Nonorganic Factors

Various psychosocial factors can lead to FTT. Child characteristics such as low appetite, food aversion, and oral-motor dysfunction make children susceptible to FTT and may interact with caregiver and social factors that exacerbate the problems. Many of the same psychosocial conditions that lead to FTT are also risk factors for obesity, suggesting that individual children respond to the same factors differently.

Although FTT can occur in children of all social classes, children living in poverty are disproportionately affected by FTT. Many children in the United States and other developed countries are “food insecure” and do not consistently have access to a minimally nutritious diet. This is particularly a problem in families that depend on the federal Women Infants and Children (WIC) program, which provides formula and food to supplement what a family is able to provide. Families may attempt to extend the supplement to supply all of an infant’s nutritional needs not realizing the dangers of using a diluted baby formula that is prepared with additional water. Supplemental coupons from WIC or food stamps are not intended to supply all of a family’s nutritional needs.

Even if a family is food secure, stressors associated with poverty can cause attachment problems, leading to difficulty in feeding for susceptible children. Families living in shelters or with many family members may have little control over when and where children are fed. Children whose temperaments and appetites require more routine or more frequent meals sometimes fail to thrive in these settings. Domestic violence can be associated with FTT through its detrimental effects on the caregiver, child, or both. Caregiver mental or physical illness, including postpartum depression (Figure 17-1), can also lead to disturbances of attachment. Children who are failing to thrive are at increased risk for abuse and neglect compared with the general population, but most experts believe that the majority of children with FTT are not abused or neglected (Figure 17-2). Some children in stressful living environments appear to have problems absorbing and using calories for growth because they grow poorly despite apparently adequate caloric intake and lack of organic causes for growth failure.

Figure 17-1 Postpartum depression.

Figure 17-2 Signs of neglect.

Cognitively impaired caregivers may prepare formula improperly or lack knowledge of an appropriate toddler diet. Some children prefer fruit juice or another single food over more nutrient-dense choices, and caregivers may not recognize this as a problem or be effective in encouraging children to eat a more balanced diet.

Caregiver health beliefs may also contribute to FTT. The influence of cultural expectations and norms, a parent’s relationship with the medical system, and individual beliefs may result in a family’s resistance to recognition of the problem or acceptance of intervention. Some caregivers may be so vigilant and concerned about nutrition and obesity that they may choose a restricted diet that is not appropriate for their child’s age.

Organic Factors

Organic factors can cause FTT by decreasing intake, decreasing absorption, or increasing metabolic demands. For example, poor motor coordination can cause decreased intake; celiac disease can cause malabsorption, and heart failure can increase metabolic demands.