Failure to Thrive 12
Running head: FAILURE TO THRIVE
Failure to Thrive
Katy Woods
University of Northern Colorado
Simply stated, healthy babies grow when fed and loved. The first few years of a child’s life are a time of rapid growth. However, there are some situations where a child’s growth is delayed or stopped. Traditionally, in the pediatric literature, this was defined as one of two possible causes; non-organic or organic failure to thrive (FTT). Organic and non-organic failure to thrive have been criticized because they were felt to be an oversimplification of a complex area but appears to be well accepted in the pediatric literature. FTT has been recognized for over a century, however, some individuals believe FTT is a condition rather then a disease and therefore a precise definition is hard to find. Non-organic FTT should not be oversimplified because there is evidence that children are dying because of psychological neglect. The following paper will define non-organic FTT and organic FTT. However, the research reviewed in the paper is based on non-organic FTT. The causes of FTT, along with how it is diagnosed, treated, the outcomes, and subgroups will be addressed.
What is Failure to Thrive?
Lana, an observant nurse at a public health clinic, became concerned about 8-month-old Melanie, who was three pounds lighter than she had been at her last checkup. Her mother claimed to feed her often and could not understand why she did not grow. Lana noted Melanie’s behavior. Unlike most infants her age, she did not mind separating from her mother. Lana tried offering Melanie a toy, but she showed little interest. Instead, she anxiously kept her eyes on adults in the room. When Lana smiled and tried to look into Melanie’s eyes, she turned her head away (Berk, 2002). Melanie’s story is a good example of what failure to thrive might look like at first glance. Berk (2002) explains that non-organic FTT is a growth disorder resulting from lack of parental love that usually presents as growth failure by 18 months of age. FTT infants may have bodies that look wasted and appear to be withdrawn and apathetic.
It is important to note that with non-organic FTT, biological/medical causes for the baby’s failure to grow has been ruled out by the medical team. Organic failure to thrive occurs when there is an underlying medical cause (Child Abuse and Neglect: A Manual, 2006). Medical causes include chronic diseases or infections, inadequate intake due to swallowing difficulties or obstruction, inability to eat large quantities or vomiting or regurgitation/reflux, and conditions interfering with appetite (Hobbs et al., 1999).
Diagnosis
Most normal babies go through plateaus of weight gain and occasionally slight weight loss. Doctors usually become concerned if a baby doesn’t gain weight for 3 consecutive months or loses weight during the first year of life. According to Bassali & Benjamin (2004), “some authors define FTT as height or weight less than the third to fifth percentiles for age on more than one occasion. Other authors cite height or weight measurements falling 2 major percentile lines using the standard growth charts of the National Center for Health Statistics (NCHS). Still others state that true malnutrition (weight <80% of ideal body weight for age) should be present to state a child is failing to thrive. All authorities agree that only by comparing height and weight on a growth chart over time can FTT be assessed accurately” (p. 2).
To determine whether the child is receiving enough food, the child's doctor (sometimes with the help of a dietitian) will do a calorie count after asking the parents what the child eats every day (Kids Health, 2005). The mother is observed caring for the baby to see where problems may be occurring. The doctor may talk with the parents and see if there are any problems at home and often will ask a social worker or mental health provider to assess the entire family. These assessments may identify emotional neglect, abuse, or household stress as the most likely cause of the FTT.
Bassali and Benjamin report that between 1980 and 1989 in the US, 1-5% of hospital admissions for infants younger than 1 year were classified as failure to thrive (2004). Research has also shown that FTT occurs in all socioeconomic branches, although it is more frequent in families living in poverty, where household stress is extreme. Non-organic FTT is reported more commonly in females than in males (Bassali & Benjamin, 2004).
Causes
Non-organic FTT usually results from various environmental and psychosocial factors. It often is associated with abnormal interactions between the caregiver and the infant or child (Bassali & Benjamin, 2004). There are prenatal and postnatal causes of non-organic FTT. Evidence exists that shows if mothers do not bond with their unborn babies, those babies may undergo FTT in utero (Child Abuse and Neglect: A Manual, 2006). Postnatal causes can range from dysfunctional family interactions, lack of preparation for parenting, child neglect, and emotional deprivation syndrome. If FTT occurs after the birth of the baby, parents may become entrenched in their own problems, therefore taking it out on the child by simply ignoring and neglecting the child or using physical abuse. According to Myers et al. (2002), “abusive adults tend to experience symptoms of affective, somatic, and behavioral distress believed to impair their parenting functions, which may contribute to unrealistic expectations of their children’s conduct and capabilities” (p. 30). In a study that looked at FTT individuals over a 20-year period, it was found that the families of failure to thrive children showed high levels of socioeconomic disadvantage in conditions in the homes. The parents experienced high levels of acute disharmony in marital relationships (Iwaniec et al., 2003). It seems evident that it is not just the parental neglect toward the child but also the dysfunction within the home that leads to FTT. It is also evident that FTT often involves psychosocial problems, compromising the relationship between parent and child. It is therefore necessary that the child’s doctor observe the relationship between child and caregiver if FTT is suspected. According to Krugman and Dubowitz (2003), “observing the interaction between a parent and child, especially during a feeding session in the office (or in the hospital or home), may provide valuable information about the etiology of FTT. Parents can be asked to feed an infant or bring in a snack for a toddler. It is important to pay attention to a caregiver's ability to recognize the child's cues, the child's responsiveness, and the parental warmth and appropriate behavior toward the child. It is similarly important to observe the nature of the child's cues (clear or not), the child's temperament, and responses toward the parent (p. 5).
Treatment
Most children with FTT can be treated as outpatients using home visits and close clinical follow-ups. However, hospitalization sometimes is necessary for diagnostic and therapeutic reasons. Diagnostic benefits of admission may include observation of feeding, parental-child interaction, and dietary habits, as well as the ability to perform specific tests and consult sub specialists (Bassali & Benjamin, 2004). If a child is suffering from needs such as dehydration, infection, or anemia, he/she may benefit from being hospitalized. If children gain weight easily during a hospitalization, it is much more likely that the cause of the FTT is non-organic (Bassali & Benjamin, 2004). If non-organic FTT is suspected then a team of pediatric, nutritional, mental health, and social workers will come together to form a treatment plan. If neglect or abuse is suspected, then child protective services will be called upon. The team will ensure that programs such as women, infants, and children (WIC), food stamps, and Medicaid can be accessed. Bassali and Benjamin (2004) found, “other advantages of using an interdisciplinary team is that the family's psychosocial situation can be addressed and intervention can be provided” (p. 12). There are times when treatment fails to work. According to Hobbs et al. (1999), “success of treatment is measured by improvement in growth and development of the child, reduction of behavioral disturbance and a more positive nurturing and caring attitude towards the child. Success is more likely if children are referred in the first year of life. The prognosis is poorer if the child is referred with a long history of failure to grow, and there may be only moderate or no improvement” (p. 57). Hobbs et al. also explains that children identified in the first year of life as FTT have an increased risk of subsequent abuse and or neglect. Failure of treatment occurs with parents who fail to comply. These individuals are not keeping doctor’s appointments or cooperating with treatment for the child. These children are at risk of death or injury and it is important for immediate action to be taken for their safety.
Subgroups within the non-organic Failure to Thrive syndrome
Research shows that there are subgroups within non-organic FTT. Two possible subgroups are psychosocial dwarfism and deprivation dwarfism.
Psychosocial Dwarfism
Children with psychosocial dwarfism (also called psychosocial short stature (PSS) are rare. PSS is a disorder of short stature or growth failure and/or delayed puberty of infancy, childhood, and adolescence that is observed in association with emotional deprivation and/or a pathologic psychosocial environment. A disturbed relationship between child and caregiver usually exists (Sirotnak, 2006). The key features include, first, a very slow rate of linear growth with height for age among the lowest 1% of the population. Second, there are remarkable features of behavior, including a disrupted sleep pattern (with wandering at night in search for food), hyperphagia (an insatiable appetite), polydipsia (an insatiable thirst), and pain agnosia (an insensibility to physical discomfort), and possible cognitive impairment (Skuse, 1995). Some children will be sent to a growth clinic and will be diagnosed with hypopituitarism. Hypopituitarism is diagnosed when an individual is not producing growth hormone from the pituitary gland. However, when medication treatment is given to children with psychosocial dwarfism, it usually does not work: they do not grow any faster. Skuse further explains, once it is recognized that they are being abused and they are removed from their abusive environment, their height increases at a greatly accelerated rate with no medication treatment al all (1995).
Deprivation Dwarfism
Children with non-organic FTT usually present before 2 years of age, the majority being under 18 months. In contrast to FTT and psychosocial dwarfism, children with deprivation dwarfism range from 2 to 15 years although the history may reveal earlier feeding and behavior problems (Oates, 1984). Oates explains that whereas in FTT it is the marked weight loss or lack of weight gain that is the striking feature, in deprivation dwarfism it is the short stature that first brings the child to attention (1984). Although these children are dwarfed, they do not look malnourished because of their short stature. Children with deprivation dwarfism are reported to steal and hoard food, gorge themselves, eat from garbage cans, and eat unusual foods such as condiments. One study showed a decrease in pituitary function in 14 of 28 children with deprivation dwarfism. In most of these children there was catch-up growth when the environment improved (1984).
Outcomes
According to Krugman and Dubowitz (2003), “Children with FTT are at risk for adverse outcomes such as short stature, behavior problems, and developmental delay. FTT is more likely a contributing or associated factor to these adverse outcomes, rather than the exclusive cause. There are a limited number of outcome studies on children with FTT, each with different definitions and designs, so it is difficult to comment with certainty on the long-term results of FTT. In addition, it is often difficult to disentangle the effects of FTT from those of the high-risk environments in which FTT often occurs (e.g., poverty, high family stress, and poor parental coping skills)” (p. 6). FTT usually occurs at a young age when children are in a critical period of growth and development, therefore it is essential that others recognize and treat FTT without delay. Recognizing and treating FTT promptly will maximize the possibility for better outcomes. Research by Drewett et al. (2006) looked at children who had failed to thrive as infants and followed them through age 12. Self-ratings of appetite, body image, anxiety, mood, and feelings were all measured. Results showed “the children who failed to thrive were significantly shorter and lighter at twelve and had significantly lower BMI’s, but this did not go into puberty or later” (p. 524). It is important to note that the children in this study and many other FTT children who survive are helped by outside services. A team of medical personnel and child protective services helps these families get on a healthy track. However, if an abusive situation is not recognized or reported then the probability of death in an FTT child is increased.
Conclusion
Despite the efforts of the child protection system, child maltreatment fatalities remain a serious problem. It is imperative that mandatory reporters and community’s as a whole keep an open eye to abuse. The National Child Abuse and Neglect Data System (NCANDS) reported an estimated 1,490 child fatalities in one year, and many of those might have been saved if suspicions of abuse and/or neglect were reported. Research shows that non-organic FTT is dangerous and life threatening but it does not have to be fatal. It is possible for children who are failing to thrive to go on to live healthy and happy lives if they are no longer in an abusive environment. Infants and very young children don’t have a voice to speak out, so it is up to others to recognize signs of abuse and speak on their behalf.