Nutritional Iimplications for Infants and Children with Failure to Thrive
MaryAnn Wilbur, BS
Deborah A. Frank, MD
Department of Pediatrics
Boston Medical Center
Boston, MA
Pretest:
Q1. Which of the following is the most appropriate component of evaluation of a child with Failure to Thrive (FTT)?
a) medical
b) nutritional
c) developmental
d) social
e) all of the above
Q2. What percentage of young children from low-income families may have FTT according to survey data?
a) 10%
b) 1%
c) 0.1%
d) 0.01%
Q3. Which is the most appropriate way to define FTT?
a) organic - illness identified
b) inorganic - no illness identified
c) neither of the above
Q4. Children with FTT may have lifelong deficits in which of the following?
a) cognitive function
b) motor abilities
c) social interactions
d) all of the above
Q5. Successful treatment of FTT always involves which of the following?
a) hospitalization
b) child protective services
c) coordination of all involved services
d) none of the above
Q6. An overwhelmed new mother has missed several appointments because, she says, "my Medicaid ran out." Her initially low birth weight infant (2,200 grams), now three month old, is only 300 grams above birth weight. True or False: It is appropriate to call Child Protective Services to supervise the family because they failed to follow-up on a high risk infant's medical care.
Q7. Which children can you plot on the NCHS chart?
a) An inner-city African-American child
b) A suburban Jewish American child
c) A newly emigrated Asian child
d) all of the above
Objectives:
On completion of this module, the learners will:
1. Be able to identify FTT and its proximal etiologies
2. Learn to assess dimensions that must be understood for diagnosis and treatment of FTT:
a. medical,
b. nutritional,
c. developmental, and
d. social
3. Plan appropriate treatments for children with FTT and their families with recognition of the importance of a multi-factorial approach based on these four dimensions.
Facilitator Preparation:
Suggested readings include:
Reece and Ludwig (Eds.) (2001) Child Abuse: Medical diagnosis and management, Lippincott, Williams, and Wilkins. Specific problems of FTT are discussed in chapter 12 (pp. 307-338). This is a very family and culturally sensitive chapter describing how to deal with complex social and parent-child interaction issues. A new edition of this is in progress to be published by the AAP.
Frank, DA, Needlman, R, Silva, M. What to do when a child won't grow. Patient Care: 107-129, March 1994. This article will help clinicians and caretakers find concrete solutions to feeding problems in children.
Frank, DA, and Zeisel, SH. Failure to Thrive. The Pediatric Clinics of North America, 35(6):1187-1206,1988. This article catalogues what is and is not presently known about the neurological deficits attributable to FTT.
The facilitator should also print out growth charts for both sexes for display and questions. The APA's Curriculum for Poor and Underserved Children has a teaching module addressing elements of growth including these curves. See: http://www.servingtheunderserved.org.html for access to Bithoney W, Casey P, Karp, RJ. Why is Johnny Small? A case presentation module on Failure to Thrive: Curriculum for Poor and Underserved Children of the Ambulatory Pediatric Association, 2000.
Patrick Casey of Little Rock Children's has developed an office-based evaluation of parent: child interaction called the PROCESS scale. See
Casey PH, et al. Pediatric clinical assessment of mother-child interaction: concurrent and predictive validity. J Dev Behav Pediatrics 1993;14:313-7. The PROCESS is included as Appendix X.
Two references of note discuss relationships between child abuse and neglect and FTT. These are:
Block RW, Krebs N. and the Committees on Child Abuse and Nutrition. Failure to Thrive as Distinct From Child Neglect Pediatrics 2005;116:1234-37.
Black M, Dubowitz H, Casey PH, et al. Failure to Thrive as Distinct From Child Neglect. Pediatrics 2006;117;1456-58. Drs. Frank and Karp are co-authors of this "counter statement." Dr. Block's reply follows the Black, et al comments. See Pediatrics. 2006; 117;1458-9.
Abstract:
Failure to Thrive (FTT) is a complex pediatric diagnosis. It is not an "eyeball" diagnosis. In the broadest terms, FTT refers to infants and children whose growth deviates from the norms for their age and sex. Generally, an evaluation is warranted when a child's weight falls below the fifth percentile for age or length/height or decreases across more than two major percentile lines on the National Center for Health Statistics (NCHS) charts after 18 months of age (i.e. from the 50th percentile to the 10th percentile). According to some surveys, FTT occurs in nearly 10% of low-income young children, but does not occur only in low-income families. Diagnosis of FTT begins with anthropometric measurements and growth parameters.
If, after consideration of the child's growth parameters, the clinician is concerned about FTT, there are four dimensions to be considered: medical, nutritional, developmental, and social. Every child with FTT, and family with a child carrying this diagnosis, should be assessed on all four of these parameters. Although the child's current nutritional status is most literally interpreted as inadequate nutritional sustenance to maintain normal growth given the child's nutritional needs (which may be increased by illness), there are many factors that can contribute to this diagnosis. Also important are the collaborative efforts of clinicians gathering and compiling this information. Optimal care involves a well-coordinated multidisciplinary team where all clinicians communicate regularly with each other, the family, and collateral services.
Consideration of abuse or neglect as a cause for failure to grow is necessary. We suggest, however, that child abuse is not a common cause. Initially approaching a family with a child with FTT as though you perceive them as abusive or neglectful will not effectively engage the family in the complex process of diagnosis and treatment. Abuse and neglect should be considered when there is "intentional withholding of food from the child; strong beliefs in health and/or nutrition regimens that jeopardize a child's well-being; and/or family that is resistant to recommended interventions despite multidisciplinary team approach. and/or inflicted trauma or grossly inadequate hygiene." (an adaptation from Block and Krebs by Black, et al.)
The most crucial component of the medical evaluation of a child with FTT is a physical examination coupled with a detailed prenatal and postnatal history. Laboratory testing should be performed on the basis of the history and physical examination. Hospitalizations and tube feeding are rarely necessary for treatment of FTT, except for the most severely affected or complex cases. The experience of hospitalization can in fact be a hindrance in many cases.
A nutritional history should begin just after birth; was the child breastfed or bottle-fed? When was the child transitioned to whole cow milk? Is the child on any vitamins? When were solid foods first introduced? There are some "red flags" commonly associated with FTT. These often include over dilute formula, improper mixing of formula, and excessive intake of juice, water, juice drinks, tea, or carbonated beverages. A complete nutritional history will scan for possible developmentally inappropriate food choices, food allergies, grazing (a lack of stable feeding schedule leading to all day snacking, depressed appetite, and inadequate caloric intake), reflux, dietary iron, zinc, calcium, or vitamin deficiency, and gluten sensitivity.
Underlying developmental issues may be either contributing to the child's FTT or evolve consequent to their depleted nutritional status. Subtle neurologic disturbances in oral motor function may contribute to FTT, as can major neurologic disorders and dysmorphic syndromes associated with developmental delay. Not only can developmental issues contribute to FTT, but many developmental delays can be attributed to FTT. Clinicians must be cognizant that children diagnosed with FTT are at risk for blunted affect, language delays, motor delays, decreased social interaction, impaired attention and school impairments through school age and into adulthood. Brain growth is at its greatest between the last three months of gestation and 36 months of life. During this time, malnutrition can lead to decrements in myelination, evolving brain structures, and neurotransmitter networks. It has been shown that refeeding alone does not ameliorate established developmental deficits in children with FTT relative to well nourished peers, but that refeeding coupled with extended developmental intervention can significantly decrease the later developmental gaps between children with FTT and their peers. Therefore, developmental assessment and enrichment should begin as soon after FTT identification as possible.
Acquiring a social history from parent/guardian of a child with FTT can be a very sensitive task. Clinicians should be mindful that parents may be reluctant to engage in such a discussion, feeling that it will lead to accusations of parental failure and possible protective service interventions with ultimate loss of custody of the child. Poverty remains the most common social risk factor for FTT, but is not present in all cases.
Caring for children with FTT must be consistent and cooperative. A multidisciplinary team is essential. Developmental intervention and enrichment should be started at diagnosis. With coordinated care from family and a multidisciplinary team, 90% of children will show positive increments in growth relative to the national norms. The goal of everyone involved must be a thriving child in a thriving environment.
Case Study Part 1:
On January 2nd, while you are supervising a "well baby" visit in a busy public health clinic, a medical student asks you to look in on a 10 month old boy "who looks kind of small for his age." The medical student wants to know if this child is failing to thrive, especially because the mother is "kind of scruffy looking."
Danny is here with his mother today. His mother says she is not worried about the baby's size because baby was "born real small, a seven months baby." On further questioning she remembers that Danny was due on May 1st, but was born on March 1st, 10 months ago with a birth weight of 3lb 12oz (which the medical student helpfully translates to 1,700 grams). The medical student thinks the baby's current weight (obtained by "throwing the baby on the scale" which may or not have been zero set) is "about 15 lbs." Once you have the mother peel off the snow suit, boots, turtle neck, overalls and wet diaper, the baby's unclothed weight today is 13lb 2oz (6 kg), length 25.6 inches (65 cm), head circumference 27inches (42 cm).
Case Questions:
Q1: Given the history and these measurements, should we share the medical student's concern or is no further workup required?
A: Yes, we should share concern.
Q2: At 10 months of age, do we still need to correct for this child's prematurely?
A: Yes, his weight needs to be corrected until 24 months chronological age. His height needs to be corrected until 42 months of age. His head circumference needs to be corrected until 18 months of age.
Clinicians should use the current growth charts published by the NCHS for sex and age. The charts are available online (www.cdc.gov/growthcharts). By international consensus, the NCHS growth charts are used to evaluate the growth of young children, regardless of ethnic or racial background. Concerns have been raised that exclusively breast fed infants might be considered to be failing to grow when weights are at or slightly below the 5th percentile on the NCHS graph. The WHO curves drawn for breast-fed infants suggest that there is a slight downward shift in the curves past 6 months of age. [See Assessment of
Nutritional Status and Breast-feeding modules for these graphs.]
Children should be weighed naked up to 24 months and in underwear only beyond that age. Recumbent length is to be used for children up to 24 months and standing height is to be used beyond that age. Head circumference should also be measured for all children and charted for children up to 36 months. Four growth parameters should be plotted: weight-for-age, height-for-age, weight-for-height (or BMI beyond age 5 years), and head circumference. The most useful growth parameters are sequential. Static measures are useful to assay nutritional status in a community. Dynamic measures are needed to assess the individual. They help the clinician consider the child's current nutritional status as well as his or her growth trajectory.
It is also important to remember to correct for prematurity. Children's parameters will look significantly different after this is done. To correct for prematurity, subtract the number of weeks of gestation from 40 weeks and use this number to correct for growth parameters in following measurements:
correct for weight-for-age until 24 months chronological age,
correct for height-for-age until 42 months chronological age,
and correct for head circumference until 18 months chronological age.
Note: Weight-for-height is not dependent on age or gestational age, and therefore does not need correction.
Children with FTT often fall below the third percentile. Therefore, a standardized system for describing children with FTT has been established, initially developed by Gomez and Waterlow. [See Assessment of Nutritional Status - Part 2, Part 2] Anthropometric measurements are defined as "percent standards," and are measured as percent of the median. For example, to calculate a child's weight-for-age, we would divide his/her current weight by the median weight for chronological (or corrected) age and sex and multiply by 100. This can be done for all four anthropometric measurements and help clinicians identify the degree of malnutrition. Please see Table 1 to identify degrees of malnutrition based on percent standards. For research purposes, z scores (standard deviation units) calculated from the NCHS growth grids are used.
Table 1
CAPTION: Note use of "Percent of Standard" rather than "Percentiles for age and gender." "Below 5th %ile" (roughly 90% of standard) is insufficient information to determine degree of malnutrition. Moreover, "Percent of Standard" measures can be used to determine the level of undernutrition for individuals and the community.
The physical examination will, of course, begin with growth parameters and vital signs including temperature, pulse, respirations, and blood pressure (over 24 months). Please see Table 2 for the remainder of the physical examination checklist. A prenatal history is an important component of the medical evaluation. Please see Table 3 for the prenatal history checklist. The final component of the medical evaluation is the postnatal history. Please see Table 4 for postnatal history checklist. These checklists can be extremely valuable for clinicians evaluating children with FTT. [Tables 2, 3 and 4 are found in the APPENDIX]
Basic screening should include CBC with differential, lead, FEP, urinalysis, electrolytes, BUN, creatinine, and a PPD. Clinicians should also have a low threshold for obtaining a urine culture, HIV screening, sweat test, secretory IgA, and anti-transglutaminase antibody to rule out occult celiac disease. If the child is a new immigrant or recent traveler, lives in a homeless shelter, has been camping, or is in daycare and has a history of diarrhea or abdominal pain, evaluation for enteric pathogens (e.g. Giardia lamblia, Cryptospiridium parvum) should be considered. Screening for hepatitis and Heliobacter pylori (H. pylori) should also be considered if suggested by history of anorexia or abdominal pain. Although otherwise healthy children with H. pylori may be left untreated, there is recent evidence that H. pylori is correlated with iron deficiency and growth retardation. Therefore, physicians should consider treating H. pylori in children who are also failing to thrive.
Case Study Part 2:
After evaluating these growth parameters you agree with the medical student that the child indeed seems to be failing to thrive. Even after correction for prematurity, the child is below the fifth percentile weight for corrected age and weight for current length. The medical student wants to know if the FTT is "organic or non-organic." As you start to elicit medical history, mother, who appears quite thin, assures you that she is Vietnamese and that the baby's father is white, but not much taller than she is (5' 3"). She adds, "we're all just small."
Nutritional history provides that the child's mother pumped breast milk for feeding of the baby for the first month in the NICU and then, as she reports, she "doesn't have enough." The child was then transitioned to milk based preemie formula. He is now on iron milk - based term formula when available. When it is not available, his mother gives him dilute condensed milk with Karo syrup. The baby began spoon feeding at 6 months chronological age. His mother says that he is "gaggy" and sometimes pushes the food out. So, his mother has been adding mixed grain cereal to his bottle and has made a larger hole in the bottle nipple to allow for feeding. In the past month, he has begun to mouth crackers. He is not on vitamins or iron.
Case Questions:
Q1: What is the current medical opinion of the "organic" vs. "non-organic" FTT?
A: It is considered obsolete and is not diagnostically or therapeutically helpful. The older literature does distinguish between "organic" and non-organic" failure to thrive. More recently, it was recognized that there is an interaction of disease states, parent and child behavior. Illness affects parental behavior and child response so what may begin as an acute illness, a series of illnesses, or a chronic disease often results in patterns of parenting thought of as engendering "non-organic" FTT. Similarly, children who are growth retarded are prone to having an increase in "organic" complications, because of recurrent infections, concomitant iron deficiency, increased susceptibility to lead poisoning, and impaired CNS function.
Q2: What more do you want to know about nutritional history?
A: What has the child's mother perceived as credible advice from medical and personal interactions that created the child's current nutritional regimen? How much does lack of financial resources impact the decisions she makes about his meals? [See Table 5 in Appendix]
Q3: Does familial short stature explain this child's anthropometric measurements?
A: No. As RJ Karp writes (1993)
"Until recently, short stature in a population has been ascribed to "racial characteristics," that is, the growth of parents influencing the growth of their children. It was thought that members of different racial groups have different potentials for growth. As the 1962 edition of Pediatrics (edited by Holt, McIntosh, and Barnett) states,`It is certainly true that there are tall and short races and nations. The question may well be asked, however, whether postnatal influences, such as better nutrition and less illness, do not seriously obscure that this difference is hereditary' (p. 4). Subsequent observations with large population groups (the older view may be correct for small tribal groups) suggest that a reversal of concern should be made in the clinical diagnoses of short stature. A more appropriate statement, especially when evaluating a disadvantaged child, would be that aberrant patterns of growth, even those which seem to affect multiple members in families, should be investigated for difficulties in nutrition or parent child relationships or the possibility of shared chronic illness.(See Birch & Gussow, 1970.)
Familial short stature may be considered when the child's weight is appropriate to height and when linear growth velocity parallels the curve on the NCHS growth chart. If the child is underweight for length (as this baby is) familial short stature is not an adequate explanation. It may be perilous to assume that poor growth in children is secondary to familial predisposition for several reasons.
- First, parental height may be a poor guide of the child's growth potential if parents themselves were nutritionally deprived as children and therefore did not attain their optimal growth (as is often the case with immigrant and impoverished families).
- Second, very thin parents may lack resources to purchase food for themselves as well as their child or in privileged families have an eating disorder or be excessively concerned with obesity and thus voluntarily restrict their own intake as well as the child's.
- Third, the child may share a growth-retarding problem with one or the other parent (e.g. HIV, lactose intolerance). Variation within ethnicities by social class in growth is much greater than variation between ethnicities in infancy and early childhood. (see Jellife, 1967)
Family history is relevant to diagnoses of growth retarding syndromes, metabolic disorders, and genetic disorders. Therefore, clinicians need to inquire carefully about possible consanguinity of parents. Obtain detailed family history to evaluate potential growth retarding conditions (e.g. gluten sensitive enteropathy, (cystic fibrosis), familial contributions to social risk (e.g. family history of mental illness, drug or alcohol abuse, developmental impairments, recent deaths, or serious illness in family members) and current stressors (e.g. overwhelmed parents trying to care for severely ill relative as well as infant).
In children with FTT, weight almost always drops off before height or head circumference is affected. In constitutional short stature, by contrast, weight and height drop off simultaneously. If the child is short but is an appropriate weight for height and over age 2, a bone age may be useful to distinguish the constitutionally short child (with a bone age equivalent to chronological age) from a child with endocrine or nutritional derangement (with a delayed bone age).
Case Study Part 3:
You push ahead with getting a post-natal medical history. The child had
"bronchiolitis" at 4 months of age and was hospitalized at that time. He was also in the hospital at age 6 months for dehydration and fever (r/o pneumonia). He has no known allergies and is currently only taking pediatric cold medicine for "congestion." He is missing his 6 month immunizations. This is why he is in the clinic today. After more questioning about his feeding and temperament, his mother offers that he is a "spitty" baby with non-bilious, non-projectile vomiting during or after feeding. His mother can't quantify, but says that she is "scared" to
feed the baby too much at one time because of the vomiting. It is also hard to tell when the baby is hungry because when he is awake, "he is always fussy, even when just fed." His mother says that he sleeps a lot and is sometimes constipated. The child has an eczematous rash on his arms and legs, in the creases of his neck and behind his ears.
You ask more about the child's diet. His mother says that she mixes the formula the way that it says on the can when she has enough. You ask her what she does when she doesn't have enough. She says that she uses more water. She can't afford to buy the formula, so the father of the child brings some when he can. You ask her about putting the cereal in the baby's bottle. She says that her grandmother taught her that this will help the baby to feel fuller and mom has noticed that he doesn't spit as much with the cereal in the bottle. You ask if anyone else in the family ever feeds the baby. His mother says that her
mother enjoys feeding the baby, especially Vietnamese rice soup in his bottle. You ask the mother how often the baby is fed. She says that she feeds him when he wakes up-he is a good sleeper-12 hours a night and two long naps. "So how often is he fed?" She says that he eats about four times a day. His mother adds that he doesn't like to eat and the nurses said not to force him. As you consider further questions, your medical student would like to know if this child will be admitted for FTT.
Case Questions:
Q1: Will a hospitalization always promote a better outcome than outpatient services for children with FTT?
A. No. Physicians must consider many factors, both positive and negative, regarding admission for FTT.
Q2: What are the "red flags" that might be contributing to FTT?
A. The table shown below provides a list of common factors that might trigger clinical undernutrition - both micronutrient deficiencies and FTT.
TABLE 6
CAPTION: Any of these findings increase the risk for FTT occurring especially when there are other risk factors, e.g., poverty, inadequate social support, etc.
Q3: What factors in this story may be contributing to poor appetite/poor feeding?
A. Medications - Cold medicines often contain appetite suppressants (These are currently considered inappropriate for use in children under the age of six years according to a recent statement from the AAP.)
Malnutrition/ketosis/lethargy
Neurological immaturity
Gastroesophageal reflux
Food allergy- cow's milk protein allergy common in children under a year with gastroesophageal reflux and atopic dermatitis
Constipation
Iron or zinc deficiency
Gluten sensitive enteropathy (rare at this young age) (Coeliac)
Q4: Is it appropriate to suggest helping Danny's mother apply to programs that can help provide a constant formula supply?
A. Yes. WIC may be very helpful to this family. In addition, there may be other programs that could help this family, such as local emergency food providers, and food stamps if they are eligible. Social work and dietician services are essential to a multi-systems approach to FTT.
Q5: How do I establish that there is a need for money or food support?
A. In the United States, the prevalence of food insecurity - an uncertainty of having enough food to meet basic needs for all household members because of insufficient money or other resources for food - in households with children under 6 is 40% greater than the rate for households without children (22% vs. 16 percent in 2004 ). Children being raised by a single mother were particularly vulnerable. (Karp 2005) A simple addition to a screening evaluation is to assess income expenses, resources for food and food insecurity. The first three questions of the USDA/Cornell Radimer food insecurity surveys will determine which children are "at-risk."
CAPTION: These questions are adapted from the CDC and Cornell/Radimer Food Insecurity Questionnaires. They are highly sensitive and likely to capture all children affected by food insecurity or hunger. (See Karp 2005 for further discussion)
Q6: Why discourage hospitalization?
A. During hospitalizations, mealtimes in the chaotic hallways of busy pediatric wards can disrupt fragile feeding interactions. Foods offered in the hospital may not be familiar or culturally appropriate for child and family and thus have little carry over to the diet post discharge. In addition, hospitalization can expose children to nosocomial infections. These can lead to further deterioration in their nutritional status. These factors must all be considered when thinking about hospitalization.
Q7. What criteria should be used for hospitalizations?
A. However, any child who can be defined by the criteria above as severely malnourished or bordering 3rd degree malnutrition should be hospitalized. Hospitalization may also be necessary to sort out complicated medical findings and coordinate laboratory assessments. Tube feeding should be used judiciously, because it can impede the natural development of children's feeding behaviors creating more obstacles to overcome later.
Q8. How does one work out a diet plan?
A. Help from a Registered Dietician is essential. The diet plan will be specific for each child with FTT, but there are some consistencies. Children should be fed on a set schedule, usually being fed 3 meals and 2-3 snacks per day. Children should be fed in a high chair or at the table, depending on age. The room should be free of distractions with the TV off and, ideally, the child is eating with others who are also eating. Children should not be force-fed and anxious parents may need to be assured that it is acceptable to offer food with a planned end time for the meal despite the child's poor intake.
Q9. What advice should be given parents?
A. Parents/guardians should also be assured that children of a young age will often be messy. This is normal and expected. It is advised for parents to wait until the meal's completion to clean up children, thus avoiding frequent interruption of the meal. Many children will want to feed themselves and the "two-spoon method" should be offered as an alternative to avoid power struggles with independence-seeking toddlers. The RD-nutritionist may also ask the parent/guardian to keep a "food record." This can be illuminating for both parent and clinician. As with all clinicians, nutritionists should remember to be sensitive to parent's cultures and beliefs and integrate them as much as possible in the diet plan to enhance cooperation and success. [Table 8]
Q10. Are other illnesses likely?
A. Yes. As noted, the old separation between "non-organic" and "organic" FTT misinforms. Chronic infections will also be common in malnourished children. Clinicians must keep in mind that malnutrition can depress cell mediated immunity and secretory IgA values and leave the child vulnerable to a chronic malnutrition/infection cycle where one may not know which came first.
Gastroesophageal reflux (GER) is relatively common in children with FTT. It usually manifests as non-bilious vomiting/regurgitation, head cocking, esophagitis, and anemia. In children under a year, GER is often associated with cow's milk protein allergy. Please see Table 9 showing recommended food selections during early life.
Q11. How much weight should be gained?
A. In conjunction with the full medical evaluation and based on the patient's age, the physician and nutritionist will need to create a diet plan for the child that aims at "catch up growth." This is defined as accelerated growth that exceeds the average weight gain for a child of this particular age and sex. In usual clinical settings, rates of gain 2 to 3 times that expected for age (see Table 10) until the child approaches an acceptable weight for height are a realistic goal. Close follow up and accurate anthropometric data will be necessary to assess the efficacy of the prescribed diet plan. Please see Table 10 for average weight gain for well children of different ages.
Q12. Are there ever children who are reported to eat enough but still fail to grow?
A. Yes. There is a syndrome, "hyperphagic short stature," described by Skuse and colleagues. At one time this was called "psychosocial dwarfism." These are older, usually school age, abused children who are restricted from food and water. They then gorge when they can, eating garbage and drinking out of toilets. The children tend to be short, but not skinny. They are growth hormone suppressed until removed from their toxic environment. It is an oft referred to but uncommon syndrome. see Skuse, et al. below.
Q13. What social variables contribute to FTT?
A. There are also many social factors that can lead to FTT including poverty, family discord or domestic violence, parental depression, intellectual impairment of caregiver(s), or psychiatric disorders. Social isolation, negative family dynamics, previous family trauma, and chaotic or over controlled feeding interactions can all be factors as well. These issues must be addressed if the FTT is to resolve. FTT is a family problem, often exacerbated by social inequalities. Blaming the mother will be both punitive and unproductive. A family system cannot properly care for a child with FTT if the system does not have enough material and affective resources with which to provide such care. A good treatment plan will encompass the needs of the household to help stabilize both the child and surrounding social system of the child. The goal is thriving children living in thriving homes.
Q14. How does one take a history without offending parents?
A. Questions may best begin with affirmation that clinicians are aware that having a child with FTT can be very stressful. They may also be receptive to questions about caregivers' views on the situation and their wish to have input on the treatment plan. These questions can then lead into discussions about the home, the child's interactions with others, and any difficulties with financial or social resources.
In simple terms appropriate to the understanding of the parents explain that FTT is a symptom, not a diagnosis. As a symptom, FTT usually indicates that the child is not receiving, not retaining, and/or not metabolizing adequate nutrients to maintain normal growth. FTT reflects multiple factors, medical, nutritional, developmental, and/or social. This is why it is imperative that clinicians evaluate the child and family on all four parameters. A thorough evaluation will provide the solid foundation on which to build a successful treatment plan. Clinicians must then remember to cooperate and communicate with each other and with the family to assure successful follow through on the treatment plan.
A Case study for residents to develop
Aaron A is four months old. He has arrived at your emergency department with a referral note from a community pediatrician. You meet Mrs. A. and review the record. You see that Aaron weighs 2,500 grams (5 pounds 6 ounces). You ask Mrs. A. how much Aaron weighed at birth. She says, "4 pounds 15 ounces." You calculate this to be 2220 grams, subtract from 2,500, reconvert and say. "He's about 7 ounces above birth weight. That seems a bit low for 4 weeks of age." Mrs. A. looks surprised and says, "But doctor, he's 4 months old." Here is the rest of the history.
Aaron was born at 36 weeks gestation at 2,200 grams. The birth was at another hospital. Initial care was in their NICU because of respiratory distress. You note that he had been intubated. Sepsis was suspected and he received a 5 day course of antibiotics. A subsequent review of those records did not show an organism being identified. He went home at 10 days of age. He was given monoclonal antibodies against RSV ("Synergis ®") because of respiratory symptoms and relatively low birth weight.
There was no further medical attention until this visit, which was triggered by some respiratory symptoms. The physician gave the first set of immunizations and sent the A. family to your hospital's emergency room for evaluation of his "severe wasting," as written on the referral note.
At your ER, the parents showed a note from the state newborn screening center indicating an abnormal test for congenital hypothyroidism.
Social History. Aaron lives with his mother, father and two older siblings (12 and 7 years of age) in a two bedroom apartment. The 7 year old has cerebral palsy, developmental delay, and a seizure disorder. The husband was working as a night watchman, but his work did not provide health insurance. Their income was higher than allowed by Medicaid. The second son had a Medicaid exemption for his care. They were unaware of State CHIP allowances up to 2.7 of the poverty level.
A diet history showed that Aaron was exclusively formulae fed. Mrs. A was making the formulae as follows: two ounces of concentrate were mixed with 4 ounces of water with two teaspoons of cereal. This was given 8 times a day. Aaron has 6 wet diapers and 3-5 greenish soft bowel movements a day.
The mother was asked, "Why didn't you take Aaron to a physician?" She answered that she didn't have insurance. This is why she did not return for well child care at the hospital of birth. She was not aware that Aaron was failing to thrive. The mother seemed to be affectionate with Aaron. There were no signs of maternal depression, physical abuse, or negligence in care other than the late arrival for care. Her visit to the local physician was triggered by URI symptoms.
Q1. Now what do you do?
For the preceptor: This is an actual case history with a name change. Have the residents evaluate the case using the material described in the module. Here are the elements in the actual case of Aaron A.
Appropriate resident suggestions:
1. Confirm birth date
2. Re-measure weight, length, and HC
3. Get a careful history of perinatal experiences -- Obtain the hospital record
4. Determine why Aaron came for first visit at 4 months of age
5. Carefully assess social history looking for
a. Objective reasons for FTT [see Table 3]
b. Subjective reasons (Process Scale)
6. Assess the nutritional history
7. Contact other hospital to determine attempts to follow-up for baby care. [Mrs. A. says that there were none.]
8. Contact the state new born screening office to determine their attempts to follow-up
Q2. What objective measures of risk for failure to grow were evident? What would you be looking for?
A. These include poverty and its associated conditions as well as elements of family structure and ability to use the services of the society at large. The elements of tables 5 and 6 should be discussed here. The facts in Aaron's care are that the family lost its health insurance just after Mrs. A's hospitalization. She believed that the child could not go for follow-up. She was not sure of herself to push the system to her advantage. On history, there was a severely handicapped child in the home. Do not ignore the first hospital's inability to follow-up on the care of a child discharged from their NICU. The State testing bureau sent a report of the positive test for hypothyroidism to that hospital. This condition would be on a list of causes for the FTT. In fact, it was a false positive. Of note, the first repeat in-hospital showed substantially diminished T3. It was a "false positive" deriving from FTT on hypothalamic pituitary axis function.
Q3. There are subjective measures, also. What characteristics do you look for in your meetings with families that might make the child "at-risk" for malnutrition? Specifically, how do you assess parent child interaction?
A. The "gold standard" is the Bradley Caldwell HOME inventory. Another respected standard is the Polansky Child level of Living Scale. The latter was developed specifically to assess parental attention to children in urban poor communities. Polansky's scale uses non-material measures entirely [See Table 11]. The table below gives elements of the inventory related to food.
These questions are drawn from Polansky N, et al. Child level of living Scale. Child Welfare 1978;62:439 . The questions were excerpted for Karp RJ. (1993).
Q4. How does one evaluate parent: child interaction? [As with all of these questions, let residents take the lead.]
A. Patrick Casey of little Rock Children's Hospital has developed a process Scale based on what a pediatrician might experience in his or her office. Casey suggests 4 steps to a process evaluation.
1. Conduct an interview with the child held or observed by the parent.
2. Conduct the non-interventional part of the examination with the child in the parent's lap.
3. Conduct the interventional part (ears and mouth exams) with the parent holding the child firmly.
4. Return to the original setting for a review of findings and guidance. As Casey and colleagues have shown, the observations can lead to support for effective parenting.
Ask the residents to list these elements. The full list is shown as Table 5 in the Appendix
- Casey's scale goes from 1 to 4 on 20 items.
- CLICK on the THUMBNAILS to see Casey's Scale
These observations can be scored a "1" for the least appropriate response to a "4" for the most appropriate.
Other examples of scoring:
1. A parent who dresses her child with great care in new clothes chosen for a meeting with a very important person (You) gets a "4." It is enormously respectful though difficult to undress and redress children. A child in clean neat clothes rates a "3." Parents who bring their children in clothes that are soiled get a "2. The child in soiled foul smelling clothes with dirt under nails, hair matted and soiled rates a "1."
2. Does the parent give every description of child development with a positive accentuation? That's a "4." Modest praise (2 or 3 times) is a "3," praise once is a "2." No praise is a "1."
3. Or does the parent give every comment a negative spin? That is a "1." No negatives rate a "4". The two's and three's are as above.
The 20 characteristics are summed with a total of 20 to 80. The lowest scoring children (20 to 40) are at great risk for growth retardation and developmental delay. It is not necessary to rate an 80 to be an effective parent. [An "80" parent would drive a child wild and make you wonder if he and she have lives of their own.]
Q5. What would make you call in Child Protective services for a child who is failing to thrive but does not show signs of physical abuse or neglect?
A. Again let residents talk this over. There is general agreement that the approach to an abused or neglected child should be used when there is:
"intentional withholding of food from the child; strong beliefs in health and/or nutrition regimens that jeopardize a child's well-being; and/or family that is resistant to recommended interventions despite multidisciplinary team approach."
or obviously concomitant physical abuse. Very poor hygiene would be included unless they are living in a car and have no realistic opportunity to wash (An adaptation of Block and Krebs used by Black, et al.)
Q6. Would you call Child protective Services for Aaron?
A. The local "Administration for Children Services" (ACS) was called by the Emergency Room staff. Subsequent discussion with social work and staff resulted in ACS providing support for the family as they enrolled in health care and food support programs. No permanent record of abuse or neglect was maintained. Aaron continued in medical care. The older child's support was enhanced. Home Health Aide Services were provided to give respite to the family. They were enrolled in WIC and Food Stamp programs. The Dietician developed nutritious meal plans for the family within their budget. Parenting staff worked with Mrs. A on ways to work with the three very different children effectively. Aaron has grown and developed well.
Summary:
Prognosis for children with FTT is better for children with a short period of malnutrition as opposed to a chronic case of FTT. Even with successful treatment, many children will be shorter than comparison children and below their genetic height potential throughout childhood. However, they may exhibit some catch up growth in stature during adolescence. They may exhibit long-term deficits on cognitive test scores, as well difficulties in school. They are also more likely to have trouble dealing with stress.
As Hepner and Maiden wrote in 1971. "A mother may have the best intentions and desire to perform adequately, but her priorities for this effort may be deflected by inundating circumstances beyond her control." Thus, caring for children with FTT must be consistent and cooperative. A multidisciplinary team is essential. Developmental intervention and enrichment should be started at diagnosis. Early intervention services are essential to enhance ability of the child to thrive emotionally and intellectually as well as to grow. Social service evaluation and intervention is often crucial. With coordinated care from family and a multidisciplinary team, 90% of children will show catch-up growth. The goal of everyone involved must be a thriving child in a thriving environment.
Post test: True or False?
Q1: You can stop correcting by gestational age for weight at 24 months chronological age.
A:True.
Q2: Physicians shouldn't be hesitant to hospitalize a mildly malnourished toddler.
A:False
Q3: Children with FTT will often show blunted affect.
A:True.
Q4: Power struggles over feeding between parents and toddlers can never lead to FTT.
A:False.
Q5: "Scruffy looking mother" is a "red flag" for FTT.
A:False.
Choose the best answer.
Q1: A CBC with differential should be taken for which of the following children?
a) Caucasian children with FTT
b) African-American children with FTT
c) Low SES children with FTT
d) All children with FTT
A: D
Q2: Which is the best way to treat children with FTT?
a) With a multidisciplinary team
b) Refer to a gastroenterologist
c) Call child protective services
d) High calorie diet and a 6 month follow-up appointment
A: A
Q3: FTT is almost always due to which of the following?
a) Caretaker neglect
b) Asthma medications
c) Developmental delay
d) None of these
A: D
Q4: Which of the following is a "red flag" for a nutritional contribution to FTT?
a) A toddler that often drools
b) A toddler with excessive intake of water, juice, or soda
c) A toddler who likes bananas
d) A toddler who is a "messy eater"
A: B
References:
Birch, H. G., Gussow, J. D. (1970). Disadvantaged children: Health, nutrition, and
school failure (chapter 5). New York: Harcourt Brace & World; Grune & Stratton.
Bithoney W, Casey P, Karp, RJ. Why is Johnny Small? A case presentation module on Failure to Thrive: Curriculum for Poor and Underserved Children of the Ambulatory Pediatric Association, 2000 http://www.servingtheunderserved.org.html.
Cahill JB, Wagner CL. Challenges in Breastfeeding: Neonatal Concerns.
Contemporary Pediatrics, 19:113-138, 2002.
Casey PH, Bradley RH, et al. The clinical assessment of a child's social and physical environment during health visits. J Dev Behav Pediatrics. 1988;9:333-8.
Casey PH, et al. Pediatric clinical assessment of mother-child interaction: Concurrent and predictive validity. J Dev Behav Pediatrics 1993;14:313-7.
Frank DA. Failure to Thrive (pp. 183-187). In Parker S, Zuckerman B, Augustyn M (Eds): Developmental and Behavioral Pediatrics, Philadelphia, Lippincott, William, and Wilkins Publishing, 2004.
Frank DA, Silva M, Needlman R. Failure to Thrive: Mystery, Myth and Method. Contemporary Pediatrics,10(2):114-133, 1993.
Frank DA, and Zeisel, SH. Failure to Thrive. The Pediatric Clinics of North America, 35(6): 1187-1206, 1988.
Frank DA, Drotar D, Cook J, Kasper D, Bleiker J. FTT (pp. 307-338) In Reece RM, Ludwig S (Eds.): Child Abuse: Medical Diagnosis and Management, Baltimore, Lippincott Williams and Wilkins, 2001. (See note above about updated book in progress)
Gomez F, Galvan R, Frenk S, et al. Mortality in second and third degree malnutrition. J Trop Pediatr 2:77-83, 1956.
Hepner R, Maiden NC. Growth rate, nutrient intake, and "mothering" as determinants of malnutrition in disadvantaged children. Nutrition Revs. 1971;29:219-23
Karp RJ. (1993) Growth of disadvantaged Children (in Karp RJ (ed) Malnourished Children in the United States: Caught in the cycle of poverty. Springer Publishing of New York, p53.
Karp RJ. (2005) Malnutrition among children in the United States: The impact of poverty. (in Shils ME, Olson, Shike M, and Ross AC. (eds) Modern nutrition in Health and Disease, 10th edition. Williams Wilkins Lippincott, Baltimore, MD.
Kedesdy JH and Budd KS. Childhood Feeding Disorders: Biobehavioral Assessment and Intervention. Baltimore, Paul Brooks Publishing Company, 1998.
Kessler D, Dawson P, (Eds.): Failure to Thrive and Pediatric Undernutrition: A Transdisciplinary Approach, Baltimore, Paul H. Brookes Publishing Co.,1999.
Skuse D, Albanese A, Stanhope R, Gilmour J, Voss L.A new stress-related syndrome of growth failure and hyperphagia in children, associated with reversibility of growth-hormone insufficiency. Lancet, 1996; 348:353-8.
Rudolph CD and Link DT. Feeding Disorders in Infants and Children. The Pediatrics Clinics of North America. 49:97-112, 2002.
Waterlow JC. Classification and definition of protein-calorie malnutrition. Br Med J, 3:566-269, 1972.
Yang YJ, Sheu BS, Lee SC, et al. Children of Helicobacter pylori-infected dyspeptic mothers are predisposed to H. pylori acquisition with subsequent iron deficiency and growth retardation. Helicobacter, 10(3):249-55, 2005.
APPENDIX
Annotated Answers to Pre-test Questions
A1. The answer is E. Through this module, you will find an emphasis on a broad multidisciplinary approach to both diagnosis and treatment of Failure to Thrive. No one element is more or less important than another. Neither should treatment in any of these areas be deferred until another is addressed.
A2. The answer is A. Some authors have referred to "Failure to Thrive" as "Failure to Grow." About 10% of children living in families with incomes below the poverty level have some element of growth failure.
A3. The answer is C. An older literature distinguished between "Organic" and "Non-organic" failure to Thrive. More recently, it was recognized that there is an interaction of disease states, parent and child behavior. Illness affects parental behavior and child response so what may begin as an acute illness, a series of illnesses, or a chronic disease often results in patterns of parenting thought of as engendering "non-organic" FTT. Similarly, children who are not well nourished are prone to having an increase in "organic" FTT.
A4. The answer is D. Much of child development in the three domains listed - cognitive, motor and social - are affected by a phenomenon called "sensitive period of development." That is, there are specific times in a child's life when they each of these are especially vulnerable because they are developing very rapidly. With respect to language, for example, the sensitive period of brain neuro development differs leading to an inability to use language as native. Rather, the child learns language as if it were foreign.
A5. The answer is C. But you knew that. Coordination of services is the key for all of the clinical situations in which FTT occurs.
A6. The answer is False. Calling child protective services would be necessary if there is "intentional withholding of food from the child; strong beliefs in health and/or nutrition regimens that jeopardize a child's well-being; and/or family that is resistant to recommended interventions despite multidisciplinary team approach, " or inflicted injury or totally neglected hygiene. (see Block and Krebs, and Black, et al.) A parent may not recognize that an infant has failed to gain weigh adequately while in the midst of family problems and insurance confusion. This does not represent neglect or abuse.
A7. The Answer is D. All children, regardless of race/ethnicity, should have their measurements entered on the standard NCHS curve. The dynamics of growth are always better indicators of FTT than single points. The "Thrive" in the Failure to … implies an inadequacy in the dynamics of growth. One limitation in the NCHC data is that bottle fed babies have a different trajectory of growth than purely breast fed ones. (Breast fed infants may actually grow faster in the first half of the first year and slower in the second. These curves from the WHO are shown in the Breast feeding module (Part 4, Section 1) and in Part 2, Section 2, Evaluation of nutritional Status.
