DOI: 10.1542/pir.

13-12-453
1992;13;453 Pediatrics in Review
William G. Bithoney, Howard Dubowitz and Harwood Egan
Failure to Thrive/Growth Deficiency
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FOCUS QUESTIONS
1. W hy is an understanding of the
concepts of growth failure In in-
fants and young children im por-
tant?
2. W hat factors are com m on to poor
growth and developm ent of In-
fants regardless of the specific
cause?
3. W hat steps should be followed to
enable the pediatrician to under-
stand the reasons for growth defi-
ciency in a child?
4. W hat are the various factors that
m ay interact to result In growth
deficiency?
5. How m ay growth deficiency be
m anaged successfully?
ARTICLE
Pediatrics in Review VoL 13 No. 12 December 1992 453
Failure to Thrive/Growth
Deficiency
William G. Bithoney, MD,* Howard Dubowitz, MD, and
Harwood Egan, MD
Definition
CLASSIFICATION AND TYPOLOGY
Although the diagnosis of failure to
thrive (FTT) is made frequently,
both the meaning of the term and its
value as a diagnosis remain debata-
ble. Because any serious disease can
cause growth failure, the term FTF
has little diagnostic usefulness. Clas-
sicably, the etiology of FVF has been
divided into organic and nonorganic
types, with nonorganic FTT defined
as growth deficiency without a diag-
nosable medical etiology and organic
FTF defined as growth failure caused
by a specific medical illness. A num-
ber of authors have questioned the
adequacy of this dichotomous view,
suggesting the need for a third cate-
gory: mixed etiology. In this
group of children, chronic, mild
problems, such as recurrent otitis
media in concert with behavioral
problems, result in aberrant behav-
iors, such as difficult temperament,
Assistant Professor of Pediatrics, Harvard
M edical School; Senior Associate in
M edicine, Childrens Hospita4 Boston, M A.
tAssistant Professor of Pediatrics, University
of M aryland School of M edicine, Baltimore,
M D; Director, Child Protection Progium,
University of M aryland Hospital, Baltimore,
M D.
Instructor in Pediatrics, Harvard M edical
School; Assistant in Pediatrics, M assachusetts
General Hospital Boston, M A.
sleep disorders, and altered eating
behavior, which together impair
growth. Even in cases in which the
growth deficiency is primarily due to
organic or nonorganic causes, the
problems seen in the children are
often multiple (eg, infants who have
cardiac failure also have feeding dis-
orders). Given the multiple contribu-
tory factors to FTT and the lack of
diagnostic specificity of the term, we
recommend that it be abandoned in
favor of the term growth defi-
ciency, which describes the presen-
tation of this entity: An underweight,
often stunted, undernourished child.
This term avoids any inappropriate
suggestion of diagnostic specificity.
After the etiology of the FTF is diag-
nosed, the child should be referred to
as one suffering from a specific dis-
order (eg, an oppositional feeding
disorder resulting in undernutrition
rather than nonorganic FIT or hepa-
titis associated with undernutrition).
DIAGNOSTIC CRITERIA
Although there are discrepancies in
the diagnostic criteria for growth de-
ficiency, the term typically is used to
describe infants and young children
whose weight is persistently below
the 5th percentile for age, on stan-
dardized growth charts, in the ab-
sence of constitutional delay. Growth
deficiency due to nutritional made-
quacy is defined through such anthro-
pometric measurements as weight for
age, height for age, and weight for
height.
W eight and height for age should
be charted by using the National
Center for Health Statistics growth
charts, which are both gender-spe-
cific and normed to be racially
representative of the population of
the United States. The W orld Health
Organization has recommended that
these charts be used as an interna-
tional standard for all children,
regardless of race. In general, the
finding of bow weight for age alone
(<5th percentile) suggests acute mal-
nutrition (wasting), while depressed
height for age (<5th percentile) sug-
gests more chronic malnutrition. The
use of these norms is problematic,
however, because they do not take
into account genetic endowment. A
number of authors have developed
quantifiable methods of correcting a
childs height for age (which relates
linearly to weight for age) given
mean parental height. Such correc-
tions should be used to modify the
growth chart quantitatively to adjust
for constitutional short stature in ge-
neticabby small children (Figure). Al-
though these corrections have their
limitations, one should not make a
diagnosis of growth deficiency with-
out at beast considering genetic en-
dowment. Such corrections are not
useful when parents themselves were
malnourished as children and, there-
fore, did not attain their genetic
growth potential. Children who fall
across two or more major percen-
tiles (eg, 55th to 20th percentile) on
the growth chart in 6 months time
should be evaluated for growth defi-
ciency even before they have fallen
below the traditional fifth percentile
threshold for the diagnosis of growth
deficiency. Children whose weight
for height is less than the fifth per-
centile also should be evaluated for
possible growth deficiency.
Epidemiology
Although growth deficiency occurs in
all socioeconomic strata, it is well
documented as occurring more fre-
quently in families living in poverty.
In 1984, findings from the M assa-
chusetts nutrition survey indicated
that 12% of children receiving
M edicaid had evidence of depressed
height for age rather than the ex-
pected 5% , suggesting that the re-
maining 7% had chronic malnutrition
due to poverty per se. Data from
other surveys have suggested that
growth deficiency affects as m any as
10% of the rural outpatient popula-
tion and a similar percentage of other
high-risk groups, such as homeless
children. It accounts for 1% of all
pediatric hospitalizations and occurs
in 80% of cases before the age of 18
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FI GURE. Tanner-Whitehouse chart. To use the chart, firs: find th e child s height and then follow
the curve until you reach the child s age. Next, pla ce a nder from this point a lon g the horizontal
line a cr oss th e middle of the chart to the r igh t side of the chart. Note the poin t wh er e th is lin e
cr osses th e ver tica l lin e of th e mean pa r en ta l h eigh t and r ecor d the per cen tile of the child s
h eigh t, given mean parental height. Repr in ted with pennission from Tanner I M , Goldstein H ,
Whitehouse Rh . Standards for ch ildr en s height a t a ges 2 to 9 yea r s a llowin g for h eigh t of
parents. Arch Dis Child 1970; 45: 755.
454 P edia tr ics in Review VoL 13 No. 12 December 1992
G R O W TH AND DE V E L O PM E N T
Fa ilu r t o Th rIv .
months. In approaching growth defi-
ciency, the physician must be aware
that the overwhelming preponderance
of cases seen in the outpatient setting
are without organic illness. Previous
data suggesting that organic illness
caused a high proportion of cases
were based on hospitalized patients
who were severe cases and not repre-
sentative of all children who are
growth-deficient.
P a t h o g e n e s is
Inadequate nutrition is central to the
development of growth deficit. Every
child who fails to thrive either has
not taken, has not been offered, or
has not retained adequate calories to
meet his or her nutritional needs
given his or her medical status. The
evaluation of pathogenesis in growth
deficiency involves the assessment of
risk factors that predispose to inade-
quate nutrition.
N O N O R G A N I C R I S K FA C T O R S
Determination of nonorganic risk
requires assessment of four areas of
functioning: temperament, interac-
tion, and feeding behavior in the
child and psychosocial stressors in
the parents. One must gather infor-
mation concerning these issues in
family interviews, observations of
feeding and play, and careful devel-
opmental assessment. Typical pat-
terns of risk include: 1) a difficult,
sickly child, an isolated, over-
whelmed mother, and a father who is
emotionally unavailable for support;
2) a d isor d er ed f eed in g sit u at ion r e-
subting in inadequate caloric intake or
retention; 3) limited interaction dur-
ing feeding; and 4) a social environ-
ment of stress or poverty. These
infants and children are described as
lethargic, passive, and immature de-
velopmentally and physically. Affec-
tive withdrawal and negative
affective communications in both
caretaker and child are common. A
spectrum of behavioral difficulties in
growth deficiency ultimately creates
t h e p er cep t ion of a b u r d en som e
child. This spectrum includes prob-
lematic eating behaviors, poor state
control, defiance, sleeplessness, and
problems of elimination. The families
of these infants often are sociably iso-
lated and overwhelmed and bess ver-
bal than comparison families. How-
ever, these families do not have a
higher incidence of overt psychopath-
ology than those of comparison
subjects.
TRANSACTIONAL M O DE L
Central to the development of growth
deficiency is the relationship between
parental problems and those of the
child and his or her environment.
The transactional model suggests that
neither the child nor the environment
alone determines the childs develop-
mental outcome; rather, each affects
and is affected by the other. Thus,
once an abnormal feeding pattern is
developed, the child may become
malnourished, anemic, and irritable.
These changes are associated with
structural, biomedical alterations in
the child (Table 1). The child then
begins to interact even more abnor-
mabby with his or her caretaker, re-
subting in perpetuation of the cycle of
irritability, anorexia, and abnormal
sleeping. It is the robe of the clinician
to alter this downwardly progressive
spiral. Abnormalities of attachment,
autonomy, self-regulation, and sepa-
ration all have been described.
T o call t h is p r ocess sim p ly m at er -
nab deprivation is an oversimplifica-
tion of etiology. Only in a minority
of cases is this extreme parental be-
havior found. More commonly, par-
ents misinterpret the infants cues of
hunger or do not understand the nu-
tritionab needs of their child. In some
cases, overdibution of formula, which
has been shown to relate to both pov-
erty and poor education, is responsi-
ble for the poor growth.
ORGANIC RISK FA C T O R S
Organic conditions that can cause a
predilection toward growth deficiency
include minor congenital anomalies,
prenatal and postnatal malnutrition,
medically complicated prematurity,
and ongoing medical conditions (eg,
anemia and bead poisoning).
Multiple miscellaneous patterns of
deformity are associated with short
stature and decreased weight (eg,
anteverted nostrils, microcephaly).
Such dysmorphic features provide
clues to management. Fetal alcohol
syndrome and other in utero toxic ex-
posures resulting in altered growth
patterns also are of interest (eg, fetal
hydantoin syndrome, maternal ciga-
rette smoking).
Infants suffering from intrauterine
growth retardation due to poor mater-
nal nutrition during pregnancy, con-
genital infections, or inadequate
placentation are born small for gesta-
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Table 1. Medical Abnormalities As s o c ia te d with Growth
Deficiency
Elevated aspartate amino transferase
Elevated abanine amino transferase
Anemia
Iron deficiency
Zinc deficiency
Lead poisoning
Decreased brain weight
Decreased neuropib#{ 176}
Depressed monamine oxidase activity resulting in decreased central nervous
system serotonin, norepinephrine
Impaired immunity
Mababsorption
Apparent renal tubular acidosis
Decreased growth hormone
Decreased thyroid hormone
Decreased somatomedin C
* The number of cel l -to-cel l connections or synapses in the central nervous system
Table 2. Gomez Criteria for Classifying
Malnutrltlon*
S e ve rity of
PERCENT MEDIAN WEIGHT/AGE
GRADE OF
MALNUTRITION
Weight 90%-i 10% of 50th percentile (median) normal
Weight 75% -85% of 50th percentile I mild
Weight 60%-74% of ideal body weight II moderate
Weight < 60% of ideal body weight III severe
(F.rample: A 9-month-old child who weighs 10 pounds is 50% of the ideal body weight (20 I bs)
for hi s age. Thi s child i s severely malnourished. Consider immediate hospitalization and
intensive evaluation with intensive nutritional resuscitation.)
*144 pfrg from Gomez F, at a!. Mortality i n third degree malnutrition. .1 T r ap Peds.
1956;2,77-83.
Pedi atr i cs i n Revi ew VoL 13 No. 12 December 1992 455
G R O W TH AND DE VE LO P ME NT
Failure to Th rIv# {1 4 9 }
tionab age (SGA). Children with evi-
dence of chronic in utero malnu-
trition, characterized by both
depressed weight and length at birth,
are represented disproportionately in
samples grouped by the diagnosis of
nonorganic FTF. Of interest, prema-
ture infants born of appropriate size
for gestational age who have neither
pre-, pen-, nor postnatal complica-
tions have a normal growth potential.
Malnutrition is the underlying
theme in all cases of growth defi-
ciency. The major impact of under-
nutrition in the child is to slow the
rate of weight gain, then height, and
then head circumference growth. The
childs metabolism changes from an
anabolic to a catabolic state. This
change is associated with other endo-
crine changes, such as a drop in so-
matomedin C bevels and bow bevels
of thyroid and growth hormones.
Other medical conditions associated
with malnutrition per se include ane-
mia, impaired immunity, diarrhea,
malabsorption, increased infection,
and apparent renal tubular acidosis
that corrects with improved nutrition.
Malnourished children living in high-
risk areas also have a high incidence
of lead poisoning, which predisposes
them to further behavioral and inter-
active problems that perpetuate ab-
normal feeding.
Depending on the timing as well
as the duration of the nutritional in-
sult, long-lasting effects on the cen-
tral nervous system occur that result
in structural brain changes associated
with gross motor delay, cognitive im-
pairment, inattention, anorexia, and
altered affect due to malnutrition.
Correcting the malnutrition, there-
fore, will improve the caretaker-child
interaction. If uncorrected, the mal-
nutrition itself can perpetuate the
growth deficiency and the behavioral
abnormalities seen in these children.
Clinical Assessment
An important first step is to review
all growth data, plotted on the appro-
priate growth chart, and to consider
whether a problem exists. Children
growing along their curves below
the fifth percentile in weight for age
and without other problems might be
small, but healthy. Premature babies
must be plotted on appropriate
charts, correcting for head circumfer-
ence until 18 months of age, for
weight until 24 months, and for
height until 40 months. In the outpa-
tient assessment of growth defi-
ciency, children whose weight is less
than or equal to 60% of the 50th per-
centile weight are severely malnour-
ished (Table 2), and hospitalizing
them immediately rather than doing
extensive outpatient evaluation
should be strongly considered. An
outpatient evaluation may be prefera-
ble, however, for children who suffer
f r om m ild or m od er at e m aln u t r it ion .
I t is n ecessar y t o con sid er f act or s
that limit a childs growth potential.
For example, special growth charts
h av e b een d ev elop ed f or ch ild r en
w h o h av e Dow n sy n d r om e. C au ses
of in u t er o gr ow t h r et ar d at ion (eg,
fetal alcohol syndrome) might impair
both pre- and postnatal growth. In
addition, a prenatal insult might be
aggravated further by a problematic
postnatal psychosocial environment.
Caution is warranted before fully at-
tributing poor gr ow t h t o a giv en con -
dition, and careful evaluation for
other possible contributors is needed.
It is important to conduct a con-
current evaluation of the likely con-
tributors to deficient growth. The
evaluation should comprise both
medical and psychosocial issues. Our
strategy focuses first on w h at a p r i-
mary care pediatrician in a busy
practice might reasonably do. This is
followed by indications for an inter-
disciplinary team evaluation, for hos-
pitalization, and for referral to child
protective services.
H I S T O R Y
Pregnancy
This aspect of the history is particu-
larly important if the baby was born
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Childr en who fall acr oss two or mor e
maj or per centiles (eg, 55th to 20th
per centile)...should be evaluated for
gr owth deficiency even befor e they
have fallen below the...Sth per centile.
456 Pediatrics in Review VoL 13 No. 12 December 1992
GROW TH AND DE VE LO P ME NT
Fai l u r e t o Th r i v e
S GA . In addition to possible m edical
problem s and tox ic ex posures (eg,
sm ok ing, drugs, alcohol), the m oth-
ers em otional reaction to her preg-
nancy should be ex plored.
Perinatal Period
Com plications, such as sev ere as-
phy x ia, during this period m ight
com prom ise subsequent grow th and,
thus, af f ect the parent-inf ant relation-
ship.
M edical H istovy
A detailed rev iew of sy stem s is
needed, and all illnesses should be
noted. M inor recurrent problem s (eg,
ear inf ections) can be im portant if
they dim inish the childs appetite. In
addition, caring f or a sick ly inf ant
can be stressf ul, w ith potential im pli-
cations f or f am ily f unctioning.
Grow th Pattern
A rev iew of the grow th patterns of
w eight, length, w eight-to-length ra-
tio, and head circum f erence is essen-
tial. Prev ious records should be
sought to f orm as com plete a picture
as possible. S pecial attention should
be paid to inf lection points in the
grow th pattern: W hat happened at
that point? Did the child begin to
hav e diarrhea? Did the parents get a
div orce? M uch can be learned by
understanding w hy an inf lection
occurred in the grow th pattern at a
particular tim e.
N utrition
A 24-hour dietary recall f or a ty pical
day or ask ing the parent to k eep a
diary of all f oods eaten during 2 to
3 day s can prov ide usef ul inf orm a-
tion f or assessing the diet. A ny unu-
sual and harm f ul parental belief s
concerning nutrition should be ad-
dressed. How ev er, the dietary history
m ight not be accurate; m any parents
sim ply do not rem em ber w hat w as
eaten.
For y ounger inf ants, f orm ula prep-
aration and daily intak e should be re-
v iew ed. For breast-f ed inf ants, the
m others diet, f luid intak e, and m ilk
supply should be assessed as w ell as
possible technical problem s w ith
nursing. Particular attention should
be paid to abnorm al, counterproduc-
tiv e f eeding patterns, such as day -
bong graz ing by the child.
Feeding/eating B ehav ior
A n assessm ent of responses to and
behav ior of the child during f eeding
is needed to identif y interactional
problem s. Usef ul questions include:
. Does y our child hav e strong
lik es and dislik es?
#{ 149} Can y ou cater to these pref er-
ences?
#{ 149} Does y our child f eed dif f erently
w ith dif f erent people?
#{ 149} Does y our child usually eat alone
or w ith others? In a high chair?
#{ 149} Does y our child usually eat at set
tim es?
#{ 149} Does he or she m ess a lot? Is
that hard f or y ou?
#{ 149} How do y ou k now w hen he or
she is or is not hungry ?
#{ 149} A re there distractions (eg, T V )
w hen y our child is eating?
#{ 149} Do y ou say or do any thing w hen
y our child eats w ell?
#{ 149} How do y ou f eel w hen y our
child eats poorly ? W hat do y ou do?
R esponses to these questions guide
the necessary f ollow -up. For ex am -
ple, if the child eats w ell w hen w ith
one person, it is helpf ul to ex am ine
w hy . A parent w ho seldom praises a
child w hen he or she does eat w ell
should be encouraged to use positiv e
reinf orcem ent. A parents f eelings,
such as those of f rustration or f ailure,
need to be addressed.
Dev elopm ent and B ehav ior
T he def inition of grow th def iciency
in this article does not include dev el-
opm entab or behav ioral problem s.
N ev ertheless, such problem s of ten
are associated w ith the psy chosocial
dif f iculties contributing to poor
grow th or w ith undernutrition. A t
tim es, the behav ior contributes to the
nutritional problem ; f or ex am ple, a
child w ho has a sleep problem m ight
be tired and irritable and hav e a poor
appetite. T heref ore, a screening as-
sessm ent of the childs behav ior and
dev elopm ent is recom m ended.
For selected children, a m ore com -
prehensiv e ev aluation is needed. T he
Denv er Dev elopm ental S creening
T est is not adequately sensitiv e f or
use in screening this high-risk group
of children. Pediatricians are encour-
aged to becom e f am iliar w ith other
m easures (eg, Early L anguage M ile-
stones) or to ref er these children f or
appropriate assessm ents, especially of
language delay , w hich is com m on in
these children and contributes to ab-
norm al interaction.
Fam ily History
M edical and m ental health problem s
in the f am ily should be rev iew ed in
addition to the parents heights and
the grow th patterns of siblings. How -
ever , this infor mation must be inter -
preted cautiously ; discrim inating
betw een genetic f actors and shared
env ironm ental problem s is not easy .
Psy chosocial History
S creening both the strengths of and
the stresses on the f am ily is needed.
A v ailable resources m ust not be
ov erbook ed; these are crucial f or
planning interv entions. Eligibility f or
the S upplem ental Food Program f or
W om en, Inf ants and Children (W IC),
Food S tam ps, M edical A ssistance,
and A id to Fam ilies w ith Dependent
Children (A FDC) m ust be considered
and participation f acilitated w hen
appropriate.
T he m others perception of her in-
f ant, her ow n f am ily ex perience, the
robe of the f ather, the relationship be-
tw een the parents, and the intellec-
tual ability of the parent(s) are other
areas that w arrant consideration.
PHY S ICA L EX A M IN A T ION
A com plete phy sical ex am ination is
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...hospitalization is indicated when
outpatient management fails...it might
be helpful diagnostically as well....
P edia tr ics in Review VoL 13 No. 12 December 1992 457
P GROW TH AND DEVELO P MENT
Fai l u r e t o Thriv e
essential. S igns related to the cause
of the grow th def iciency or indicativ e
of dif f erent f orm s of undernutrition
(eg, m arasm us, z inc def iciency )
m ight be f ound. Caref ul m easure-
m ents of the w eight, recum bent
length (standing height af ter 2 y of
age), and head circum f erence (until
age 2 y ) are needed. A m ore ref ined
assessm ent of nutritional status is
possible by determ ining the f at and
m uscle m ass v ia m easuring triceps
sk inf old and the m idarm circum f er-
ence; percentiles can be plotted by
using norm ativ e data. T he upper-to-
low er body (head-to-sy m phy sis pubis
and sy m phy sis pubis-to-bottom of
heel) ratio can be calculated to screen
f or sk eletal dy splasias. Usually the
ratio is about 1.6 in new borns and
1.4 at 1 y ear of age.
PA R EN T -CHIL D IN T ER A CT ION
T he interaction betw een the parent
and child should be observ ed. T his is
an integral part of prim ary care pedi-
atrics. T he w arm th and appropriate-
ness dem onstrated by the parent in
addition to the responsiv eness to the
childs cues and the ex tent to w hich
the child ref ers to the parent f or sup-
port ref lect their relationship.
Observ ation of a f eeding interac-
tion can prov ide v aluable inf orm a-
tion. T his can be reasonably done
w ith inf ants w ho are being bottle-f ed.
T he parents com f ort in holding the
inf ant and in positioning the bottle,
her ability to encourage f eeding, her
persistence, and her responsiv eness
to the inf ants cues help determ ine
w hether a problem atic f eeding inter-
action is contributing to the poor
grow th. In the case of older inf ants
and children, observ ations can be
m ade in the hom e by a com m unity
health nurse.
La b o ra to ry A s s es s m en t
T he lim ited v alue of laboratory tests
in determ ining the etiology of grow th
def iciency has been am ply docu-
m ented. N earby alw ay s, the history
and phy sical ex am ination prov ide the
necessary inf orm ation, and laboratory
tests m ight conf irm a diagnosis. A t
tim es, specif ic tests are indicated.
For ex am ple, it is appropriate to
ev aluate thy roid f unction in a child
w hose length is prim arily af f ected or
to screen f or HIV inf ection in chil-
dren at risk .
Iron def iciency im pairs appetite
and should be screened f or w ith a
serum f erritin bev el; a bow hem oglo-
bin count is a relativ ely late sign of
depleted iron stores. Z inc def iciency
also has been f ound to com prom ise
grow th, and elev ated lead lev els hav e
been associated w ith def icient
grow th.
Man ag em en t
T he m anagem ent of grow th def i-
ciency requires a clear understanding
of all contributory f actors that com -
prom ise the inf ants grow th. Ideally ,
m anagem ent of grow th def iciency
should address as m any of the con-
tributory f actors as possible, but par-
tial solutions are still w orthw hile. For
ex am ple, counseling about nutrition,
im prov ing the parent-child interac-
tion, or treating the m others depres-
sion m ight substantially im prov e the
childs grow th, ev en if other prob-
bem s are not resolv ed.
T he initial approach inv olv es gath-
ering the data described prev iously .
Clearly , this is a considerable am ount
of inf orm ation, and it m ight w ell re-
quire tw o or three v isits to com plete.
T he concern about the inf ants
grow th should be conv ey ed clearly ,
w ithout ev ok ing unnecessary alarm .
A lthough m any parents already are
anx ious about their inf ants siz e, oth-
ers m ight not be. It is not unusual to
hear comments such as, I w as also
sm all. A lthough this m ight point to
a possible genetic f actor, the need f or
ev aluation and interv ention m ust be
ex plained.
T he specif ic m anagem ent should
be tailored to the needs of the indi-
v idual child and f am ily , according to
the sev erity of the grow th def iciency .
In general, outpatient m anagem ent
should be attem pted f irst, w ith f re-
quent (perhaps w eek ly ) v isits recom -
m ended. A ny m edical problem
should be ev aluated and treated. Pc-
diatricians need to be f am iliar w ith
those conditions that can im pair
grow th. How ev er, ev en f or cases that
appear to be prim arily organic, due
consideration should be giv en to
nutritional and psy chosocial issues.
A t tim es the problem is relativ ely
straightf orw ard and easily corrected
(such as an error in diluting f or-
m uba). M ore of ten, the issues are
quite com plex , and m anagem ent is
lik ely to ex tend f or sev eral m onths or
longer. It is helpf ul to state this m i-
tially so that parents do not harbor
unrealistic ex pectations of a quick
f ix .
N UT R IT ION A L M A N A GEM EN T
In the case of sev ere undernutrition,
early consultation w ith a nutritionist
should be sought; initial rehabilita-
tion m ust be cautious to av oid com -
plications such as circulatory decom -
pensation. For m ild or m oderate un-
dernutrition, ad bibitum oral f eedings
are appropriate, and the pediatrician
can adv ise parents to bolster the ca-
boric intak e by increasing the caloric
density of liquids and f oods (T able
3). T he num ber of calories per ounce
of f orm ula can be increased, and f or-
m ulas are av ailable that contain 30
k cab per ounce. T he 24-hour dietary
recall of f ers a basis f or im prov ing the
diet. Foods that hav e m inim al nutri-
tional value (eg, soft drink s) should
be discouraged, and high-calorie
m eals and nutritious snack s should be
recom m ended.
S pecif ic nutrient def icits m ust be
treated. A m ubtiv itam in preparation
that includes iron and z inc is recom -
m ended f or all undernourished chil-
dren. Unusual dietary belief s of
parents need to be addressed w hen
the grow th and health of the child are
com prom ised. How ev er, dif f erent
diets m ight be acceptable, such as a
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Nonfat dty milk - 25 kcabfFbsp
Stir into potatoes, ground meats, cereals, pudding, and yogurt. Also use to
fortify whole milk: 8 oz whole milk + 2-3 Thsp fat dry milk = 24-26 kcab/
oz. Use only if renal status is normal.
Cheese - 100 kcal/oz
Add melted cheese to a variety of dishes, including vegetables, casseroles,
fish.
Sour cream - 30 kcab/Tbsp
Add to beans, squash, potatoes, gravies, casseroles, or salad dressing or use
as a dip.
Heavy (whipping) cream - 60 kcalfTbsp
Mix in gravies, add to casseroles, salad dressings, hot chocolate, cereal,
potatoes, and eggs ______________________________
Butter, margarine, oil - 40 kcal/tsp
Add to gravies, mashed potatoes, cereal, rice, pasta, breads, muffins, and
spaghetti sauce.
Peanut butter - 100 kcab/Thsp
Spread on toast, bread, cookies, apples, and bananas.
I nstant breakfast preparation - 130 kcal/packet
I ncreased formula concentration
Example: 13 oz infant formula concentrate with 10 oz water = 24 kcab/oz
high-calorie formula. Use only if renal status is normal.
* Adapted from Tougas, L. Department of Nutrition, Children s Hospital, Boston, MA.
458 Pediatrics in R eview V oL 13 N o. 12 Decem ber 1992
I G R O W TH AND DE VE LO P ME NT
L Fai l u r e t o Th rIv# {1 4 9 }_ _ _ _ _
vegetarian diet that includes eggs and
dairy products; consultation with a
nutritionist is recommended to make
appropriate determinations.
Poverty is an important contributor
to undernutrition. It is necessary to
inquire as to whether a back of
money is making it difficult to pur-
chase enough food. Participation in
the WIC program, Food Stamps,
Medical Assistance, and AFDC pro-
grams should be facilitated. How-
ever, WIC is provided only to
approximately 50% of eligible fami-
lies nationally. Furthermore, even
when a family has all these benefits
(and access to free school breakfasts
and bunches for the children), only
two thirds of the cost for an adequate
diet might be covered. Therefore, pe-
diatricians should advocate for poli-
cies and programs that ensure enough
food for all children and adults.
BEHAVIORAL INTERVENTIONS
At times, the problems with feeding
and other behaviors are quite com-
plex, and expert consultation should
be sought. However, pediatricians
can intervene effectively in many
feeding problems. Useful guidance
for parents includes the following in-
structions:
1) Try to relax; feeding/eating
and meal times should be pleasant
for everyone.
2) Avoid battles over eating. En-
courage your child, but avoid forced
feeding or punitive approaches.
3) You are responsible for decid-
ing what food your child is offered
(with consideration for your childs
preferences); your child decides how
much to eat.
4) Use positive reinforcement
(eg, praise for eating well).
5) The withholding of food is not
an appropriate form of punishment.
6) Accept your childs wish to
feed him- or herself. Accept that
there will be a mess and be prepared
(eg, newspaper on the floor).
7) Try to eat together as a fam-
ily. Good eating behavior can be
modeled, and young children like to
mimic older siblings and parents.
8) Allow about 1 hour without
food or drink (except water) before a
meal to stimulate the appetite.
9) Consumption of excessive
fluids reduces the intake of solid
foods; offer solids first and limit
juices to 4 to 8 ounces per day.
10) Establish a routine of meals
and snacks at set times, with some
flexibility; however, avoid snacks
right after an unfinished meal.
1 1) Recognize your childs cues
indicating hunger, satiety, and food
preferences.
12) Limit possible distractions (eg,
television) during meals.
PSYCHOSOCIAL INTERVENTION
Assessment of the psychosocial situa-
tion guides the optimal interventions.
Depending on the pediatricians skills
and interest, support and counseling
might be offered. For some families,
home-based intervention is necessary;
a community health nurse or bay
home visitor can provide valuable
guidance, support, and monitoring.
Referral to a mental health profes-
sionab or community resource (eg,
parents group) also might be appro-
priate. The pediatrician has an impor-
tant robe as case manager, acting
as a liaison between the family and
other professionals while continuing
to monitor the childs progress. If
these modes of intervention fail, re-
ferrab to a behavioral psychologist or
other interaction expert should be
considered.
INTERDISCIPLINARY TEAM
APPROACH
Recalcitrant cases are best managed
by an interdisciplinary team approach
that combines pediatric, nutritional,
mental health, and social work exper-
tise. The pediatrician might form an
ad hoc team by using available re-
sources or refer to an existing team.
HOSPITALIZATION
In general, hospitalization is indi-
cated when outpatient management
fails. Additional considerations in-
clude the severity of the growth defi-
ciency, the vulnerability of the
infant, the presence of significant
medical problems, and psychosocial
circumstances that preclude outpa-
tient management. In particular, a
hostile stance by the parent toward
the child or the apparent risk of child
abuse justifies hospitalization. Hospi-
talization might be helpful diagnosti-
cally as well as therapeutically. For
example, observation of the parent-
infant interaction can provide useful
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Pediatrics in Review VoL 13 No. 12 December 1992 459
information. However, weight gain
in the hospital is not conclusive evi-
dence that psychosocial problems
alone caused the poor growth; both
children who have organic and non-
organic growth deficiency have been
found to gain weight in the hospital.
If a child is hospitalized for
growth deficiency, the parents should
be included as much as possible in
the treatment plan. Parents of these
children often feel a sense of failure,
and the success of hospital staff
might exacerbate this feeling. In
most cases, infants will remain in
their parents care, with the goal
being to enhance their nurturing abil-
ities. Careful discharge planning with
necessary support and follow-up is
needed.
Ref er r al t o Ch i l d Pr o t ec t i v e
Ser v i c es (CPS)
One definition of child neglect fo-
cuses on important needs of children
that are not met; most undernour-
ished children meet this criterion.
Clearly, multiple factors (eg, pov-
erty, parental ignorance, a childs
disability) might contribute to poor
nutrition. CPS should become in-
volved only in those cases in which
the major responsibility (or blame)
for the poor growth is attributed to
the parents.
Legal definitions of neglect are
typically vague, allowing room for
clinical judgment. One approach is
first to provide available interven-
tions that are less intrusive in a con-
structive effort to improve the
situation. However, if reasonable ef-
forts have been made and the parents
still are unable to care for their infant
adequately, CPS should be involved.
Even then, a strategy guided by a
philosophy of family preservation (ie,
use of support services to keep the
family intact) should be tried. If this
fails, foster care and adoption need
to be considered.
Some children whose growth defi-
ciency is due mainly to family dys-
function also are abused. The mor-
bidity and mortality in such children
has been found to be substantial, and
CPS must be involved immediately.
However, CPS agencies often have
little expertise to help these families,
and it is important for the pediatri-
cian to continue to care for the child
and to work with CPS.
Pr ev en t i o n
Pediatricians are well placed to help
prevent growth deficiency in many
situations. This requires close atten-
tion to the medical and psychosocial
risk factors described earlier, coupled
w it h the appropriate interventions.
Political advocacy for food assistance
programs for poor children is also
important.
Pr o g n o s i s
Given the many possible factors con-
tributing to growth deficiency, it is to
be expected that the outcomes are ex-
tremeby variable. Although it is diffi-
cult to discriminate the effects of
undernutrition from the frequently as-
sociated environmental deprivation,
there is ample evidence that undernu-
trition itself can impair cognition and
behavior, with bong-term effects on
development. It is important to note
that most of the follow-up studies of
children who failed to thrive during
infancy involved the more serious
cases who were hospitalized and
lacked control groups; the prognosis
for children meeting the definitional
criteria in this article is likely to be
quite different.
Long-term growth decrements ap-
pear likely with chronic major medi-
cab problems or severe, chronic
undernutrition of early onset. For
most children in developed countries
where undernutrition tends to be mild
or moderate, the prognosis for subse-
quent growth is good, particularly
with early intervention.
Specific conditions are associated
with different growth outcomes. For
example, both healthy premature and
asymmetrical intrauterine growth-
retarded infants (in whom weight is
primarily affected) frequently achieve
good catch-up growth, whereas
infants who experience symmetrical
intrauterine growth retardation (all
growth parameters similarly affected)
usually fare less well. In addition,
there is naturally a substantial genetic
influence on growth.
The effect of growth deficiency on
intellectual development and behavior
depends on the etiology. However,
severe, chronic, early-onset undernu-
G R O W T H A ND DEVEL OPMENT
Fai l u r e t o Th r i v e
trition has been associated with alter-
ations in the developing nervous
system, some of which are likely to
be permanent. Moreover, minor nu-
tritional deficits (eg, iron deficiency
anemia) have been found to influence
behavior.
Deficient growth during infancy
and childhood does harbor potential
risks for subsequent growth and de-
vebopment. The heterogeneity in out-
come reflects the many different
factors that can contribute to the defi-
cient growth. In many situations the
prognosis can be excellent if the
medical, nutritional, and psychoso-
ciab needs of these children and fami-
lies are met.
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DOI: 10.1542/pir.13-12-453
1992;13;453 Pediatrics in Review
William G. Bithoney, Howard Dubowitz and Harwood Egan
Failure to Thrive/Growth Deficiency
Services
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