Introduction
For many clinicians, dealing with a child who is failing to thrive can invoke a complex assortment of emotions, ranging from dread to excitement. Dread arises because the evaluation and management of these children can be time-consuming, confusing, and sometimes unsatisfactory in terms of clear diagnoses, immediate results, and long-term outcomes; excitement because of the necessity to solve a possibly complex diagnostic puzzle, the potential to effect change, and the hope for a positive long-term results. This chapter discusses the history of failure to thrive (FTT) as a concept, definitions, etiology, treatment, and outcome in an attempt to move clinicians toward a clearer understanding of this often complex condition.
Early pediatric textbooks in the United States provided descriptions of malnutrition, infantile atrophy, and athrepsia that are recognizable today as FTT. Authors speculated on etiologies, recognizing that in some cases there was no clear evidence of a medical disease causing poor growth. The terms hospitalism and anaclitic depression were used by René Spitz in the 1940s to describe both the physical and psychological effects of institutionalization and lack of a primary caregiver. , Although Spitz used these terms to describe problems more far-reaching than simple growth difficulties, he recognized the environmental effects on growth and development, the importance of a primary caregiver in the life of an infant, and the idea that psychiatric disorders can have their origins in early childhood.
Spitz’s work in part led to the term maternal deprivation syndrome , used to describe poor growth in young children living in their own homes, but with mothers who for various reasons could not meet the children’s needs. This concept acknowledged the role of children’s emotional and social environments in their growth and development. However, the assignment of blame to a parent, specifically a mother, could inhibit clinicians’ searching for the often multifactorial etiologies of FTT and inappropriately label caregivers. Two decades ago this emphasis on parental culpability was called erroneous, but “maternal deprivation syndrome” can still be found as a synonym for nonorganic FTT today.
The term nonorganic failure to thrive has become a catchall term to describe growth failure in the absence of a major acute or chronic medical illness. With the background of Spitz’s work, children with poor growth might immediately be suspected of having deficient psychosocial environments, especially as it relates to parenting. In part to avoid this rush to inappropriate diagnosis and judgment, in part to recognize the transactional nature of the disorder, and in part to recognize that the main defect in these children is poor physical growth caused by lack of appropriate nutrition, several other terms have been suggested as replacements of what some feel is an obsolete description. Various suggested terms include pediatric undernutrition, inadequate growth, growth failure, growth deficiency, growth faltering, and failure to gain weight . Replacement of the word failure is particularly desirable because of its pejorative nature ; others believe faltering growth implies something less severe or persistent than FTT.
Definition
Notwithstanding the concerns just mentioned, the term failure to thrive (FTT) will be used throughout this chapter, as well as some of the other terms mentioned. As for defining FTT, there is no accepted “gold standard” in the medical literature. Although the early precursors of FTT such as anaclitic depression included both growth and developmental factors in their descriptions, FTT is almost universally defined only in terms of physical growth. At its most basic, it means postnatal physical growth that deviates from the norm. The use of anthropometric indices to define FTT is critical, but highly variable. Two commonly used criteria are weight (or weight-for-height) less than 2 standard deviations below the mean for age and sex, and/or a weight curve that has crossed more than two major percentile lines on standard growth charts after the child had achieved a previously stable pattern. Even these apparently straightforward definitions are subject to interpretation, and they each evaluate a different aspect of children’s growth. The first considers attained growth, a one-time measurement, whereas the second deals with growth velocity.
Different researchers and clinicians have used various definitions for growth failure when considering only the attained growth of a child as a static measure, and each method has limitations. When evaluating weight according to age and sex, varying growth charts allow clinicians to use either the fifth or the third percentiles as cutoffs. The use of Z-scores, based on standard deviations, is a similar method. However, designating as abnormal all of the lowest-weighing children for a specific age and sex is an oversimplification, since many of those children will in fact be normal but small. When a clearly undernourished child is being evaluated, however, expression of the weight as a percentage of median weight-for-age can be used to assess the severity of the malnutrition. Instead of using only weight-for-age, some undernourished children are identified based on their weight-for-height being less than the fifth or third percentile. This too is not ideal as a solitary measurement, since some normal, petite children will be inappropriately labeled, whereas other children whose height growth is stunted because of chronic malnutrition will not be identified. For example, children with kwashiorkor and the edema that arises from protein malnutrition can fall within the normal range of weight-for-height percentiles. The 2000 CDC edition of growth charts includes norms for body mass index (BMI), which is now being evaluated as an assessment tool to evaluate growth failure. ,
Assessing growth velocity relies on the availability of more than one measurement, providing a more dynamic view of a child’s growth. When available, multiple measurements can detect a fall-off in weight-for-age by two major percentile channels, as well as changes in the child’s weight-for-height. In addition, repeated measurements allow for assessment of the daily growth rate that can be compared with normative values found in incremental tables such as those developed by Guo et al. Evaluating growth velocity can also allow for adjustment based upon conditional weight gain, consistent with the normal statistical phenomenon of regression to the mean. This tendency for weights either at the low or high end to become less extreme could lead to some children being inappropriately labeled as failing to thrive, so conditional reference charts have been developed. Conditional weight gain can also be calculated using the “Thrive Index” in which changes in weight Z scores from birth to a later age are adjusted for regression to the mean. This method and the conditional reference charts are predominantly used in the United Kingdom rather than the United States, just as Z scores based on standard deviations rather than percentiles are also used more commonly abroad.
Having multiple measurements to assess growth velocity is not always possible, given our highly mobile societies and the ability of caregivers to choose multiple sites for medical care, or none at all. In addition, for the most precise assessment, the anthropometric values must be obtained accurately, ideally on the same scale, by the same clinician, and with the young child in the same state of undress at each measurement.
Two reviews of the medical literature verified the problems of defining FTT using anthropometric measurements. Wilcox et al and Olsen performed literature reviews and found that there is no standard definition of FTT, although in Olsen’s review all definitions used anthropometric indicators. In another study, Olsen used seven different anthropometric criteria for FTT to evaluate a birth cohort of 6090 children in Copenhagen. The concurrence among all seven criteria was generally poor, and none of the children identified as FTT met all the criteria. No single measurement on its own was adequate for identifying all cases of growth faltering. Rather than reflecting disagreement among clinicians and researchers, this lack of a gold-standard definition represents the multiple different ways in which childhood undernutrition presents. The existing medical literature on FTT must always be evaluated in this light, especially when comparing studies using different methodologies.
Despite the varying uses of growth charts to evaluate and identify children with FTT, there is a typical progression of change on these charts when children are not gaining weight appropriately. First the weight measurement will show a drop-off from previous percentiles. If the child actually loses weight rather than simply failing to gain appropriately, the drop-off on the growth curve can be precipitous. Actual weight loss, other than that associated with an acute illness or therapeutic diet, is an indicator of pathology and is never normal in young children. A malnourished child will stop normal gains in height once the inadequate weight gain continues for weeks or months, depending upon the severity. Head circumference is the last measurement to show a drop-off. If a child manifests a different pattern, a search for causes besides malnutrition, such as genetic or constitutional issues, is indicated.
Acute malnutrition—when the weight-for-age has dropped to a greater degree than the height-for-age—is called wasting and is associated with a low weight-for-height. Over the longer term, as the height-for-age percentile falls, weight-for-height might normalize. This stunting is one reason that only using the weight-for-height measurement to identify poor growth is insufficient. These stunted children do not always appear malnourished at first glance, since they can seem proportionally normal. Evaluating both weight-for-age and height-for-age can make the difference in correctly identifying growth failure in these children.
Although no clear, consistent definition of FTT exists, malnutrition is the underlying defect in all cases. FTT is therefore only a descriptive term of a child’s condition, rather than a diagnosis. It is the clinician’s duty to determine the often multifactorial etiologies causing this malnutrition; simply identifying a child as failing to thrive is inadequate. A useful analogy is that of abdominal pain. Abdominal pain is a symptom, for which a clinician is obligated to determine the correct etiology. Simply labeling a patient as suffering from abdominal pain without searching for the cause would be inappropriate.
Even though suggestions have been made to abandon the term failure to thrive , there is some utility in its use of the word “thrive.” To thrive generally means to have a flourishing, prosperous state. In many cases, malnourished children are not only growing too slowly, but they are truly not thriving. Even descriptions of malnourished children in early pediatric textbooks discussed their loss of strength, lack of normal development, excessive crying, and later, apathy. Children who are failing to thrive are usually affected in other ways besides growth failure, a fact that is not conveyed by terms such as growth faltering or undernutrition .
Etiology
The possible causes of FTT traditionally have been divided into two main categories: organic and nonorganic. The first referred to malnutrition caused by major illness or organ system dysfunction, whereas the latter was attributed to environmental causes such as hospitalism or the maternal deprivation syndrome. In 1981, Homer and Ludwig recognized that in some cases, FTT was caused by both organic problems and environmental or psychological problems. As more clinicians and researchers began studying FTT, this classification scheme has been rendered obsolete. It is an oversimplification of the often multifactorial etiology of this complex problem and can result in premature, inappropriate labeling of children and/or families. Furthermore, lack of recognition of the complex interplay of different factors will make treatment more difficult, time-consuming, and possibly unsuccessful. Despite these problems with the binary categorization scheme, it continues to be taught to medical professionals and to lay professionals such as child welfare workers and law enforcement personnel. Professionals should be taught that FTT is only a symptom, and that the cause or causes of malnutrition must be sought. In this chapter, the term nonorganic FTT is only used when the medical literature being discussed uses that term specifically.
The Biopsychosocial Model
1n 1977 George Engel presented the biopsychosocial model as a way to understand diseases and illnesses. He advocated that physicians understand not only the biomedical facts of patients’ illnesses, but also the psychological and social aspects. When considering FTT, the biopsychosocial model is critically important to use. The biological, psychological, and social spheres all have the potential to greatly influence a child’s growth and development.
The Biological Sphere
The most obvious problems in the biological sphere contributing to growth failure are those related to major medical illness, either acute or chronic. Even a cursory glance at Table 57-1 (categories of failure to thrive) reveals that multiple ailments can result in FTT. Medical providers sometimes focus all their attention on the search for a major medical illness. However, care must be taken to avoid attributing growth problem in an individual child entirely to a known medical cause. Growth failure can also reflect psychosocial issues. For example, an infant with unrepaired congenital heart disease might fail to thrive not only because of the increased caloric requirement inherent in the disease, but also because the caregivers are noncompliant with medications, are unable to afford special formulas, or are inadequately bonded with their special needs child. Simply treating the biomedical problem in the child will not satisfactorily resolve the growth issues.
| Inadequate Caloric Intake |
| Poor Quality or Caloric Content |
|
| Feeding Difficulties |
|
| Inadequate Absorption and/or Excess Losses |
| Persistent Vomiting |
|
| Gastrointestinal Disease |
|
| Increased Caloric Requirements |
| Cardiorespiratory Disease |
|
| Chronic Infection |
|
| Other |
|
| Defective Utilization |
|
Minor medical problems also fall within the biological realm and are capable of causing FTT. For example, even minor degrees of neurological dysfunction can interfere with a child’s ability to eat and be fed appropriately. , Feeding is a complex process with three phases. Phase one involves the recognition of hunger, acquisition of food, and process of bringing food to the mouth. Phase two includes the preparation of ingested food for swallowing, with safe transfer of the food bolus to the esophagus without aspiration. Phase three is the passage of the food bolus through the esophagus into the stomach and intestines for digestion and absorption. A disruption in any of these phases can result in inadequate growth. In addition to neurological dysfunction, gastrointestinal problems can also interrupt this process. Disorders that cause vomiting, such as “nervous vomiting” and rumination, can cause failure to gain weight and are correctly categorized in the biomedical realm, despite their significant psychosocial components.
Certain prenatal risk factors associated with FTT are most correctly classified in the biological realm. A population-based cohort study found that both parental height and higher parity were risk factors for FTT. An earlier study that excluded children with “organic abnormality that could explain the lack of growth” found that medical complications of pregnancy and the perinatal period correlated significantly with later FTT. These conditions included less weight gain during pregnancy, pregnancy complications, shorter gestations, feeding difficulty in the nursery, and unresolved health questions at hospital discharge.
Low birth weight itself is a risk factor for FTT, with symmetric intrauterine growth retardation carrying a worse prognosis for growth and development than asymmetric intrauterine growth retardation. Low birth weight resulting from prematurity can cause confusion for clinicians. Growth curves should be corrected for prematurity up to 24 months postnatal age for weight, 40 months for height, and 18 months for head circumference. Analysis of growth curves is especially important in these children to avoid either inappropriate labeling as FTT or inappropriate attribution of low weight to prematurity alone. Premature babies are often at risk for neurological, pulmonary, cardiac, and gastrointestinal problems that predispose them to growth failure. Sometimes their problems do not rise to the level of major illnesses, but even minor degrees of dysfunction can cause problems with weight gain.
Postnatally, biological risk factors for poor weight gain include weak sucking in the first 8 weeks of life, the duration of breastfeeding, and difficulty weaning. An obvious postnatal risk factor is medical illness, either acute or chronic. Recurrent infections can cause FTT but can also be a secondary manifestation of immune system dysfunction associated with malnutrition. With each infection the child might lose weight or fail to grow appropriately because of a decrease in appetite, decrease in intake, higher metabolic rate, and/or increased losses caused by vomiting or diarrhea. This creates a vicious cycle in which poor growth causes immune dysfunction, which causes recurrent infections, which causes poor growth.
Elevated lead levels can correlate with impaired growth. These children often have anemia and other nutritional deficits which can enhance lead absorption. They sometimes develop anorexia, causing a decrease in caloric intake. Behavioral issues can also develop, causing further difficulty for the caregivers. In children with elevated lead levels, there are often psychosocial issues at play, which themselves can contribute to their poor growth, inadequate nutrition, and exposure to lead.
The Psychological Sphere
Psychological factors in FTT usually center on the mental health issues of the caregivers, with the mother being the most often studied and evaluated. However, failure to evaluate the child’s contribution is inappropriate and might lead to failure of treatment. Parents affect their children, but children also affect their parents. Each interaction influences future interactions in either a positive or negative direction. The transactional model promulgated by Sameroff and Chandler considers this complex interplay and its effect on the child’s ultimate development. Recognition of this transactional model in part led away from the overly simplistic idea of maternal deprivation syndrome causing FTT, and continues to lead current thinking about growth failure. It is important to consider both the child and the parent when discussing the psychological sphere of the biopsychosocial model of FTT.
A key aspect of the child’s contribution to the transactional model is temperament. This behavioral style is innate in young infants but can be modified by environmental influences as they grow. Components of a child’s temperament include the following: activity level, adaptability, rhythmicity (the level of predictability in a child’s biological functions), distractibility, initial response to stimuli, threshold of responsiveness, intensity, and persistence. , A baby who eats and sleeps on a regular schedule, responds to stimuli in a predictable manner, and is easily soothed would be described as an “easy” baby, whereas one who fusses constantly and unpredictably and does not soothe easily would be harder to parent. Some children’s temperaments are not good “matches” with their parents. For instance, a young infant who sleeps a lot and must be awakened to feed might seem ideal to a depressed mother who only wants to sleep. Although this seems to be a good match for the mother, the infant might not receive appropriate feedings. In addition, as parents modify their responses to a given child’s temperament, they will influence that child’s future behavior.
Some studies looking at temperament in infants with growth failure found more FTT babies classified as difficult, but others provided conflicting views. Darlington and Wright studied 75 infants divided into three groups by their rate of weight gain: slow, average, or fast. Temperament was assessed by a validated survey completed by mothers, which assessed six domains of temperament in different settings. Infants with slow weight gain scored significantly higher than the other groups on the fear dimension, equating to rejection of new objects or persons. Infants with fast weight gain scored higher than the other groups on the distress to limitations domain, meaning they had more negative emotionality and reaction to frustrating situations. It is certainly plausible that the fast-gaining infants were more vocal with their distress, causing the mothers to respond by feeding them. Less vocal infants sometimes suffer relative undernutrition by not expressing their needs. A retrospective case-control study evaluating infants with poor weight gain found that there were no significant differences in temperament between the two groups. However, temperament studies done by maternal report might not be accurate, whereas studies done with observation only capture one point in time rather than the day-to-day behavior of the child.
The contribution of the child to the transactional model can be a cause or a result of growth failure. Although not specific to growth difficulties, children with feeding disorders have been shown to express more negativity and withdrawal and have been described as apathetic, or conversely, fussy and difficult. Irregular sleep patterns, in addition to feeding patterns, have been described in growth deficient children, but the convenience sample was of a small size and all the children had major medical problems that could have confounded both their eating and sleeping behaviors.
Parental ratings of appetite as well as measurements of energy intake have been found to be lower in children with FTT. Although not all children with poor appetites have difficulties with growth, the possibility exists that those children who do have growth problems have some innate differences in eating habits. Of course, children with some nutrient deficiencies develop anorexia, so once FTT is evident, a vicious cycle can ensue.
It is intuitive that parental psychological disturbance will affect the parent–child relationship, and quite possibly the child’s growth and development. Recognizing this possibility is of critical importance, not for the purpose of assigning blame, but rather for offering appropriate treatment.
Evaluation of the psychological contribution of caregivers to FTT has been centered on mothers. The use of the term maternal deprivation syndrome clearly describes the attitudes of clinicians and researchers evaluating children who have FTT without a clear biological etiology. Early studies found a considerable degree of maternal psychopathology in these cases; however, these studies had several methodological flaws calling their conclusions into question. Boddy and Skuse in 1994 published a detailed discussion of the problems with these studies. One problem was retrospective design, in which mothers were evaluated after their children had been identified as nonorganic FTT. The parental characteristics might have been caused in part by the identification of the growth failure. Also, study subjects were often hospitalized children with more severe FTT. The willing and truthful participation of some of these mothers could have been compromised by the labeling of their children, especially if they were under investigation. In addition, some assessments of family functioning were based on parental interviews of uncertain validity and might not have been appropriate for illiterate or less-educated parents. In addition, observation of the mother–child relationship, especially in a hospital setting, might be subject to misinterpretation because people often act differently when their children are hospitalized. ,
Families of children with FTT do not have a higher incidence of overt psychopathology than those of comparison subjects. However, one study with several of the concerning methodological characteristics noted previously showed an extremely high percentage of psychopathology in parents of infants with FTT. Ninety three percent of the mothers and 38% of the fathers showed Axis 1 psychopathology during the first week of their children’s hospital admission. Parents were provided psychotherapy and treatment focused on the parent–infant relationship. Notably, there were significant reductions in psychopathology for both parents when reassessed 3 and 12 months later. The issue of causality is important. How much did the parental psychopathology cause or contribute to the growth failure? How much did the growth failure contribute to the psychopathology? Did the improvement in the parents result from the psychotherapeutic interventions, from the child’s improvement, or both?
Perinatal depression is a common problem, with prevalence rates estimated at roughly 10% in the general population and higher among low-income and ethnic minority women. A case-control study found that 21% of mothers with children falling off the growth curve were in a depressive episode compared with 11% of matched controls. A selection bias in case ascertainment caused some obviously depressed mothers of growth faltering babies not to be referred for study inclusion, meaning the results could have been even more compelling. A prospective study confirmed the association of slow weight gain in infancy with postpartum depression. Again, however, this association does not necessarily indicate causality, since the negative implications of their infants’ growth problems might have exacerbated mood disturbances. Other studies have found that depressive symptoms and affective disorders might be more common in mothers of malnourished children.
Questioning parents about their own childhoods could provide some insight. A prospective study showed a significant correlation between mothers who were physically abused or had negative perceptions of their own childhoods with the development of growth failure in their children. These mothers were also more likely to reject their own mothers as role models. Perhaps this reflects a lack of adequate social or emotional support for the mothers. A case comparison study demonstrated a significantly higher percentage of mothers of children failing to thrive endorsed a history of being abused and/or neglected during childhood. Despite this link between maternal childhood experiences and FTT, the association is neither direct nor inevitable.
Clinicians evaluating children with poor growth often encounter very thin mothers. The possibility exists that some of these mothers are suffering from eating disorders themselves. In two case series, children of mothers with anorexia nervosa or bulimia nervosa had feeding difficulties and/or poor weight gain. , McCann et al studied the eating habits and attitudes of mothers of 26 children referred for evaluation of nonorganic FTT. None of the mothers met diagnostic criteria for either anorexia nervosa or bulimia nervosa, but they did show more dietary restraint than matched controls. Even though the children all had low weight, half of the mothers were restricting the children’s diet of sweets and a third restricted intake of food they felt to be fattening. Another prospective study failed to find an association with maternal dietary restraint and infant weight gain, although this study used a different scale to assess the mothers’ eating attitude.
Children’s food intake might be purposely limited by caregivers because of other psychological issues. The disorder of medical child abuse (previously called Munchausen syndrome by proxy) can present with children failing to thrive for no reason despite extensive medical workup, often demanded by the parent. , Other parents develop a fixed belief that their children suffer from multiple food allergies requiring an extremely limited diet that can cause growth failure. In some cases, double-blinded food challenges under extremely controlled medical conditions are needed to help convince parents otherwise. Some parents place children on nutritionally deficient diets because of concerns about the relationship of food to disorders such as eczema. Other well-intentioned parents sometimes limit their children’s diets because of a misapplication of diets for adults designed to prevent obesity or cardiovascular disease, or simply because of their own history of childhood obesity.
Questions about parental competence arise in evaluation of growth-faltering children. Neglectful parenting patterns, such as poor communication and socialization at mealtimes, have been found. , The range of mothers’ responses to children’s poor eating can also vary greatly. Although these parents’ problem-solving ability needs to be high, Robinson et al’s study of 37 mothers found that the mothers of children with FTT performed poorer on a problem-solving evaluation than control mothers, showing a narrower repertoire of solutions and poorer quality of responses. Once again, however, the question of cause and effect arises. Were their children failing to thrive because of the mothers’ skills, or were the mothers’ deficits caused in part by the children’s growth failure?
One other issue related to parental competence bears mentioning: maternal IQ. An older study with some of the methodological flaws mentioned above examined the homes of 58 3-year-olds who had been hospitalized as infants for FTT. Although three different interventions were applied to these cases, there were no differences in the scores evaluating the quality of the home environments. However, mean maternal IQ was quite low (80.8), and maternal IQ did account for variance in the scores. Although parents of below-normal intelligence can successfully raise healthy children, in this study lower IQ was a risk factor for problems in the home environment, and quite possibly for their children’s growth failure.
The Social Sphere
In this sphere of the biopsychosocial model of FTT, poverty is the most pervasive risk factor in children evaluated for growth failure. Poverty can be severe enough to limit food availability. , Societal safety nets are sometimes inadequate for families to obtain enough food to avoid episodes of hunger, given the lack of appropriate funding and the nutritional needs of rapidly growing infants and young children. In addition, poor families can have difficulty accessing public resources or might be concerned about their immigration status, keeping them from benefiting from governmental programs. In times of economic downturns, charitable donations to community services often dwindle, affecting the ability of nonprofit organizations to help families.
Three important points about poverty and FTT must be made. First, FTT does not occur exclusively in economically disadvantaged families, a fact recognized in early studies of the “maternal deprivation syndrome.” , Second, although poverty is a risk factor for growth failure, a relative minority of poor children have FTT. Determining the exact percentage is impossible because of the inability to accurately measure the number of children living in such situations and the lack of ability to uniformly assess those children for growth failure. The sometimes restricted access to preventive medical care resulting from lack of health insurance limits the ability to detect and treat early growth failure. Lack of reliable transportation, difficulty accessing primary care, and lack of adequate sources providing primary care also complicate this issue.
The third key point has arisen through recent studies questioning the long-held premise connecting poverty to FTT. Blair and colleagues examined a large cohort and found that parental socioeconomic status was not related to FTT. Wright and colleagues examined a prospective birth cohort and found that both the highest and lowest levels of socioeconomic deprivation were associated with faltering weight. Both of these studies took place in the United Kingdom, and the specific features of that country’s benefits for families with children and the lower cost of food there could have accounted in part for these findings.
In some cases, family income is associated directly with FTT, but it can also be a risk factor for other factors related to FTT. Drotar and Sturm found that the quality of the home environment is related to family income. The relationship between this association and the development of FTT again leads to questions of cause and effect.
Other issues within the family that are associated with FTT include family stressors, lack of social support, social isolation, and quality of interpersonal relationships. , Regarding family stress, Altemeier et al’s prospective study looked specifically at sources of stress in parents of children with failure to thrive. Four maternal life stressors were significantly correlated with FTT. Of these four, three dealt with the mother’s relationship with the baby’s father: arguments with him, separation from him, and reconciliation with him or his family. The fourth maternal life stressor was death of a friend within the preceding year. The two paternal life stressors significantly correlating with FTT were leaving a job within the preceding year without being fired and getting arrested.
The issue of family stress is a difficult one because the identification of the child as having growth difficulties would, in most cases, be expected to cause stress in itself. Again, separating out cause and effect is difficult. In addition, the experience of stress is a personal one and depends on the parents’ perceptions, which in turn is determined by individual characteristics including age and personality. The role poverty plays in adding to family stress can also be significant.
Social isolation and lack of social support contribute to parents’ stress and to their inability to mobilize resources in the face of other stressors. In addition, social isolation can limit the input of others outside the family to such a degree that considerable wasting is not noticed until the malnutrition is severe.
Problematic interpersonal relationships contribute to social isolation and lack of support as well as to parental stress. Drotar and colleagues published results of a study of the families of children with FTT and found that they had less optimal relationships than comparison families. In addition, their scores on a standard measure of family relationships were worse both at time of diagnosis and approximately 4 years later, regardless of the type of intervention received during course of treatment. Weston and colleagues found that in addition to childhood abuse, mothers of children with nonorganic FTT had experienced more abuse as adults than comparison mothers. However, the subjects were allowed to self-define abuse and no objective documentation of maltreatment, either in childhood or as adults, was provided. It is intuitive, however, that intimate partner violence would affect parental stress levels and could be associated with FTT.
Child neglect is often implicated in cases of FTT in which no clear biological etiology is detected. Yet, there are multiple other possible causes, and it is important not to assume, “… without question that poor growth in a child from a materially or emotionally deprived background adds up to neglect.” Although there might be elements of child neglect in many of these situations, it becomes easier to label the caregivers as negligent when there is intentional withholding of food from the child or if the family is resistant to recommended interventions or is frankly noncompliant. In addition to neglect, child abuse is sometimes present in FTT cases as well. Infants in abusing families are at greater risk of FTT. Severe withholding of nutrition can be classified as starvation and can result in criminal prosecution.
Evaluation
The medical evaluation of children with faltering growth should be guided by careful consideration of the many possible etiologies discussed previously. The goal is to determine the diagnosis or diagnoses causing the symptom of FTT. This section discusses the evaluation of children with FTT based on the biopsychosocial model.
Growth Charts
The medical evaluation of FTT starts with examination of the child’s anthropometric data reflected in the growth chart. Accurate measurements of weight, height, and head circumference must be carefully plotted on growth charts for reliable assessments. For serial measurements, children should be weighed and measured repeatedly in the same manner to correctly assess growth over time. This can be difficult when children are taken to different medical providers, or when infants are hospitalized and different staff members weigh them each day, often on different scales.
Different growth charts are available. In the United States, the Centers for Disease Control and Prevention published new growth charts in 2000 based on data collected by the National Health and Nutrition Examination Survey (NHANES) (available at http://www.CDC.gov/GrowthCharts ). These replaced charts published in 1977 by the National Center for Health Statistics (NCHS). The newer charts were an improvement because of a larger sample size, a more racially and ethnically diverse sample, the inclusion of more breastfed babies, the addition of body mass index, and statistical refinement of data analysis. In 1990, the United Kingdom also released new growth charts.
The World Health Organization (WHO) had designated the 1977 NCHS growth charts as their international standard until their own charts were released in 2006. This release culminated a multiyear project that included collection of data from six countries, recruiting only nonsmoking mothers who were willing to exclusively breastfeed their infants for 4 months. The goal was to create the optimum standard for growth while establishing breastfeeding as the biological norm. These growth charts are meant to be used for children in all countries regardless of ethnicity, socioeconomic status, or type of feeding. Experts in pediatrics and nutrition in the United Kingdom have recommended the use of the WHO 2006 charts for UK children only after 2 weeks of age .
Growth charts are available for children with specific special health issues such as Down syndrome, Turner syndrome, and velo-cardio-facial syndrome. Using typical growth charts for children with some types of health problems can lead to inaccurate labeling and unnecessary testing.
History
A thorough history will point to the correct diagnosis in the majority of cases of FTT. It is best to start chronologically in the prenatal period and proceed to the child’s birth, neonatal period, and infancy in order. Using the biopsychosocial model and remembering the different etiologies of FTT, the following tables provide examples of the type of information to be obtained. The psychological and social spheres have been combined because of the frequent overlap of issues in those categories.
Table 57-2 deals with the prenatal period. Review of the mother’s obstetrical record is necessary to obtain a thorough history. No single answer is likely to indicate the etiology of a child’s growth problem. For instance, if the pregnancy was unplanned and the mother considered termination, that is possibly a psychosocial issue contributing to growth failure, but it cannot be taken as a primary cause while ignoring other historical factors.
| Prenatal History |
| Biological Sphere |
|
| Psychosocial Spheres |
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