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Failure to Thrive

Failure to Thrive


Failure to thrive is defined as poor growth in children during the first three years of life. A child's growth is evaluated by comparison with standard growth charts for normal children. Poor growth will sometimes be apparent because a child does not grow as fast as other children: Over time his or her position on the growth chart becomes lower. It may also be apparent because he or she is at the bottom of the chart in terms of weight, length, or weight in relation to length. There is no single definition on which everyone agrees. Interpretation of children's growth requires knowledge and care.

Failure to thrive commonly arises without medical causes. In such cases the family is often blamed for emotional or psychosocial deprivation. Because of the negative connotation of the term failure to thrive, many clinicians prefer to use more neutral terms such as pediatric undernutrition. The term failure to thrive is used in developed countries. In developing countries, on the other hand, the term more often used is protein-energy malnutrition, and the emphasis is on alleviating poverty and increasing food supplies. These two traditions could learn from each other.


Causative Factors

A basic lack—and maldistribution—of food is the major factor in undernutrition in developing countries. Even in wealthy countries, however, food may not be readily available to all people, especially the poor. Surveys in the United States have shown that as many as 12 percent of households experience inadequate access to food at some time during a year.

Cultural beliefs and practices around the world influence young children's nutritional intake. Cultures differ with respect to the nutritional value of foods given to children of different ages, prestige and status of food types, healing values that people attribute to food, religious customs such as fasting, who is responsible for feeding children, caregiver versus child control of eating, and toddler-weaning practices (Sturm and Gahagan 1999). Even in developing countries where poverty is widespread, nutrient intake can be affected by differences in cultural norms and parents' beliefs.

Families' choices of foods for their infants may impair their nutrition. For example, parents may give soda pop or too much fruit juice, so that infants take less milk and solid foods. Some parents, in an effort to be healthy by avoiding fat in their diet, unduly limit their infants' intake of fat, which is especially needed in the first two years for brain and bodily growth.

Infants may themselves have difficulties in feeding. These difficulties may be obvious in infants with problems in moving the body, like cerebral palsy, or they may be subtle in children who have trouble chewing and swallowing. Such children may, for example, lose excessive amounts of food or milk from the mouth, pocket food in the mouth, be unable to move their tongues well, or refuse foods with rough textures. Children's eating behavior can also contribute to poor intake and is often a focus of parental concern. Probably the most common behavioral problem is food refusal, in which children close their mouths, turn their faces away, and cry. All these factors can make meals take a long time.

During the first two years, infant-parent relationships change, and so does child feeding. During the first two months, parents help babies establish a regular schedule of eating and sleeping. If parents do not learn to tell when a baby wants to be awake or asleep, or is hungry or full, the baby many not get enough milk or formula. Between approximately three and eight months, babies look for more social interaction with their caretakers. If parents have trouble recognizing, interpreting, or responding appropriately to their cues, feeding may be affected. At the end of the first year and during the second year, babies seek more and more independence from their parents during feeding and other parts of everyday life. This process of psychological separation and individuation may lead to control struggles over the child's becoming an autonomous self-feeder (Birch 1999; Satter 1987).

Lack of daily structure can result in an absence of predictable mealtime and sleep routines, two processes intrinsically interrelated for babies and toddlers (Yoos, Kitzman, and Cole 1999). Toddlers who are allowed to snack and drink caloric beverages without a reliable schedule of mealtimes and snacks may not develop the internal cycles of hunger and satiety that are the basis for self-regulation of eating and good growth. Adequate amounts of sleep at night and daytime naps are necessary for the child to attend to the task of eating during meals. Appetite can be limited because of inappropriate timing and size of meals across the day (Kedesdy and Budd 1998).

Many aspects of family functioning can affect how much a child eats and the nutritional value of what is eaten. Within the family unit, general life stressors and worries can interfere with the primary caretakers' ability to monitor the child's nutritional intake, to provide regular meals, and to respond attentively and sensitively during meals (e.g., with encouragement and praise). Parental psychological disorders, family interaction problems such as marital conflict, and problems in parent-child relationships can impair caloric intake. Although research has been inconclusive as to whether there are more psychiatric problems in parents of babies with failure to thrive compared to parents of babies with normal growth, clinical case reports indicate that such problems can damage the feeding relationship. Maternal depression, social isolation, alcohol use and substance abuse, domestic violence, and a history of problematic parental childhood can make it harder for parents to have good relationships with their young children (Drotar and Robinson 2000).

Infants with low birth weight (less than 5.5 pounds or 2500 grams) start out life small and are more likely than others to be small later on. If their growth rate is normal, there may be no problem, although it is important to make sure they receive good nutrition. Many illnesses can impair children's growth. Most of those illnesses are common infectious diseases, such as repeated ear infections, respiratory infections, and diarrhea. Less commonly, infants may gain weight poorly because they have a cleft palate, their intestines fail to absorb nutrients, stomach contents slide up the esophagus (gastroesophageal reflux), or they have a long-term medical disorder like Down's syndrome or fetal alcohol syndrome.


Effects of Failure to Thrive

Studies in developing countries have shown that poor nutrition in early childhood leads to problems in cognitive functioning. Attention, self-regulatory skills for self-control, organizational skills, and performance on tests of cognitive functions and academic skills all appear to be vulnerable to the effects of malnutrition. The link between early, severe malnutrition and long-term deficits in emotional and cognitive development appears to extend into adolescence (Galler and Ramsey 1989). Research from industrialized countries where milder undernutrition is more typical suggests that it places young children at risk for developmental delays in all areas of development. At the time of the undernutrition, babies and toddlers typically score lower than well-nourished counterparts on tests of development, may have more behavioral feeding problems, are more likely to be insecurely attached to their mothers, and may show altered social responsiveness and irritability (Benoit 2000). Long-term effects of early failure to thrive have not been extensively studied, and the findings thus far are inconsistent. Some studies show little difference in cognitive and academic functioning between children with prior failure to thrive and well-nourished comparison children, whereas others indicate continued school-related difficulties and problems with behavior and personality development. It is important, in looking toward a child's future, to recognize that many other factors besides nutrition influence development (Shonkoff and Phillips 2000).

Undernutrition can limit long-term growth, which is why middle-aged and elderly people from developing countries are often short. In the United States, children from families below the federal poverty level are one to two centimeters shorter than children from families above it. Stunted children are likely to become stunted adults (Institute of Medicine 1996). Undernutrition can weaken the body's defense against infection; conversely, infection can impair nutrition. These effects are especially serious in developing countries, but in developed countries they are also important with certain chronic illnesses, such as cystic fibrosis and acquired immunodeficiency syndrome (AIDS).


Evaluation and Treatment

An initial assessment is important for planning treatment and is best accomplished by a multidisciplinary team that can continue to provide long-term follow-up care to the family (Frank and Drotar 1994). A detailed review of what the child eats and drinks provides basic information. Parent-child feeding interactions and the child's feeding behavior and oral-motor skills should be evaluated. Psychosocial evaluation should include information from all of the child's caretakers (e.g., child care staff, relatives), the family, and the child. Assessment of the family environment should include the caretakers' cultural beliefs, psychological functioning, family stressors, and social supports and community resources that can be used on the child's behalf.

Intervention should be guided by the family needs identified in the evaluation. Treatment is typically multifaceted and requires good interdisciplinary and interagency collaboration (Black 1995). Parents may obtain advice about increasing calories in the child's diet. They may be given iron or zinc supplements for their child if needed. Any medical or physical problems the child has are treated. Parents may get advice about managing children's behavior during mealtime; they can often benefit from coaching around viewing videotapes of feedings. Much of the treatment can be done in the home. Referral for early intervention services may aid the child's general development. Helping families access community-based resources from government programs should be a priority with low-income families. In the United States those include the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and the Food Stamp program (Baer 1999). In the event of severe malnutrition or failure of intensive outpatient intervention, pediatric hospitalization may be justified. Parental mental health and substance-abuse problems usually require individual attention. In the minority of cases that involve neglect or abuse, intervention by child protective services may be necessary to protect the child's physical and developmental well-being. With comprehensive evaluation and treatment, most undernourished children improve their nutritional status, growth, and development.

Public Policy

Governmental policies can improve maternal and child nutrition through public programs. In the United States, for example, in 2001 the WIC program served seven million participants at a cost of $4 billion. Programs to promote maternal nutrition and breast feeding can help to prevent undernutrition in children. Governmental policies can also help families buy food by providing money. All industrialized countries except the United States provide family allowances to parents to help with the costs of raising children. Many countries subsidize housing; cash benefits for maternity are available in more than 100 countries (Kamerman 1996). Such approaches indirectly help families feed their children. Provision of good nutrition to infants and young children is a basic responsibility of society. As Sir Winston Churchill said in 1943, "There is no finer investment for any community than putting milk into babies."


See also:Child Abuse: Physical Abuse and Neglect; Childhood, Stages of: Infancy; Childhood, Stages of: Toddlerhood; Development: Cognitive; Development: Emotional; Family Policy; Food; Orphans; Poverty


Bibliography

baer, m. t. (1999). "community food and nutrition programs." in failure to thrive and pediatric undernutrition: a transdisciplinary approach, ed. d. b. kessler and p. dawson. baltimore, md: paul h. brookes.

benoit, d. (2000). "feeding disorders, failure to thrive, and obesity." in handbook of infant mental health, 2nd edition, ed. c. h. zeanah, jr. new york: guilford press.

birch, m. (1999). "psychological issues and infant-parentpsychotherapy." in failure to thrive and pediatric undernutrition: a transdisciplinary approach, ed. d. b. kessler and p. dawson. baltimore, md: paul h. brookes.

black, m. (1995). "failure to thrive: strategies for evaluation and intervention." school psychology review 24:171–185.

churchill, w. (1943). quoted in the oxford dictionary ofquotations, 4th edition, ed. a. partington. oxford, uk: oxford university press, 1992.

corrales, k. m., and utter, s. l. (1999). "failure to thrive."in handbook of pediatric nutrition, 2nd edition, ed. p. q. samour, k. k. helm, and c. e. lang. gaithersburg, md: aspen.

drotar, d., and robinson, j. (2000). "developmental psychopathology of failure to thrive." in handbook of developmental psychopathology, 2nd edition, ed. a. j. sameroff, m. lewis, and s. m. miller. new york: kluwer academic/plenum.

frank, d. a., and drotar, d. (1994). "failure to thrive." inchild abuse: medical diagnosis and management, ed. r. reece. philadelphia: lean and febiger.

frank, d. a.; silva, m.; and needlman, r. (1993). "failure to thrive: mystery, myth, and method." contemporary pediatrics (february):114–133.

galler, j. r., and ramsey, f. (1989). "a followup study of the influence of early malnutrition on development: behavior at home and school." journal of the american academy of child and adolescent psychiatry 28:254–261.

institute of medicine. (1996). wic nutrition risk criteria:a scientific assessment. washington, dc: national academy press.

kamerman, s. b. (1996). "child and family policies: aninternational overview." in children, families, and government: preparing for the twenty-first century, ed. e. f. zigler, s. l. kagan, and n. w. hall. cambridge, uk: cambridge university press.

kedesdy, j. h., and budd, k. s. (1998). childhood feeding disorders: biobehavioral assessment and intervention. baltimore, md: paul h. brookes.

kessler, d. p., and dawson, p. (1999). failure to thrive and pediatric undernutrition: a transdisciplinary approach. baltimore, md: paul h. brookes.

lieberman, a. f.; silverman, r.; and pawl, j. h. (2000)."infant-parent psychotherapy." in handbook of infant mental health, 2nd edition, ed. c. h. zeanah, jr. new york: guilford press.

satter, e. (1987). how to get your kid to eat . . . but nottoo much. palo alto, ca: bull publishing.

shonkoff, j. p., and phillips, d. a. (2000). from neurons to neighborhoods: the science of early childhood development. washington, dc: national academy press.

sturm, l., and gahagan, s. (1999). "cultural issues inprovider-parent relationships." in failure to thrive and undernutrition: a transdisciplinary approach, ed. d. b. kessler and p. dawson. baltimore, md: paul h. brookes.

yoos, h. l.; kitzman, h.; and cole, r. (1999). "familyroutines and the feeding process." in failure to thrive and undernutrition: a transdisciplinary approach, ed. d. b. kessler and p. dawson. baltimore, md: paul h. brookes.

peter dawson

lynne sturm

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Failure to Thrive

Failure to thrive

Definition

Failure to thrive (FTT) is a term used to describe children whose physical growth over time is inadequate when compared to a standard growth chart.

Description

There is no universally accepted definition of failure to thrive, though it has been recognized as a medical condition since the early 1900s. It describes a condition rather than a specific disease. Children are considered as failing to thrive when their rate of growth does not meet the expected growth rate for a child their age. The difficulty lies in knowing what rate of growth is expected for any individual child, since many factors, including race and genetics, may influence growth.

Recognizing abnormal growth requires an understanding of normal infant growth. Infants normally lose up to 10 percent of their weight in the first few days of life. However, this weight should be regained within two weeks. The average full-term baby doubles its birth weight by six months and has tripled it by one year. Children with failure to thrive are often not meeting those milestones. If a baby continues to lose weight or does not gain weight as expected, he or she is probably not thriving.

Children who fail to thrive are either not receiving or have an inability to take in or retain adequate nutrition in order to gain weight and grow. If the condition progresses, the undernourished child may become irritable and/or apathetic and may not reach typical developmental markers such as sitting up, walking, and talking at the usual ages.

Demographics

The incidence of growth failure of American children is difficult to assess. Failure to thrive is believed to affect up to 5 percent of the population but is most common in the first six months of a child's life. It is commonly seen in babies born prematurely. Most diagnoses of failure to thrive are made in infants and toddlers in the first few years of life. An estimated 10 percent of children seen in primary care settings have symptoms of failure to thrive. The condition can appear in all socioeconomic groups, although it is seen more frequently in those families experiencing poverty. There is an increased incidence among children receiving Medicaid, those living in rural areas, and in children who are homeless.

Causes and symptoms

Failure to thrive may have several underlying causes. The causes of failure to thrive are typically differentiated into organic and non-organic. Organic causes are those caused by an underlying medical disorder. Inorganic causes are those caused by a caregiver's actions. However, these definitions are simplified, as both medical and behavioral causes often appear together.

Organic causes of failure to thrive may include:

  • premature birth, especially if the fetus had intrauterine growth retardation
  • maternal smoking , alcohol use, or illicit drugs during pregnancy
  • mechanical problems present, resulting from a poor ability to suck or swallow, for example, presence of cleft lip and cleft palate
  • unexplained poor appetites that are unrelated to mechanical problems or structural abnormalities, for example, breathing difficulties that can result from congestive heart failure (Any difficulty in breathing makes eating more difficult and can result in FTT. Inadequate intake also can result from metabolic abnormalities, excessive vomiting caused by obstruction of the gastrointestinal tract, or kidney dysfunction. In addition, gastroesophageal reflux causing regurgitation of formula or refusal of feeding.)
  • poor absorption of food, inability of the body to use absorbed nutrients, or increased loss of nutrients

Some examples of non-organic causes of failure to thrive are:

  • poor feeding skills on the part of the parent
  • dysfunctional family interactions
  • difficult parent-child interactions
  • lack of social support
  • lack of parenting preparation
  • family dysfunction, such as abuse or divorce
  • child neglect
  • emotional deprivation

Studies show that only between 5 percent and 26 percent of FTT cases are due to a purely organic cause. Children in abusive or neglectful families are at higher risk of FTT, but these cases make up only a small proportion of the total. The most common cause of failure to thrive is malnutrition , either as part of an organic problem or simply because of an energy imbalance.

The following symptoms are possible indications of failure to thrive:

  • delayed social and mental skills
  • delayed development of secondary sexual traits in adolescents
  • height, weight, and head circumference in an infant or young child not progressing as expected on growth charts
  • edema (swelling)
  • wasting
  • enlarged liver
  • rashes or changes in the skin
  • changes in hair texture

When to call the doctor

Parents should notify their physician if their child does not seem to be developing at a normal pace. If parents notice a drop in weight or if the baby does not want to eat, the doctor should be notified. A major change in eating patterns also warrants contact.

Diagnosis

If a child fails to gain weight for three months in a row during the first year of life, physicians normally become concerned. The most important part of a physician's evaluation is taking a detailed history. Prenatal history is important, and the doctor will want to know if the pregnant mother smoked, consumed alcohol, used any medications, or had any illness during the pregnancy. The doctor will also want a dietary history, to determine if there have been any feeding problems. A history of how formula is mixed is important, because improperly prepared formula can result in failure to thrive. Parents will also be asked about whether the child had any illnesses, as some can cause a problem with the growth potential of children. A family and social history will also be done.

Doctors diagnose failure to thrive by plotting the child's weight, length, and head circumference on standard growth charts. Children who fall below a particular weight range for their age or who dip below two or more percentile curves on the chart over a short period of time will likely have a more thorough evaluation to find out if there is a problem. A complete blood count, various serum chemical and electrolyte tests, and a urinalysis may be helpful in discovering any underlying medical disorders. The doctor will want to determine if the child is receiving enough nourishment. To do this, the parents will be asked to record what the child eats each day, and a subsequent calorie count will be done. The doctor may also talk to the parents to help identify any home problems like financial difficulties, household stress, or neglect.

It is important to remember that some children will normally fall below the standards on growth charts. If children are full of energy, interacting normally with their parents, and show no signs of illness, then they are probably not failing to thrive and are just smaller children.

Once the diagnosis of failure to thrive has been made, the physician will attempt to determine if it is from an organic or non-organic cause.

Treatment

Because there are numerous factors that may contribute to a failure to thrive diagnosis, children diagnosed with the disorder sometimes have an entire medical team working on the case. If there is an underlying physical cause, correcting that problem may reverse the condition. The doctor will recommend high-calorie foods and place the child on a high-density formula like Pediasure. More severe cases may involve tube feedings, which can take place at home. A child with extreme failure to thrive may need hospitalization , during which he or she can be fed and monitored continuously. This will give the treatment team an opportunity to also observe the caregiver's interactions with the child.

The duration of treatment will vary from child to child. Weight gain takes time, so several months may go by before a child returns to his normal weight range. Children requiring hospitalization usually stay for approximately two weeks or more to get them out of danger, but many months can pass before the symptoms of malnutrition disappear.

Nutritional concerns

The long-term goal for every child with FTT is to provide adequate energy intake for growth. Therefore, even if no causative factor is uncovered for a child with FTT, aggressive dietary management is the key to successful treatment. Proper feeding can be achieved through infant formulas that are adjusted to meet the child's specific nutrient needs. Infants may be given concentrated formulas, assuming their kidney function is normal. In cases of kidney disorders, increasing the fat content of the formula may be useful as a way of delivering additional calories. Older children with FTT may benefit from adding cheese, sour cream, butter, margarine, or peanut butter to meals. Also, high-calorie shakes can be used to supplement meals. Multivitamin and mineral supplements, including iron and zinc, usually are recommended to all undernourished children. Tube feeding is usually not indicated except for severe cases of malnutrition.

Prognosis

Whether FTT results from organic or non-organic reasons, children with this condition require aggressive calorie supplementation. Some cases may lead to significant developmental delays in children. The cognitive outcome of children who have had FTT is not clear, and this may lead to emotional and behavioral problems later. However, carefully looking for the causes of failure to thrive and implementing calorie supplementation is important for obtaining a positive outcome in these children.

Prevention

Initial failure to thrive caused by physical defects cannot be prevented but can often be corrected before they become a danger to the child. Maternal education as well as emotional and economic support systems may help to prevent failure to thrive in those cases where is no physical deformity.

Parental concerns

Parents who note any of the symptoms of failure to thrive should report them to their child's physician so that treatment can begin.

KEY TERMS

Inorganic causes Cases of failure to thrive brought on by a caregiver's actions.

Organic causes Underlying medical or physical disorders causing failure to thrive.

Resources

BOOKS

Bremmer, J. Gavin, et al. The Blackwell Handbook of Infant Development. Oxford, UK: Blackwell Publishing, 2004.

Slater, Alan, et al. Introduction to Infant Development. Oxford, UK: Oxford University Press, 2002.

PERIODICALS

"Failure to Thrive." Update (June 17, 2004): 567.

Krugman, Scott D., and Howard Dubowitz. "Failure to Thrive." American Family Physician 68 (September 1, 2003): 5, 87984.

WEB SITES

Bassali, Reda W., and John Benjamin. "Failure to Thrive." Emedicine, August 11, 2004. Available online at <www.emedicine.com/ped/topic738.htm> (accessed January 11, 2005).

"Failure to Thrive." Kidshealth.org, February 2001. Available online at <www.kidshealth.org/parent/growth/growth/failure_thrive.html> (accessed January 11, 2005).

"Failure to Thrive." MedlinePlus, November 3, 2002. Available online at <www.nlm.nih.gov/medlineplus/ency/article/000991.htm> (accessed January 11, 2005).

Deanna M. Swartout-Corbeil, RN

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Failure to Thrive

Failure to Thrive

Definition

Failure to thrive (FTT) is used to describe a delay in a child's growth or development. It is usually applied to infants and children up to two years of age who do not gain or maintain weight as they should. Failure to thrive is not a specific disease, but rather a cluster of symptoms which may come from a variety of sources.

Description

Shortly after birth most infants loose some weight. After that expected loss, babies should gain weight at a steady and predictable rate. When a baby does not gain weigh as expected, or continues to loose weight, it is not thriving. Failure to thrive may be due to one or more conditions.

Organic failure to thrive (OFTT) implies that the organs involved with digestion and absorption of food are malformed or incomplete so the baby cannot digest its food. Non-organic failure to thrive (NOFTT) is the most common cause of FTT and implies the baby is not receiving enough food due to economic factors or parental neglect, or do to psychosocial problems.

Causes and symptoms

Occasionally, there may be an underlying physical condition that inhibits the baby's ability to take in, digest, or process food. These defects can occur in the esophagus, stomach, small or large intestine, rectum or anus. Usually the defect is an incomplete development of the organ, and it must be surgically corrected. Most physical defects can be detected shortly after birth.

Failure to thrive may also result from lack of available food or the quality of the food offered. This can be due to economic factors in the family, parental beliefs and concepts of nutrition, or neglect of the child. In addition, if the baby is being breast fed, the quality or quantity of the mother's milk may be the source of the problem.

Psychosocial problems, often stemming from a lack of nurturing parent-child relations can lead to a failure to thrive. The child may exhibit poor appetite due to depression from insufficient attention from parents.

Infants and toddlers, whose growth is substantially less than expected, are considered to be suffering from FTT.

Diagnosis

Most babies are weighed at birth and that weight is used as a base line for future well-baby check-ups. If the baby is not gaining weight at a predictable rate, the doctor will do a more extensive examination. If there are no apparent physical deformities in the digestive tract, the doctor will examine the child's environment. As part of that examination, the doctor will look at the family history of height and weight. In addition, the parents will be asked about feedings, illnesses, and family routines. If the mother is breastfeeding the doctor will also evaluate her diet, general health, and well being as it affects the quantity and quality of her milk.

Diagnosis of FTT is confirmed by a positive growth and behavioral response to increased nutrition.

Treatment

If there is an underlying physical reason for failure to thrive, such as a disorder of swallowing mechanism or intestinal problems, correcting that problem should reverse the condition. If the condition is caused by environmental factors, the physician will suggest several ways parents may provide adequate food for the child. Maternal education and parental counseling may also be recommended. In extreme cases, hospitalization or a more nurturing home may be necessary.

Prognosis

The first year of life is important as a foundation for growth and physical and intellectual development in the future. Children with extreme failure to thrive in the first year may never catch up to their peers even if their physical growth improves. In about one third of these extreme cases, mental development remains below normal and roughly half will continue to have psychosocial and eating problems throughout life.

When failure to thrive is identified and corrected early, most children catch up to their peers and remain healthy and well developed.

Prevention

Initial failure to thrive caused by physical defects cannot be prevented but can often be corrected before they become a danger to the child. Maternal education and emotional and economic support systems all help to prevent failure to thrive in those cases where there is no physical deformity.

Resources

ORGANIZATIONS

American Humane Association, Children's Division. 63 Inverness Drive East, Englewood, CO 80112-5117. (800) 227-4645. www.americanhumane.org.

Federation for Children With Special Needs. 1135 Tremont Street, Suite 420, Boston, MA 02120. (617) 236-7210. http://www.fcsn.org.

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892-3570. (800) 891-5389. http://www.niddk.nih.gov/health/digest/nddic.htm.

KEY TERMS

Esophagus The muscular tube which connects the mouth and stomach.

Psychosocial A term referring to the mind's ability to, consciously or unconsciously, adjust and relate the body to its social environment.

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Failure to Thrive

Failure to Thrive

Failure to thrive is a term used to describe infants and young children who are not growing or are losing weight due to malnutrition , neglect, abuse, or medical conditions. In failure to thrive, the child may have a low body weight (below the third percentile for the child's age), a low height for age, or a small head circumference. A child with failure to thrive is not eating or being offered enough calories to meet his or her nutritional needs. Besides impaired growth, other symptoms include tiredness, sleeplessness, irritability, lethargy, resistance to eating, vomiting, and problems with elimination. The child may be suffering from an illness, medical condition, or recurring infections; taking medications; or come from a poor, distressed, or socially isolated family. To attain normal growth levels, a child with this condition requires from 1.5 to 2 times the normal amount of calories.

see also Infant Nutrition.

Heidi J. Silver

Bibliography

Bithoney, W. G.; Dubowitz, H.; and Egan, H. (1992). "Failure to Thrive/Growth Deficiency." Pediatrics in Review 13:453460.

Schwartz, D. (2000). "Failure to Thrive: An Old Nemesis in the New Millennium." Pediatrics in Review 21:257264.

Internet Resource

American Academy of Pediatrics. "Failure To Thrive." <http://www.medem.com>

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failure to thrive

failure to thrive (FTT) (fayl-yer tŏ thryv) n. failure of an infant to grow satisfactorily compared with the average for that community. It is detected by regular measurements and plotting on centile charts. It can be the first indication of a serious underlying condition, such as kidney or heart disease or malabsorption, or it may result from problems at home, particularly nonaccidental injury.

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Failure to Thrive

FAILURE TO THRIVE

Children who fail to grow properly have always existed. In earlier times when many children did not survive the first few years, small or sickly children were a fact of life. More recently, medicine has increasingly turned its attention to the unique problems of children, among them the problems of growth failure and most interestingly to the problem of malnutrition and growth failure in children without obvious organic illness. The case of so-called nonorganic failure to thrive, growth failure without apparent medical cause, is the main focus of this discussion.

The medical concept of "failure to thrive" in infants and young children dates back about a century.L. Emmett Holt's 1897 edition of Diseases of Infancy and Childhood included a discussion of a child who "ceased to thrive." Chapin correctly recognized in 1908 that growth failure was primarily caused by malnutrition, but that temporarily correcting caloric in-take and improving growth often proved futile after the child returned to her (often impoverished) environment. By 1933 the term "failure to thrive" formally entered the medical literature in the tenth edition of Holt's text.

Failure to thrive is not a discreet diagnosis or a single medical condition (such as chicken pox), but rather a sign of illness or abnormal function (as a rash or fever may be a sign of chicken pox virus infection). In infants and young children, the term "failure to thrive" is most broadly defined as physical growth that for whatever reason falls short of what is expected of a normal, healthy child. Statistical norms have been published for the growth patterns of normal children. Plotting a child's height, weight, and head circumference on such charts yields valuable diagnostic information. In children younger than age two, inadequate growth may be defined as falling below the third or fifth percentile for the age, where weight is less than 80 percent of the ideal weight for the age, or where weight crosses two major percentiles sequentially downward on a standardized growth chart.

The concept of failure to thrive, however, encompasses not just disturbances of the more obvious aspects of physical development but the more subtle aspects of psychosocial development in infancy and early childhood. "Thriving" is a concept that implies that a child not only grows physically in accordance with published norms for age and sex, but also exhibits the characteristics of normal progress of developmental milestones in all spheres—neurological, psychosocial, and emotional.

Early observations that an organic illness could not be found in many cases of failure to thrive led to the categorization of failure to thrive into the subclasses of organic and nonorganic causal factors. This classification ultimately proved too simplistic, both organic and environmental factors acting together may cause poor growth, but it served to sharpen thinking about the nonorganic causes.

Organic versus Nonorganic Failure to Thrive

Organic failure to thrive is that caused by the harmful effects on growth of organic disease. Growth failure can be an extremely sensitive marker for unsuspected systemic disease, revealing illness long before it would normally be detected. Likewise, the progress of therapy is often dramatically mirrored by improvement in growth. Any significant illness in an infant or young child can cause growth failure. Thus growth failure alone alerts the physician to search for possible medical causes. Nevertheless, the search for organic disease in young children with an initial diagnosis of failure to thrive most often finds no physical (organic) condition to explain the growth failure; the failure is therefore termed nonorganic.

The modern understanding of this disorder views it as a fundamental failure of maternal-infant attachment. In fact, it is referred to in psychiatric literature as feeding disorder of attachment, as well as maternal deprivation, deprivation dwarfism, and psychosocial deprivation. Nonorganic failure to thrive reflects a failed relationship between a mother and her infant during the first year of life. Its chief characteristic is a lack of engagement or bonding between mother and infant in the daily routine of care, most dramatically with respect to feeding.

Diagnosis

Nonorganic failure to thrive can be understood in terms of both physical and emotional deprivation of the child, and has both physical and behavioral signs. Caloric deprivation of an infant may be caused more or less innocently by lactation failure, extreme poverty, parental ignorance of proper infant feeding, or strange nutritional beliefs. Parents of children with nonorganic failure to thrive, however, typically give a history of adequate or often exaggerated amounts of nutritional intake belied by the child's obvious malnourished state.

By interviewing and observing the mother, it is noted that feedings are marked by a lack of the mutual pleasurable relationship of giving and receiving that is the hallmark of normal feedings. In contrast, the mother may admit that she props the bottle or even sometimes forgets regular feedings.

There may be other evidence of poor caregiving and physical neglect, such as unwashed skin, diaper rash, skin infections, and dirty clothing. The back of the baby's head may be flat with a bald patch over the flattened area, implying that the child is left unattended for long periods of time lying on his back in the crib. The baby may exhibit a lack of appropriate social responsiveness, with an expressionless face and classic avoidance of eye contact. Normal vocal responses, such as cooing and blowing raspberries, may be absent. In children older than five months, there may be no anticipatory reaching for interesting objects. Motor milestones may be delayed. When held, instead of cuddling normally, the baby characteristically arches his back and scissors his legs, or lies limp as a rag doll in the examiner's arms. By contrast, babies with organic failure to thrive typically do not show the characteristic withdrawal behaviors of non-organic failure to thrive infants, and respond best to their mothers.

Prominent features in the mother's history may include symptoms of acute or chronic depression, personality disorder, substance abuse, and a generally high level of psychosocial stress related to poverty, social isolation, or spousal abuse. Often the mother was abused or neglected as a child, producing an apparently transgenerational pattern of insecure attachment. Parents of infants with nonorganic failure to thrive are often initially evasive. They usually take the baby to an emergency room for another illness, whereupon the baby's malnutrition attracts attention. Upon the child's admission to the hospital, the parents may disappear for several days.

Treatment

Inpatient investigation and initial treatment is warranted for infants under a year in the following cases: when the infant is suffering from more severe growth failure; when there are signs of emotional deprivation; when the parents have not sought medical intervention; when the infant shows signs of physical abuse; when the infant's hygiene has been seriously neglected; when the mother appears severely disturbed or is abusing drugs or alcohol or is living a chaotic lifestyle overwhelmed with stresses; or when the mother-infant interaction appears uncaring and includes feelings of anger.

During hospitalization, a primary-care nurse is assigned to establish a warm and nurturing relationship with the baby. The baby typically begins to blossom in its social interactions and rapidly gains weight. As the baby begins to improve both in terms of weight gain and psychosocially, hospital personnel can help the mother engage with her baby, teaching her to receive and express the mutual signals of mother-infant bonding. Understanding and addressing the mother's needs for emotional support and encouragement is essential to rehabilitating the mother-infant relationship. The degree to which parents are aware of the cause of the problem and actively cooperate in their baby's reattachment has been found to be predictive of the long-term outcome. Appropriate referrals to child protective services agencies must be made both to ensure the child's continued safety and to monitor the efforts to help the parents learn needed skills.

Long-Term Prognosis for Recovery

Severe nonorganic failure to thrive is a potentially fatal illness. Nutritional deprivation can lead to death from starvation or overwhelming infection due to a weakened immune system. With detection and intervention, infants can in some cases recover from the effects of their condition. Brain size as measured by head circumference may be permanently reduced, especially if the failure to thrive occurred in the first six months of life. During this time of its most rapid growth, the brain is very susceptible to permanent damage from the effects of poor nutrition.

Later emotional and learning problems are common in these children. A 1988 Case Western Reserve University study found that the mean IQ score for three-year-old children with a prior history of failure to thrive was 85. A follow-up study of children from this group showed that even those who subsequently participated in early intervention programs had problems of personality development, deficient problem-solving skills, and more behavioral problems in general as compared to the controls. These problems included impulse control, gratification delay, and the ability to adapt behaviorally to new situations. An Israeli study found that at age five, about 11.5 percent of children with a history of failure to thrive had some manifestations of developmental delay, compared with no delays in the control children. They likewise found an 18 percent incidence of poor school performance compared with a 3.3 percent rate in the control group. Another follow-up study of children diagnosed with nonorganic failure to thrive found that at age six, half of the children in the study sample of twenty-one had abnormal personalities and two-thirds learned to read at a later-than-normal age. Two of the twenty-one had died under suspicious circumstances, pointing up the vulnerability of children with psychosocial failure to thrive. Another study determined that out of fifteen children initially diagnosed with growth failure caused by emotional deprivation, only two were functioning well three to eleven years after diagnosis. Infants hospitalized with failure to thrive prior to six months of age exhibited decreased cognitive development, despite long-term outreach intervention programs. Earlier age of onset of growth failure, lower maternal education level, and lower family income all predicted lower cognitive level.

Summary

Failure to thrive in young children represents significantly suboptimal growth due to intrinsic medical (organic) or environmental (nonorganic) factors. Nonorganic failure to thrive in particular represents a recognizable syndrome of poor growth in infants and young children with specific diagnostic features. Nonorganic failure to thrive in early infancy poses a significant risk of adverse long-term developmental effects.

See also:MILESTONES OF DEVELOPMENT; RESILIENCY

Bibliography

Berwick, D. "Nonorganic Failure to Thrive." Pediatrics in Review 1(1980):265-270.

Berwick, D., J. C. Levy, and R. Kleinerman. "Failure to Thrive: Diagnostic Yield of Hospitalization." Archives of Disease in Childhood 57 (1982):347-351.

Bithoney, William, Howard Dubowitz, and H. Egan. "Failure toThrive/Growth Deficiency."Pediatrics in Review 13 (1992):453-459.

Casey, P. "Failure to Thrive." In M. Levine, W. Carey, and A. Crocker eds., Developmental-Behavioral Pediatrics. Philadelphia: Saunders, 1992.

Drotar, D., and L. Sturm. "Prediction of Intellectual Development in Young Children with Early Histories of Nonorganic Failure to Thrive." Journal of Pediatric Psychiatry 13 (1988):281-296.

Frank, D. A., and Susan H. Zeisel. "Failure to Thrive."Pediatric Clinics of North America 35 (1988):1187-1206.

Gahagan, S., and R. Holmes. "A Stepwise Approach to Evaluation of Undernutrition and Failure to Thrive." Pediatric Clinics of North America 45 (1998):169-187.

Ramsay, M., E. Gisel, and M. Boutry. "Nonorganic Failure toThrive: Growth Failure Secondary to Feeding Skills Disorder."Developmental Medicine and Child Neurology 35 (1993):285-297.

Schwatrz, I. David. "Failure to Thrive: An Old Nemesis in the New Millennium." Pediatrics in Review 21 (2000):257-264.

Skuse, D., A. Pickles, D. Wolke, and S. Reilly. "Postnatal Growth and Mental Development: Evidence for a 'Sensitive Period."' Journal of Child Psychology and Psychiatry 35 (1994):521-545.

Zenel, Joseph. "Failure to Thrive: A General Pediatrician's Perspective." Pediatrics in Review 18 (1997):371-378.

Jeffrey W.Hull

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