Failure to Thrive

Published on 06/06/2015 by admin

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Last modified 06/06/2015

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17 Failure to Thrive

Etiology and Pathogenesis

FTT can arise from organic disease or nonorganic (psychosocial) factors and is very often multifactorial. The underlying cause of FTT in almost all cases is undernutrition.

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.

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.

Clinical Presentation

Patients may present throughout infancy and early childhood, although most cases of FTT start in the first year of life. Weight is generally affected earlier and more severely than length. Psychosocial dwarfism is a distinct problem that occurs in patients older than 3 years of age and primarily affects height. Waterlow’s categorization of FTT as mild, moderate, and severe is determined by comparing a child’s growth parameters with the median values for the child’s age and height. Growth patterns demonstrating each of the three classes of FTT are shown in Figure 17-3.

Children who were born prematurely or with intrauterine growth retardation (IUGR) should be evaluated in the context of their gestational age and birth weight. Many children with prematurity and IUGR will catch up to their peers; however, if these children have not started to show significant catch-up growth in the first 6 months of life, they are unlikely to reach normal size. Children of short parents may be of low height and weight because of their genetic potential; however, the parents may have not reached their full genetic potential secondary to their own malnourishment as children.

Children with FTT generally have decreased height and weight in middle childhood compared with children who grew adequately during infancy. Long-term cognitive delays had been a concern for these children in the past, but recent research using community-based, rather than hospital-based patient samples, shows no significant difference in IQ between children with a history of FTT and children with adequate growth.

Differential Diagnosis

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