as Obsessive Compulsive Disorder (OCD), celiac disease (intolerance to gluten and malabsorption in the gut) and Autism Spectrum Disorders.

Pica can also affect children between the ages of two and three, children who have had a brain injury, and children with epilepsy.

Your toddler may have signs of OCD and severely restricted food intake with the sudden on-set of symptoms from Pediatric Acute-onset Neuropsychiatric Syndromes (PANS) or Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS).

The severely restricted food intake and abnormal eating pattern of the PANS diagnosis can lead to failure to thrive.

In some children, pica may be an indicator of OCD.

Pica can often result in lead toxicity, anemia (low iron), growth retardation and spoon nail.

Many young children will eat dirt because they are looking for minerals that they are missing in their bodies.

Parasitic infestations, infectious organisms and other heavy metal toxicity such as arsenic and lead can be found in the gastrointestinal tract from eating dirt or feces.

Pica not only leads to failure to thrive, but also negatively affects neurological functioning of a developing brain with the ingestion of toxic items such as:

  • Foam
  • Chalk
  • Clay
  • Crayons
  • Feces
  • Sand
  • Dirt
  • Metal
  • Plaster
  • Cigarette butts
  • Glue
  • Cornstarch
  • Chalk
  • Paint chips
  • Paper
  • Soap
  • Burnt match heads

These toxic foreign particles pass through the gastrointestinal tract and eventually develop holes in the mucosa (gut lining), causing the digestive tract to permeate; also known as leaky gut syndrome.

A leaky gut allows toxic waste to leak through the intestinal wall into the bloodstream, causing an immune reaction.

Small children with developing neurological, immune, sensory, and nervous systems are a risk to develop autism spectrum disorders and other devastating autoimmune conditions from pica.

Lead Toxicity

Lead toxicity is known as the silent killer for children and is found in three main items:

  • Paint chips
  • Paper, especially newspaper
  • Dirt

Symptoms of lead toxicity include:

  • Hyperactivity
  • Inattentiveness
  • Distractibility
  • Hand-eye coordination impairment
  • Delayed motor skills
  • Abnormal reflexes

Many children with ADD (Attention Deficit Disorder) and ADHD (Attention Deficit Hyperactivity Disorder) have lead toxicity.

Children with ADD, ADHD, pica or failure to thrive should be tested for lead levels.

Common Nutritional Deficiencies in Pica

Iron

Iron is the essential mineral that carries oxygen in the blood; iron deficiency can lead to decreased blood cells and iron-deficiency anemia.

Iron-deficiency anemia can cause significant developmental delays because not enough oxygen is getting to the developing brain.

Iron deficiency can also cause:

  • Fatigue
  • Weakness
  • Shortness of breath
  • Stunted growth

Infants are prone to iron deficiency after six months; in the first six months they have enough stored iron from the mother’s pregnancy.

Therefore, babies need more iron-rich foods when starting on solids around six months of age; otherwise, they could become iron deficient.

Zinc

Zinc is a very important mineral that is needed to:

  • Enhance the functioning of the immune system
  • Support the gastrointestinal and hormonal systems
  • Improve physical growth
  • Activate a sense of smell (olfactory)
  • Stimulate taste buds (for picky eaters)

Did you know that without zinc, the stomach does not create enough hydrochloric acid and pepsin to break down foods for digestion?

Pepsin is one of the crucial factors in the absorption of vitamin B12.

Zinc plays an integral part in failure to thrive.

Calcium

Calcium is one of the most important minerals necessary for bones and teeth development in children, as are magnesium and phosphorus.

Calcium is also important in emotional development.

Potassium is important for the nervous system and muscle function, both of which affect growth and development.

Vitamin D

Vitamin D deficiency can lead to rickets in babies which can cause skeletal deformities.

Vitamin D is not only necessary for calcium and phosphate absorption for the bones, but also improves immune and hormonal functioning.

Vitamin D deficiency can cause a child’s growth to be slow or delayed.

Supplement from 400 to 1000 IUs daily of D3 for preemies infants three months and older and try to get as much sunshine as possible when available.

Please note that vitamin D3 should be taken with vitamin K2 to prevent constipation and other side effects.

Vitamin B12

A vitamin B12 deficiency is a common occurrence with the vegan diet, which Joseph Mercola DO feels can be deadly.

Here’s what researcher Michael Donaldson, PhD of Cornell University has to say:

“Based on the published studies and our results, adequate vitamin B12 status of vegans cannot be taken for granted. Pregnant women, nursing mothers, infants, and small children are particularly vulnerable to B12 shortages. Ensuring adequate B12 is critical for normal neurological development and maintenance, with shortages resulting in permanent damage.”

If your child has the genetic mutation variant MTHFR, then processing the methylation of vitamin B12 for important neurological functioning is going to be difficult and will require methylation support.

Other reasons why the gastrointestinal tract is unable to absorb vitamin B12 are:

  • Bacterial dysbiosis
  • Insufficient stomach acid (hydrochloric acid)
  • Insufficient pepsin
  • Parasites, such as Giardia
  • H. pylori bacterial infection
  • Inflammatory conditions such as Crohn’s or celiac disease

Beneficial bacteria in the baby’s gut can help protect their immune system.

Certain bacteria can also help baby grow, and the microbiome affects baby’s weight, growth, energy and nutrition.

Trace Minerals

Trace minerals are necessary for:

  • Muscle tone (externally and internally)
  • Proper bone mass
  • Gross and fine motor skills
  • Increased height and weight
  • Decreased sensory meltdowns
  • Improve ability to climb
  • Expanding a limited picky eater’s diet
  • Stopping chronic constipation due to poor internal muscle tone

Other Factors

Toddlers who eat sugar-laden snacks and drink sugar-laden beverages without a consistent reliable mealtime schedule may not acquire or develop the internal cycles of hunger and satiety that is needed for the basis of self-regulation and self-control of eating and healthy growth patterns.

It is also crucial for babies and toddlers to get enough sleep at night with intermittent daytime naps to be able to eat during meals without fussing.

Acquiring an appetite may be difficult due to appropriate timing, the size of meals and the amount of snacking and grazing all day long.

Studies have been done that show attention, self-regulatory skills for self-control, organizational skills and cognitive functioning and academic abilities all tend to be at risk with the effects of malnutrition.

Checklist for Failure to Thrive

It is critical that you work with an experienced integrative healthcare practitioner who can help you get to the bottom of the condition.

Ultimately, as a parent, it is up to you to be your child’s “health detective” and get to the root cause of the failure to thrive diagnosis.

Check your breastmilk supply:

Some women use a nipple shield to alleviate the pain of breastfeeding from cracked nipples and sore breasts; however, it can reduce the amount of breastmilk supply to baby if not applied properly.

Check with your lactation consultant, pediatrician, midwife or doula to make sure your supply of milk is not limited.

Make dietary changes:

Babies and toddlers need a diet high in protein, high fat, complex carbohydrates and no refined white sugar/flour, lots of vegetables, leafy greens and some fruits.

  • Avoid PediaSure because it is high in sugar, contains synthetic vitamins that are not in a bioavailable form, and contains food dyes and genetically modified (GMO) foods
  • Eat whole foods
  • Buy organic foods
  • Remove all GMO foods
  • Remove all fast and processed foods
  • Remove all foods with:
    • Artificial colors
    • Artificial ingredients
    • Preservatives
    • Phenols
    • Salicylates
  • With an elimination diet, remove potentially inflammatory foods such as:
    • Casein
    • Gluten
    • Soy
    • Corn
    • Eggs
    • Fish
    • Shellfish
    • Nuts
    • Peanuts
  • Strictly limit:
    • Sugars
    • Refined salt
    • Refined carbohydrates
  • Join the Feingold Association to learn more about eliminating preservatives, artificial colors and artificial flavors from your child’s diet.
  • Try protein shakes and smoothies for toddlers and add predigested protein (collagen) called Arthred by Allergy Research Foundation or Nutricology to increase muscle tone and protein.
  • Supplement with iron-rich foods such as:
    • Nut butters
    • Meats
    • Eggs
    • Poultry
    • Beans
    • Leafy greens such as:
      • Kale
      • Collards
      • Turnip tops
    • Seaweed
    • Squash
    • Quinoa
    • Black strap molasses
    • Pumpkin seeds
    • Sesame seeds
    • Sweet potatoes
  • Add vitamin C sources (such as strawberries, citrus fruit and cruciferous vegetables) to increase iron absorption.
  • Supplement with zinc-rich foods such as:
    • Peas
    • Beans
    • Lentils
    • Chickpeas
    • Asparagus
    • Whole grains
    • Seafood

Include plenty of good quality fats:

Babies’ and toddlers’ brains needs lots of fats.

The following nutrient-dense fats can be added to baby’s formula and given with solid foods for toddlers:

  • Coconut oil
  • Cold-pressed extra-virgin olive oil
  • Avocados
  • Wild salmon
  • Organic chicken
  • Organic turkey
  • Grass-fed ghee or butter
  • Organic eggs
  • Essential fatty acids from:
    • Cod liver oil
    • Hemp seeds
    • Flax seeds
    • Evening primrose oil
    • Borage oil
    • Walnut oil
    • Krill oil

Remove vegetable oils such as:

  • Canola
  • Corn
  • Soy
  • Safflower
  • Sunflower

Heal the gut with special diets that focus on removing grains and reducing sugars, fructose and starchy carbohydrates, such as:

Learn more about healing diets and foods.

Add fermented foods and probiotics daily:

These will keep the gastrointestinal system and microbiome healthy and strong which in turn will keep the immune system strong.

  • Eat kefir yogurts
  • Eat fermented vegetables
  • Eat umeboshi plums (very alkalizing)
  • Eat miso soup, if soy is tolerated

Some good probiotics are:

  • VSL#3
  • Gut Pro
  • Dr. Ohirra’s Live Cultured Probiotics
  • Garden of Life
  • Culturelle
  • Klaire Labs

Use digestive aids with your practitioner’s guidance:

  • Betaine hydrochloric acid (HCl) for low stomach acid (with meals)
  • Digestive enzymes with DPP-IV for gluten and casein intolerances (with meals)
  • Proteolytic enzymes (on an empty stomach)
  • BiCarb (on an empty stomach)
  • Bromelain (with meals)
  • Papaya (with meals)

Ask your pediatrician to run some laboratory tests for:

  • Possible food sensitivities and allergies
    • Enzyme-Linked Immunosorbent Assay (ELISA) IgG, IgA, IgE and IgM
  • Nutritional deficiencies in vitamins and minerals. The NutrEval by Genova Diagnostics Labs covers the following areas:
    • Malabsorption
    • Dysbiosis
    • Cellular energy
    • Mitochondrial metabolism
    • Neurotransmitter metabolism
    • Vitamin deficiencies
    • Toxin exposure
    • Detoxification need
  • Bacterial and yeast overgrowth
  • Gluten and casein sensitivities
  • Organic acids: The organic acid test by Great Plains Laboratory for:
    • Yeast overgrowth (Candida)
    • Oxalates
    • Other microbial infections
  • Comprehensive Stool Analysis by Genova Diagnostic Labs to identify:
    • Malabsorption
    • Maldigestion
    • Altered gastrointestinal function
    • Bacterial/fungal overgrowth
    • Chronic dysbiosis

Always observe the color and consistency of your baby’s stool, which tells the story of the state of the gastrointestinal tract.

Stools should not be green or yellow with mucous and runny. If they are not normal, then ask your doctor to run some of the above tests.

Further testing for failure to thrive may also be useful:

  • Thyroid function
  • Ferritin levels
  • Lead levels
  • Electrolytes
  • Iron levels
  • Liver enzymes
  • Ammonia levels
  • Lactate levels
  • Pyruvate levels
  • Sweat chloride test
  • Urine organic acids
  • Serum amino acids

Use herbs, essential oils and natural supplements with your practitioner’s guidance:

  • Liquid chlorophyll (from alfalfa which extends deep into the earth to absorb minerals) by World Organics or Nature’s Way can increase iron levels without constipation like iron pills do and is very absorbable.
  • Liquid zinc by Trace Minerals or Pure Encapsulations is in drops and is very easy to add to food.
  • Trace minerals with fulvic acid (colloidal trace minerals have no taste)

Avoid supplemental iron which can worsen gut dysbiosis, SIBO (Small Intestinal Bacterial Overgrowth) and yeast overgrowth in the gut.

Reduce lead exposure:

Public health agencies have attempted to reduce the risks of lead exposure and poisoning by enforcing a drinking water standard for lead of 15 parts per billion; reduced the lead content of canned foods; eliminated lead additives in gasoline; and banned lead in residential paints in 1977, but lead-based paint remains the primary source of lead exposure for children.

  • Lead-containing paint cans should be removed from the house.
  • Children and pregnant woman should evacuate an old house while undergoing renovation or paint removal.
  • If your tap water contains more than 10-15 parts per billion of lead, run the faucet until the temperature is cold before drinking or cooking.
  • Do not use hot water from the tap to mix infant formula or for cooking because it usually contains lead.
  • Do not use pottery or cans to store food and beverages.
  • Do not use ceramic dishes for heating food unless you know they are lead-free.
  • Check imported, highly decorated, glossy, multicolored ceramic dishes or mugs for lead content, as they typically contain more lead.

See a craniosacral practitioner:

These practitioners use approaches rich in vestibular, proprioceptive and tactile input, which can help alleviate birth trauma and failure to thrive.

The New York College of Osteopathic Medicine at St. Barnabus Hospital in the Bronx, New York City discovered that babies who have undergone birth trauma may be able to reverse their failure to thrive with craniosacral therapy.

See a reflex-integration practitioner:

An infant should establish primitive reflex responses such as rooting, suck/swallow, tongue thrust and gag right after birth.

By six months of age, an infant should show some developmental signs of solid-food readiness.

If this is not the case, the infant may have developmental regression and retained primitive reflexes, which can lead to failure to thrive.

A chiropractic neuorologist such as those at Balance Brain Achievement Centers can help with integrating the left and right hemisphere in the brain for proper neurological functioning of the sensory and nervous systems.

These practitioners can also help with the inhibition of retained primitive reflex inhibition that may be disrupting your child’s sensory system.

Other practitioners that can help with reflex-integration are those trained in the Masgutova Method and Rhythmic Movement Training (RMT), such as Move Play Thrive.

See a chiropractor:

The spinal cord adjustments, treatment of subluxations and improvement of neurological flow that chiropractors offer can improve nervous-system functioning and calm down the “fight or flight” sympathetic nervous-system overdrive.

Digestive problems can be caused by a physical compression of the vagus nerve (also known as the wandering nerve).

The vagus nerve exits the upper cervical spine and descends to the heart and the stomach.

The vagus nerve controls:

  • Heart rate
  • Blood pressure
  • Gastric motility
  • Gastric acid secretion

If the vagus nerve is compressed, the child may need an upper cervical correction by a chiropractor to restore proper digestive functioning; this correction can help children with failure to thrive.

See a sensory-integration occupational therapist:

These OTs address a variety of sensory issues with a child using hands on equipment to:

  • Calm down the nervous system
  • Integrate the senses
  • Help build muscle tone and stamina
  • Inhibit retained primitive reflexes

See a NAET or Bioset practitioner:

These practitioners offer allergy elimination treatment that can eliminate food allergies that may be contributing to your child’s failure to thrive.

Still Looking for Answers?

Visit the Epidemic Answers Provider Directory to find a practitioner near you.

Related Pages

Attention Deficit Disorders (ADD and ADHD)

Autism Spectrum Disorder

Elimination Diet

Failure to Thrive: Red Flags All Over the Place

Gastrointestinal Disorders

Getting Good Supplements into Picky Eaters

Gut Dysbiosis

Help for a Picky Eater with Kelly Dorfman (Webinar Replay)

Immune Dysregulation

Improving Picky Eating by Changing Adult Behavior

Mitochondrial Dysfunction

MTHFR Mutation

PANS/PANDAS

The Picky Eaters

Reflex Integration

Retained Reflexes

Robby: Failure to Thrive

Websites

Balance Brain Achievement Centers

Masgutova Method

Move Play Thrive

My Child Will Thrive: Primitive Reflexes Cheat Sheet

Naturopathic Pediatrics: Failure to Thrive in Babies/Toddlers Eating Solid Foods

Organic and Thrifty: What to Feed Your Baby Besides Breastmilk

Rhythmic Movement Training (RMT)

The Weston A. Price Foundation: Feeding Babies