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Failure to thrive, or failure to grow or gain weight, could have several causes that are reviewed in this article. Infant behaviors are discussed, together with nutritional management, catch-up growth, effects of nutritional rehabilitation on body composition, follow-up, and long-term prognosis.
Failure to thrive is a presenting symptom, rather than a diagnosis. Organic failure to thrive may be caused by defects in food assimilation, excessive loss of ingested calories, increased energy requirements or prenatal insults. Nonorganic failure to thrive may occur accidentally, or it may be related to economic or emotional deprivation, as well as to child abuse or neglect. Assessment of a child with failure to thrive includes a comprehensive history and a thorough physical examination. Some basic laboratory screening tests may be helpful in the evaluation. More extensive investigation may be required, based on the clinical findings and the results of the initial screening tests. Early intervention is essential, because children may develop significant long-term sequelae from nutritional deficiency.
Failure To Thrive is a phenomenon often encountered in the ambulatory pediatric setting. This disorder is usually classified into two main categories: organic or non-organic/psycho-social depending upon the causative factor(s). The first section of this paper discusses evaluation and assessment of the child suspected of having failure to thrive. The second section deals with specific management techniques which can be implemented by the nurse practitioner in caring for the child with non-organic failure to thrive.
Failure to thrive is one of the most common diagnostic problems in pediatrics. The term is applied to describe a still poorly defined entity. We will define failure to thrive, review the frequency of various etiologies, and present a logical approach to this problem.
Failure to thrive is a complex problem affecting long-term health and development of the child. This paper describes a multidisciplinary approach to management and treatment of children and families where there is a child who is failing to thrive. The experience described in this paper is based on many years work of an interdisciplinary nature involving a Paediatrician, Psychologist and Dietician which lead to the creation of a special clinic for these children in 1993.
Failure to thrive (FTT) in infants with congenital heart disease (CHD) can be attributed to their low energy intakes and high resting energy expenditures. Energy intake, energy expenditure and growth were studied in infants with CHD on normal formula feeds and then on feeds supplemented with glucose polymer to see whether supplementation improved energy retention and growth. Mean gross energy intakes increased by 31.7% on high-energy feeding and mean weight gain improved from 1.3 g/kg per d on control to 5.8 g/kg per d on high-energy feeding. Resting oxygen consumption (VO2 ml/kg per min) was not significantly different on the two feeding regimens, although respiratory quotient rose on high-energy feeding reflecting the increased carbohydrate intake. Estimated energy costs of growth on high-energy feeding fell within the previously described range for normal infants. It is recommended that infants with CHD known to be associated with FTT are fed on high-energy diets from the time of diagnosis in order to optimize growth.
In this article the authors propose that non-organic failure to thrive (FTT) is a growth failure secondary to feeding-skills disorder, and that this disorder is neurophysiological in origin. The symptoms of feeding-skills disorder were suggestive of an oral sensorimotor impairment which is usually present from birth or early life, but tends to go unrecognized. Data from 38 infants with non-organic and 22 infants with organic FTT demonstrated that early clinical symptoms of feeding impairment, and observed maternal and infant feeding behaviours and interactions, were similar for both groups, suggesting a need to redefine the term 'non-organic'.
The study group comprised 40 unselected Caucasian children admitted to hospital whose ages were between 3 months and 3 years and whose weights were less than 3rd centile. A comparison group comprised 34 children from a similar background whose weights were between the 25th and 75th contiles. The mothers of all 74 children were interviewed and information was obtained on physical health of the child, social and family factors, bonding, feeding difficulties, and maternal childhood experience. In 23 of the 40 underweight children the organic disease was considered to be insufficient to explain the child being underweight and to be probably insufficient in a further 9 children. Three factors occurred more frequently in these 32 underweight children. The mother often perceived herself as having a disturbed mood and used the word "depression" to describe these feelings. She also tended to come from a lower social class than the mother in the comparison group, and her infant frequently had a low birthweight. Identification of these children is not difficult; clinical investigations need to be minimal, and therapy should be directed towards supporting the mother emotionally, improving her relationship with her child, and increasing her mothering skills.
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Geriatric failure to thrive (GFTT) is a syndrome associated with functional decline, depression and malnutrition. Adverse drug reactions are cited as one of the most common causes of GFTT. Two distinct drug-related issues should be considered. Firstly, failure to provide appropriate treatment for conditions such as anaemia, depression, nutritional deficiencies and pain may precipitate GFTT. Secondly, drug-induced functional decline and decreased nutrient intake may cause or contribute to the syndrome. Pharmacological intervention may include discontinuing potentially offending agents for a trial period, or drug treatment of anorexia and depression.
Nonorganic failure to thrive (NOFTT) is characterized by physical and developmental retardation and a disturbed mother-infant relationship. This study sought to quantify differences in interactions between mother-NOFTT infant pairs and control mother-thriving infant pairs. Eleven mother-NOFTT infant dyads and 11 control mother-infant dyads were videotaped for 30 minutes through a one-way mirror. Mother and infant behaviors were evaluated for 21 behavioral categories: 12 maternal, 7 infant, and 2 mutual. Statistically significant differences were noted in five (24 percent) categories. The quantity of maternal and infant vocalizations and the responsiveness of the mother to the infant's vocal cues were strikingly reduced in the NOFTT dyads.
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Failure to thrive is a common manifestation of human immunodeficiency virus (HIV) infection in children. Given the role of insulin-like growth factor I (IGF-I) in stimulating postnatal growth, we have examined whether HIV-infected pediatric patients with growth failure have lower serum concentrations of IGF-I than age-matched control subjects. IGF-I was measured in 16 HIV-infected children and 13 HIV-negative controls. Ten of the HIV-infected children failed to thrive based on height and linear growth that was below the National Center for Health Statistics 10th percentile. IGF-I levels were significantly lower in children who failed to thrive compared to those in age-matched controls (20 vs. 60 micrograms/L; P < 0.001). Children who failed to thrive also displayed lower IGF-I levels than HIV-positive children, who exhibited normal growth velocity (20 vs. 91 micrograms/L; P < 0.001). Failure to thrive was associated with a significant reduction in circulating levels of IGF-binding protein-3 (IGFBP-3), as determined by ligand and Western blotting (P < 0.001), enhanced IGFBP-3 proteolysis (P < 0.001), and a decrease in the serum concentration of the acid-labile subunit of the IGFBP-3 ternary complex (P < 0.005). IGFBP-3 proteolysis was negatively correlated with IGF-I (r = 0.78) and IGFBP-3 levels (r = 0.70). Failure to thrive was associated with a reduction in the formation of the ternary complex, but the ternary complex could be restored by the addition of an excess of IGFBP-3 to serum. These results indicate that low levels of IGF-I, IGFBP-3, and acid-labile subunit are associated with a failure to thrive in HIV-infected children.
This paper describes the characteristics of thriving and failure to thrive (FTT) children and their mothers and examines the effect of short-term lay health visitor intervention in cases of nonorganic failure to thrive (NO FTT). Twenty-five FTT children and mothers received lay health visitor (LHV) intervention in addition to other community and medical treatment; 25 other FTT children and mothers did not receive the LHV intervention but did receive all other medical and community treatment. Twenty-five thriving children and mothers were matched with the FTT children and mothers in the LHV group on the child's age at intake, sex, birth weight, and the mother's age, ethnicity, and number of living children. At initial assessment, the FTT and thriving groups were found to be comparable on demographic factors, infant birth weight percentiles, apgar scores, complications of pregnancy or delivery, and separations in the newborn period. There were more premature births in the LHV group although the proportion of premature births for the FTT and thriving groups overall were similar. A majority of mothers in the FTT groups had negative memories of childhood in contrast to more positive memories in the thriving group. At initial assessment, the majority of thriving children were developmentally normal and had increased from their birth weight percentiles whereas all of the FTT children had decreased from their birthweight percentiles and over half were developmentally delayed. There were clear differences in mother-child interaction patterns in the thriving and FTT groups. Three patterns of interaction were identified in the FTT group: benign neglect, incoordination, and overt hostility. Intervention had no measurable effect on the child's weight, development, or interaction patterns. Only 8 of 37 FTT children reevaluated 6 months later showed "catch up" growth and only 7 had improved in developmental score category. Patterns of interaction were found to persist over the 6 months in all cases. One to three year follow-up of 44 families emphasized the severity of the condition and the need for differentiation of the severity of the disturbance in the mother-child relationship and for more intensive intervention than was available in this study. Of these 44 cases, 2 children had died, 5 had been physically abused or further neglected, and 10 were in alternative care arrangements.
Nonorganic failure-to-thrive (NOFT) is a clinical syndrome that is poorly understood and inadequately studied. Because empirical data are lacking, an attempt was made to identify differentiating aspects of the mother-infant interaction and environment of infants with NOFT compared with those of matched infants who grew normally. Prospectively, 23 infants who were suffering from NOFT were chosen in a referral clinic. Each infant was matched with a control subject with normal growth by age, sex, and race of the infant and family income, maternal education, and number of people living in the household. An assistant who was unaware of infant growth status visited the homes of these infants within 3 weeks of diagnosis and gathered: the Home Observation for Measurement of the Environment (HOME); the Coddington Life Events Record; and the Index of Parent Attitude Scales. The total HOME Inventory and the subscales entitled Maternal Acceptance of the Child, Organization of the Physical Environment, and Emotional Responsivity were significantly less favorable (P less than .05) in the NOFT group. There were no group differences in the Life Events Record and the Parent Attitudes Scales. A discriminant function analysis correctly placed 32 of the 46 infants into failure-to-thrive and control groups. It is concluded that certain aspects of the home environments of infants with NOFT differ from those of infants of similar socioeconomic status who grow normally.
Every child with failure to thrive has at least one organic medical disease: malnutrition. It is well documented that lead and other heavy metals are absorbed more readily in the presence of both malnutrition and iron deficiency anemia. Malnutrition and lead exposure tend to be found in the same population groups. Furthermore, lead poisoning is correlated with many of the identical intellectual and behavioral deficits demonstrated in children suffering from nonorganic failure to thrive. Because of these facts, whole blood lead levels were determined for 45 children with nonorganic failure to thrive and 45 age-, race-, and socioeconomically matched comparison subjects. Children with failure to thrive had a lead level of 22.67 +/- 10.29 (micrograms/dL (mean +/- SD); for control children, it was 14.33 +/- 5.42 (P less than .001). Children with failure to thrive were more frequently anemic (P less than .0001), a possible lead effect, and had higher free erythrocyte protoporphyrin levels. Children with failure to thrive were developmentally delayed on the Denver Developmental Screening Test (unblinded observation) with high failure rates in both language (P less than .001) and gross motor skills (P less than .02). Although failure on the Denver Developmental Screening Test within the failure to thrive group was not linearly correlated with lead level, any such effects may have been masked by the effects of malnutrition and failure to thrive per se. A number of authors have suggested that lead levels formerly thought to be inconsequential are clinically toxic.(ABSTRACT TRUNCATED AT 250 WORDS)
Failure-to-thrive (FTT) is a chronic symptom accounting for 1% of all patients admitted to pediatric hospitals. FTT, which is traditionally attributed to organic (OFTT) and/or nonorganic (NFTT) causes, results in undernutrition. Undernutrition has potentially serious effects on child development, behavior, and cognitive skills. We undertook a study of children with FTT to determine whether multidisciplinary team treatment resulted in improved weight gain compared with children treated in a primary care setting. Fifty-three children with NFTT referred to our outpatient FTT consultative clinic and 107 children with NFTT identified as comparison subjects from our primary care clinic (PCC) were enrolled in the study. Growth outcomes over a 6-month follow-up were analyzed using growth quotient (GQ) analysis. Children followed in the multidisciplinary team clinic grew better (GQ = 1.75 +/- 0.39 SD) than did children in the PCC (GQ = 1.18 +/- 0.42 SD, p less than .001). The use of a multidisciplinary team offers special advantages in the rapid correction of undernutrition in children with NFTT.
Studies of failure to thrive often work to different definitions, and replication studies are rarely undertaken. A recent study completed in southern England encompassed an area previously studied some 5 years earlier. Although recognition of failure to thrive was not the focus of the focus of this work, the data are used to draw some conclusions regarding changes in recognition. There has been an improvement in recognition of children whose weight falls below the 3rd centile. Previously one in three of these children passed unrecognized as such by health professionals. Recent work indicates that now only one in five children below the 3rd centile are not recognized by health professionals as a cause for concern. However, in extending a definition of failure to thrive to include children whose growth deviated from an established growth curve for 3 consecutive months, crossing major centile lines, it was found that one in two of these children were not picked up by health professionals. The case is made for improved recognition of failure to thrive, and the implications of current patterns of child health surveillance, including moves to parent-held records are addressed.