Parental Health Beliefs as a Cause of

Nonorganic Failure to Thrive

Michael T. Pugliese, MD, Michelle Weyman-Daum, MS RD,

Nancy Moses, MNS, RD, and Fima Lifshitz, MD

From the Departments of Pediatrics, North Shore University Hospital, Manhasset, and
Cornell UnWersity Medical College, New York

ABSTRACT. Parental misconceptions and health beliefs In the developing countries, poverty and limited
concerning what constitutes a normal diet for infants is access to foodstuffs remains a major factor in the
reported as a cause for failure to thrive. There were seven parents’ ability to feed and nurture their children.4
patients (four boys, three girls), 7 to 22 months of age,
In the developed countries, access to foodstuffs is
who were evaluated for poor weight gain and linear
growth. They were only consuming 60% to 94% of the not a concern. However, it is being increasingly
recommended caloric intake for age and sex. The chil- recognized that certain health practices and beliefs
dren’s caloric intake had been restricted by their parents. can restrict a child’s nutrition and/or nurturing to
They were concerned that the children would become the point of nutritional dwarfing and/or disease in
obese, develop atherosclerosis, become junk food depend- spite of an abundant food supply.7
ent, and/or develop eating habits that the parents be-
Fear of obesity in adolescence has been recog-
lieved were unhealthy. The parents instituted diets con-
sistent with health beliefs currently in vogue and rec-
nized as a cause of growth failure. In this condition,
ommended by the medical community for adults who are the child voluntarily restricts his food intake to
at risk for cardiovascular disease. These diets caused the avoid becoming obese and incurring its associated
infants to experience inadequate weight gain and have a social and health stigmata.8 Parents may have be-
decreased linear growth rate. With nutritional counsel- liefs that can affect a child’s development. These
ing, all food restrictions were removed, the caloric intake
often well-intentioned beliefs may lead the parents
was increased to 94% to 147% ofthe recommended intake
for age. The weight gain rate increased significantly (P to engage in alternate of raising
methods their
< .05) from 0.1 ± 0.1 kg/mo to 0.4 ± 0.3 kg/mo, and the children, often to the child’s detriment.5’6 A well-
linear growth rate increased significantly (P < .05) from cited example is the occurrence of pernicious ane-
0.4 ± 0.4 cm/mo to 1.0 ± 0.6 cm/mo within 3 months of mia due to dietary vitamin B12 deficiency in chil-
therapy. Exaggerated concerns about excessive food in- dren of American parents who practice strict vege-
take in childhood and/or concern about the sequelae of
tarianism.7 Parental health beliefs and expectations
eating an improper diet has resulted in this entity of
can also lead a child to acquire anorexia nervosa-
failure to thrive due to parental health beliefs. Pediatrics
1987;80:175-182; nonorganic failure to thrive, growth, like symptoms merely to please the parents.9
health belief, athoroscierosis, infant-feeding practice. In this paper, we report a study of seven children,
all younger than 2 years of age, who were evaluated
for failure to thrive. They had no signs or symptoms
of organic disease; there was no evidence of neglect,
Infants are dependent on their parents for their lack of availability of food in the household, or
nutrition and nurture for an extended period of exotic feeding practices. Rather, their poor growth
time. Failure of the parent to supply either can was secondary to decreased caloric intake due to
cause the infant to fail to thrive.13 feeding practices influenced by their parents’ health
beliefs. These beliefs are based on health practices
currently in vogue and recommended for adults by
the medical community.’0” Following nutritional
Received for publication April 7, 1986; accepted Aug 27, 1986. counseling and institution of a liberalized diet with
Reprint requests to (F.L.) North Shore University Hospital, 300
Community Dr, Manhasset, NY 11030.
caloric intakes appropriate for age and sex, the
PEDIATRICS (ISSN 0031 4005). Copyright © 1987 by the children gained weight and grew in a manner ap-
American Academy of Pediatrics. propriate for age and sex.

PEDIATRICS Vol. 80 No. 2 August 1987 175

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MATERIALS AND METHODS Nutritional Evaluation
Assessment of the patients’ caloric intakes were
Patient Demographic Data
by a seven-day food record for four patients, in-
The patients in this study were seen at the North hospital calorie counts for two patients, and an
Shore University Hospital, Department of Pediat- unstructured interview for one patient. Standard
rics, Division of Nutrition, Endocrinology, and Me- references were used to calculate caloric values of
tabolism in Manhasset, NY, from July 1981 to the foods consumed’4”5 and to determine the rec-
November 1985. ommended daily requirements for age and sex.’5’7
There were seven children (four boys, three girls), The data were also analyzed by a computer program
ranging from 7 to 22 months of age. They were (NutriQuest) to determine the macro- and micro-
referred by their private family pediatricians for nutrient content.’8
evaluation of a possible organic cause for failure to
thrive. Two of the children, patients 6 and 7, were Psychosocial Evaluation
dizygous twins. No abnormalities were noted on
All of the families underwent a nonstructured
physical examination. These children came from
psychiatric evaluation and a review of their child-
skilled blue collar or white collar middle- and upper-
rearing attitudes during the initial consultation and
middle-income suburban families. Many ofthe par-
during the hospital stay for the children who were
ents were college educated. Five of the six families
hospitalized.
were intact, and both parents came with the child
for the majority of the visits to the physician. One
Elucidation of the Health Beliefs of Parents
family was intact at the beginning of therapy but
initiated divorce proceedings allegedly related, in As part of the initial consultation, the families
part, to disagreement about child-feeding practices. underwent a structured medical interview to eluci-
Four of the patients were first-born children. One date the presenting complaint of failure to thrive.
was a second child whose older sibling, by history, In the interview, the parents of patient 5 stated
was mildly overweight for height. The twin patients that they believed that, if breast milk was a superior
were the youngest of five siblings who were all food for infants, it would also be a superior food for
appropriate weight for height. older children. They also believed that an ideal diet
was one that was low in fat and protein of animal
Growth and Physical Assessment origin. This was volunteered during the initial in-
terview. For four other patients, the health belief
Prior growth data, including height, weight, and
was verbalized after the physical examination of
head circumference, were supplied by the private,
the child when the families, as part of the case
referring physician. All patients were also measured
discussion, underwent an unstructured open-ended
by Holtain anthropometer at the initial consulta-
psychosocial interview in which their attitudes to-
tion and on subsequent visits. National Center for
ward nutrition were explored and the various causes
Health Statistics charts for appropriate sex were
of failure to thrive were discussed. During these
used.’2 At the initial nutritional evaluation, triceps
interview sessions, the parents of patients 1, 2, 3,
skinfold thickness and midarm circumference were
and 4 voiced their fears about obesity and cardio-
measured and compared with published stan-
vascular disease to the physician. The parents of
dards.’3
patients 6 and 7 disclosed their health concerns and
The history and findings from examination in-
the fear of creating “junk food addicts” not at the
dicated no developmental delay or neurologic deficit
medical interview but subsequently during the
in five of the patients. The twins demonstrated a
structured nutritional interview conducted by the
mild developmental delay commensurate with their
nutritionist.
premature birth history without evidence of neu-
rologic deficit. RESULTS

Biochemical Assessment Growth Data

Hemoglobin, hematocrit, RBC indices, and The growth data of the seven patients are sum-
serum chemistry values, including renal and hepatic marized in Table 1. All children were below the
function studies, electrolytes, and serum proteins, fifth percentile for weight (Fig 1). Although five of
were studied. Also, urinalysis, thyroid function the seven children were below the fifth percentile
studies, and venous blood gas analysis were ob- for length, all were demonstrating deteriorating
tamed. A body iron store profile was obtained in linear growth and had crossed major percentile
two patients with microcytosis. lines. A deterioration of the weight gain rate pre-

176 NONORGANIC FAILURE TO THRIVE

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 TABLE 1. Physical Data
Patient No.
1 2 3 4 5 6 7
Sex M F F M M F M
Age (mo) 7 16 17 18 20 22 22
Wt (kg) 6.2 7.6 8.5 9.2 8.7 7.2 7.4
Wt %tile <5 <5 <5 <5 <5 <5 <5
Height (cm) 67.2 72.0 77.3 76.0 79.0 73.0 71.0
Height %tile 10-25 <5 10-25 <5 <5 <5 <5
Wt deficit for 21.0 14.6 15.3 8.7 18.7 20.8 16.4
height (%)

ceded the deterioration in the linear growth rate by

2 to 6 months. The weight deficit for height was
8.7% to 21.0%. The average weight gain rate in-
creased significantly (P < .05) from 0.1 ± 0.1 kg/
mo to 0.4 ± 0.3 kg/mo with liberalization of the
diet, and the linear growth rate increased signifi-
cantly (P < .05) from 0.4 ± 0.4 cm/mo to 1.0 ± 0.6
cm/mo within 3 months of initiation of therapy
(Fig 2).
Anthropometric measurements of four of the
children taken prior to intervention revealed evi-
dence of poor nutrition status characterized by 2
deficient muscle mass in one child (arm muscle area
below fifth percentile), deficient fat stores in an-
other (arm fat area below fifth percentile), and
deficient fat and muscle mass in a third. The fourth
child did not demonstrate a deficiency of fat or
muscle by arm measurements.
Fig 1. Growth data for seven children with nonorganic
Laboratory Data failure to thrive. Arrow, age when nutritional rehabilita-
tion instituted shaded area, fifth to 50th percentile areas
None of the children had evidence of acidosis,
for appropriate sex; No. at end of individual growth
and results of all urinalyses were normal. All had curves, patient’s identification No.
normal serum calcium and alkaline phosphatase
values for age and were without chemical evidence 2.0

of rickets. All had normal thyroid function indices. 1.8

None of the children had hypercholesterolemia a 1.
E
when routine chemistry studies were evaluated. 1.1
Analysis of the peripheral blood smears revealed no
microcytosis by age-corrected standards’9 or other
1.(
abnormalities. However, two children demon- 0

strated iron depletion on measurement of ferritin

levels. z
-J
0.1

Nutritional Intake 4

Preintervention. The preintervention food intake 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9

recalls and records indicated that all of the children WEIGHT GAIN RATE kg!mo.

were reported to be consuming less calories than Fig 2. Improved weight gain and linear growth after
the recommended among for age and sex (Table 2). nutritional rehabilitation instituted. Each arrow repre-
Many of the reported diets of the children were low sents one patient (No. 1 to 7).
in overall caloric supply due to a low percentage of
calories by fat. Fats made up 25% to
contributed in these children. The carbohydrates consumed
37% of the diet, with the difference made up by were usually of the complex type. This low-fat,
protein (15% to 26%). Low-fat dairy products and/ high-complex carbohydrate diet was consistent
or lean meats were used to decrease the fat intake with the desire, expressed by the children’s parents,

ARTICLES 177
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TABLE 2. Nutritional Data*
Patient Preintervention Postintervention
No. Met hods Used to Decrease Caloric
Calorie Intake Diet Calorie Intake Diet
(% Ideal Composition Intake (% Ideal for Composition (%)
for Age and Age and Sex)
Sex) Carbo- Pro- Fat Low Infrequent Low-Fat Decreased Carbo- Pro- Fat
hydrate tein Volume Snacking Dairy Junk hydrate tein
Products Food
1 94 55 20 25 + + + + 147 NA NA NA
2 NA NA NA NA + + + + 107 44 10 43
3 72 42 26 32 ± ± ± - 97 47 14 39
4 74 54 16 29 + - - + 97 62 13 25
5 63 NA NA NA + -t + - 94 71 9 20
6 67 48 15 37 + + - + 115 40 23 37
7 67 48 15 37 + + - + 114 40 23 37
* Abbreviations and symbols: NA, not available; +, present; -, absent; ±, method used occasionally.
t Child offered low-calorie between-meal snacks such as raw vegetables.
:1:Diet included whole breast milk but no other full-fat dairy products. Calorie contribution of breast milk not included
in table.

to reduce fat diet because

in the of fears of obesity and protein contributing 9% to 23% of the calories.
or premature atherosclerosis. Analysis of the food The complex carbohydrates were retained in the
records revealed eating patterns ofdecreased caloric diet.
intake, accomplished by decreasing the volume of Patient 1 exhibited catch-up growth when super-
food consumed at all meals in all children (Table vision of his diet was entrusted to the grandparents
2) and by decreased snacking in five ofthe children. to bypass the mother’s continued fear of making
Four families used low-fat dairy products, although the child obese and ensure the fulfillment of the
all reduced total fat intake. Five children were also nutritional plan (Fig 1). Supposedly, all dietary
not given junk foods which are characteristically restrictions were eliminated as recommended by
calorie dense. the physicians, but details of the dietary intake are
The diets provided 100% of the recommended not available (Table 3). The parents of patient 2
daily allowance of the vitamins A, B1, B,2, C, and implemented the dietary suggestions and in the
D and the minerals magnesium and calcium. Three short run the patient appeared to do well. However,
children had diets that were iron deficient. How- the family moved out of state which made long-
ever, only two of these had iron deficiency demon- term follow-up difficult. The parents of patient 3
strable by low ferritin levels. appeared to agree with our recommendations and
Postintervention. All patients received intensive did increase the child’s caloric intake from 72% to
nutritional counseling of their treatment.
as part 97% ofthe recommended daily allowance. However,
This consisted of private sessions between the flu- the diet remained low in calories derived from fat.
tritionists and the parents in which the composition The child’s growth has only paralleled the fifth
of normal children’s diets were discussed. Addition- percentile and she has not demonstrated any true
ally, three patients (No. 1, 6, and 7) were hospital- catch-up growth.
ized to definitely rule out organic disease and to In the case of patient 4, the parents agreed with
initiate the proper nutritional program. In general, the recommendations given and planned to imple-
the eating patterns were altered in that full-fat ment them as directed. The patient was seen mi-
dairy products were to be substituted for low-fat tiafly only recently, thus long-term follow-up is not
products, more volume was to be offered to the available. However, the early results appear en-
children at mealtimes, and calorie-containing couraging.
snacks were to be offered between meals. Addition- The parents of patient 5 implemented our rec-
ally, five of the children were given iron supplemen- ommendations with respect to adding whole milk
tation. The two children with proven deficiency and table foods to implement breast-feedings. How-
received therapeutic doses, and the other three were ever, table foods for this family are low-fat, high-
given maintenance doses. complex carbohydrate foods which did not com-
Following therapy and nutritional counseling, the pletely replace the percentage of fat normally in a
food intake recalls and records indicated a signifi- child’s diet. Also, the mother became pregnant, and
cant (P < .05) increase in the amount of calories this helped terminate the breast-feeding for the
consumed (Table 2). However, there was not much patient. In spite of the partially restricted diet, the
change in the overall nutrient distribution, with fat child is growing normally along the fifth percentile.
making up 20% to 43% of the calories consumed The parents of patients 6 and 7 were given the

178 NONORGANIC FAILURE TO THRIVE

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TABLE 3. Health Misconceptions and Remedy
Patient Health Concern Response to Health Concern Remedy
No.
1 Mother concerned that child will be Formula diluted with water No restrictions on food,
obese adult whole milk
2 Mother concerned about obesity in Sweets restricted, high calorie No restrictions on food in-
family and child foods restricted take
3 Mother concerned about obesity and Only low-fat milk and lean meat Whole milk, full range diet
cardiovascular disease in child used in diet
4 Father was obese child and adoles- High-fat foods restricted, high- No restriction on food or
cent and concerned that child, too, complex carbohydrates en- whole fat dairy products
would become obese couraged
5 Parents believed breast milk was su- Prolonged dependence on Liberalization of diet with
perior to any other food and breast-feeding, restricted inclusion of table foods
avoided fatty foods and red meat foods of animal origin
in healthy diet
6 & 7 Parents did not want to create “junk No snacking Mealtimes lengthened,
food addicts” snacking encouraged

same counseling about their childs’ diets, but the had experienced lifelong problems with weight con-
children’s intake remained erratic to the extent that trol. They were also concerned that the child would
on some days it was complete in the recommended become obese. They therefore restricted the child’s
daily allowance for calories, protein, fat, and iron snacks and intake of sweets, simple sugars, and
and on other days it was inadequate. After their high-calorie foods (junk food).
iron deficiency was treated, the children resumed The father of patient 4 was obese as a child and
normal growth rates and have maintained a normal as an adolescent. Only with extreme difficulty did
intake. the father lose weight as an adult. Therefore, he
restricted the child’s fat intake and relied heavily
Health Beliefs on complex carbohydrates in the diet.
Coru,ern About Atherosclerosis. The parents of
The health concerns that led to the children’s patient 3 were concerned about the high incidence
failure to thrive can be summarized as follows: (1) of atherosclerotic cardiovascular disease in their
fear of obesity, (2) fear of atherosclerotic disease, immediate family members. Several relatives had
and (3) desire for a healthy
diet. died of coronary artery disease; the parents and the
Concerns About Obesity. The parents’ concerns entire family were, therefore, ingesting a restricted
about inducing obesity in their children or predis- diet low in saturated fats, red meat, and full-fat
posing them to it took the following forms (Table dairy products. They also restricted the child’s in-
3). The mother of patient 1 had been obese as a take of these products, although they gave the child
child and had dieted extensively to achieve normal low-calorie snacks and did allow lean meats and
weight. She became concerned that the child was low-fat milk.
becoming obese and began to dilute the infant’s Pursuit of a Healthy Diet. The parents of patient
formula and juices with water. She also used only 5 avoided cow’s milk and processed cereals to elim-
low-fat milk and low-fat dairy products. The child mate fat and processed sugar which they considered
was evaluated by the pediatrician at 9 months of important for good health. They had adopted a
age and was referred to our service, which recom- partial vegetarian diet which consisted mainly of
mended increasing the calorie intake and the use fruits, vegetables, and whole grain products, but
of full-fat dairy products. The mother, however, included lean meats and dairy products. They were
rejected this advice and continued her usual feeding aware of the published benefits of breast milk as a
plans. At 13 months of age, the child was taken by sole source of nutrition for infants, and they ex-
his father to a different pediatrician for evaluation tended this idea to conclude that breast milk should
as part of custody proceedings. The child was ad- be a good source of nutrition for older children.
mitted to the hospital for evaluation and nutritional Therefore, they continued to use breast milk as a
therapy. At this time, the maternal grandparents major source of nutrition for this child late into the
intervened and agreed to institute the physician’s second year of life.
recommendations. The child’s custody, under the The parents of patients 6 and 7 were concerned
supervision of the grandparent, was awarded to the that their children would become dependent on
mother and the patient has done well on the unre- sweets and junk food, which were “unhealthy.”
stricted diet. Therefore, these children were not offered sweets
The parents of patient 2 were obese adults who or between-meal snacks.

ARTICLES 179
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DISCUSSION Abnormal mother-child interactions were noted
by Haynes et a124 in patients with nonorganic fail-
The seven children had nonorganic failure to
ure to thrive. The interactions were characterized
thrive due to decreased caloric intake imposed by
as benign neglect, uncoordination, and overt hos-
the parents in the interest ofpromoting good health
tility. Intervention geared toward modifications of
in the child. These parents were hoping to impart
the disordered maternal-child interaction resulted
good eating practices, avoid obesity, and/or avoid
in improved growth in only eight of 37 children
atherosclerosis. They imposed a low-fat, low-calorie
after 6 months of observation. In contrast, in our
restrictive dietary regimen on their children which
study, attention was aimed solely at the dietary
resulted in inadequate weight gain and poor linear
intake of the child, with the result of improved
growth. Elimination of the dietary restrictions re-
growth in all seven subjects. Although the children
sulted in the restoration of normal growth patterns.
were not studied with the same rigor regarding the
Much has been written about the causes of non-
maternal-child interactions as in the Haynes study,
organic failure to thrive. A debate has occurred as
it appears that the parents were acutely aware of
to whether there is inadequate nurture or made-
the child’s feeding cues and they responded to them,
quate nutrition or both.#{176}The role of nurture in the
albeit with the inappropriate food. It also points
normal development of infants was recognized by
Spitz,2’ who in 1945 coined the term “anaclitic out that with a precise diagnosis of the cause of
depression” to describe growth failure in infants poOr nutritional intake, the intervention was su-
cessful.
who were separated from their mothers. Recogni-
tion of an infant’s need for social stimulation and Fear of obesity in the adolescent age group has
human contact eliminated this disorder from insti-
been well described.8 In that syndrome, as in other
tutionalized infants. However, in re-
1957, it was adolescent eating disorders, such as anorexia ner-
ported that growth failure could occur even in the vosa, anorexia athletica, etc, it is clearly the pa-
mother’s presence.22 This led to the opinion that tient who shuns eating; the role of the parents in
nonorganic failure to thrive could be purely nutri- the etiology of these disorders is a source of debate
tional in origin, and therapy was focused on supply- beyond this paper’s scope. In fear of obesity, be-
ing the proper nutrition for growth to occur. cause of concerns about the decreased physical
In the field of child abuse studies, the concept of attractiveness, poor health, and shortened life span,
“target child” has been formulated. This refers to patients restrict their own intake of calories irre-
the finding that within . a family, the child who is spective of their parents concerns. However, in the
perceived as “different” because he or she is “. . .
cases described in this paper, it is clearly the par-
difficult to satisfy or who makes increased demands ents, fearful of the consequences of obesity and/or
on the parent is more likely to be the victim of atherosclerosis in their children, who restricted
abuse.”23 The possibility that the children pre- their children’s food intake. There are other simi-
sented in this paper with failure to thrive were larities to the adolescent fear of obesity syndromes
target children is unlikely. The parents perceived in that the parents recognized a problem in their
these children as being similar to themselves, i.e., child’s development, but sought medical attention
obese, prone to atherosclerotic disease, chronically because of poor linear growth, not body weight/
dieting to reduce weight. This led to the parents’ habitus. This is like the adolescents with fear of
desire to alter their children’s futures by altering obesity who complained of short stature but be-
their diet. lieved their weight to be ideal.8
For the patients presented here, there is little Whether it is ever possible to modify the chances
evidence of deprivation of maternal or paternal of obesity in a child by dietary manipulation is
affection, although the quality of the nurture could highly controversial. A recently published study
be questioned. Also, there was no desire of the demonstrated a strong genetic determinant to obes-
parents to nutritionally “deprive” their children but ity, in adopted children, that apparently cannot be
rather they sought to give them an “ideal” diet. The easily modified by environment in an advanced
failure to thrive appeared to arise from an overcon- Western society where food is freely available.26
cern about the nurtural and nutritional needs of Iron deficiency has been associated with anor-
the children by the parents, rather than by parental exia.27 Three of the seven children had dietary
neglect or deprivation. The parents believed in cer- record evidence of decreased iron intake and two of
tam nutritional practices anddid not wish to mod- the seven had overt iron deficiency. These two
ify them readily, despite evidence of failure to thrive patients (No. 6 and 7) were dizygous twins with
in their children. They thought that being thin and proven iron deficiency and were the same patients
avoiding obesity may be more desirable than eating who demonstrated only 67% of the recommended
potentially harmful foodstuffs. intake when observed in the hospital on an un-

180 NONORGANIC FAILURE TO THRIVE

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restricted diet. It is possible that iron deficiency 2. Glaser K, Eisenberg L: Maternal deprivation. J Pediatr
1956;18:626-642
added anorexia to an already calorie-reduced diet,
3. Powell GF, Brasel JA, Blizzard RM: Emotional deprivation
thereby worsening the failure to thrive. Iron defi- and growth retardation simulating idiopathic hypopituitar-
ciency-induced anorexia, however, does not explain ism: I. Clinical evaluation of the syndrome. N Engi J Med
1967;276:1271-1278
the decreased intake of the five other patients,
4. Keller W, Fillmore CM: Prevalence of protein-energy mal-
especially that of the child with adequate iron in- nutrition. World Health Stat Q 1983;36;129-167
take and iron stores, proven by blood smear, who 5. Bachrach S, Fisher J, Parks JS: An outbreak of vitamin D
deficiency rickets in a susceptible population. Pediatrics
nonetheless failed to thrive.
1979;64:871-877
Milk is a major foodstuff in a child’s diet. How- 6. Zmora E, Gorodicher R, Bar-Ziv J: Multiple nutritional
ever, it has been shown that prolonged reliance on deficiencies in infants from a strict vegetarian community.
Am J Di.sChild 1979;133:141-144
breast milk and delayed introduction of solids can
7. Lampkin BC, Saunders EF: Nutritional vitamin B,2 defi-
lead to delayed growth.28 This was probably a con- ciency in an infant. J Pediatr 1969;75:1053-1055
tributing factor in patient 5 who at 20 months of 8. Pugliese M, Lifshitz F, Grad G, et al: Fear of obesity-A
cause of short stature and delayed puberty. N Engi J Med
age was still using breast-feeding as his major
1983;309:513-518
source of calories. 9. Katz R, Mazer C, Litt I: Anorexia nervosa by proxy. J
Whole cow’s milk is a major source of cholesterol Pediatr 1985;107:247-248
10. Eating for a hialthy heart. Dietary treatment of hyperlipid-
and saturated fats. With the demonstration that
mia. Dallas, American Heart Association Office of Corn-
the fat deposits of atherosclerotic disease begin in munications, 1983
chi1dhood, many have voiced the opinion that 11. National Heart, Lung, and BlOOd Institute/American Heart
whole milk should be eliminated from a child’s diet Association. Heart-to-Heart: A Manual on Nutrition Coun-
seling for the Reduction of Cardiovascular Disease Risk Fac-
to reduce the child’s fat intake.30 The current opin- tors, National Institutes of Health publication No. 83-1528.
ion of the American Heart Association, as inter- Government Printing Office 1983.
preted by the American Academy of Pediatrics,3’ is 12. Hamill PVV, Dried TA, Johnson CL, et al: Physical growth:
National Center for Health: Statistics percentiles. Am J
that only children whose plasma cholesterol level Clin Nutr 1979;32:607-614
decreases in the top decile of their age and sex or 13. Frisancho AR: New norms of upper limb fat and muscle
children with a family history of myocardial infarc- areas for assessment of nutritional status. Am J Clin Nutr
1981;34:2540-2545
tion, stroke, or peripheral vascular disease before 14. Kraus B: Caloric Guide to Brand Names and Basic Foods.
age 50 years should be screened and considered for New York, Signet, 1980
a fat-modified diet. There is no evidence that whole 15. Pennington J, Church HN: Food values of Portions Com-
monly Used, ed 13. New York, Harper & Row, 1980
milk consumption alone leads to obesity,32 although 16. Recommended Dietary Allowances, ed 9. Washington, DC,
better weight gain and more normal body fat stores National Academy of Sciences, 1980
have been demonstrated in infants fed whole milk 17. Loupus WE: Nutritional requirements, in Vaughan VC,
McKay Ri (eds): Nelson Textbook of Pediatrics, ed 10.
formula compared with infants fed skim milk. In
Philadelphia, WB Saunders Co, 1975, pp 146-161
fact, low-fat milk consumption has resulted in es- 18. NutriQuest II: A Microcomputer-Based Nutrient Analysis
sential fatty acid deficiency in infants34 and could System. Kensington, MD, Capital Systems Group, Inc
19. Dallrnan PR, Siimes MH: Percentile curves for hemoglobin
lead to excess intake of protein.
and red cell volume in infancy and childhood. J Pediatr
Patient 3 meets the American Heart Association 1979;94:26-32
criteria for at-risk children for atherosclerosis and 20. Powell GF: Nutrition in nonorganic failure to thrive. Clin
Nutr Suppi 1985;4:54-58
needs to be followed carefully now that she is eating
21. Spitz R: Hospitalism, an inquiry into the genesis of psychi-
a liberalized diet. However, as demonstrated here, atric conditions in early childhood. Psychoanal Study Child
these atherosclerosis risk-reducing diets are not 1945;1:54-74
22. Coleman R, Provence 5: Environmental retardation (hos-
without their own risks in children and need careful
pitalism) in infants living in families. Pediatrics
supervision. For some children, a thin line can exist 1957;19;285-292
between obesity or failure to thrive and nutritional 23. McNeese MC, Hebeler JR: The abused child-A clinical
approach to identification and management clinical syni-
dwarfism.
posium. Ctha Found Symp 1977;29:2-36
In summary, the failure to thrive observed in our 24. Haynes CF, Cutter C, Gray J, et al: Hospitalized cases of
seven patients was due to primary malnutrition nonorganic failure to thrive: The scope of the problem and
short-term lay health visitor intervention. Child Abuse NegI
arising from parental health concerns. The failure
1984;8:229-242
to thrive resolved when a liberalized diet was im- 25. Smith NJ: Excessive weight loss and food aversion in ath-
plemented. It appears that society’s obsession with letes simulating anorexia nervosa. Pediatrics 1980;66;139-
being slim and trim and its fear of heart disease 142
26. Stunkard AJ, Sorensen TIA, Hanis C, et al: An adoption
has resulted in another disease of poor growth and study of human obesity. N Engi J Med 1986;314:193-197
delayed development in infancy. 27. Oski FA: Nutritional anemias in infancy, in Lifshitz F (ad):
Pediatric Nutrition New York, Marcel Dekker, 1982, pp
123-138
REFERENCES
28. Victora CG, Vaughan .JP, Martines JC, at al: Is prolonged
1. English PC: Failure to thrive without organic reason. Pediatr breast feeding associated with malnutrition? Am J Clin Nutr
Ann 1978;7:774-781 1984;39:307-314

ARTICLES 181
Downloaded from http://pediatrics.aappublications.org/ by guest on December 10, 2017
29. Strong JP, McGill HC Jr: The pediatric aspects of athero- 1972;49;305-307
sclerosis. J Atheroscier Res 1969;9:251-265 32. American Academy of Pediatrics, Committee on Nutrition:
30. Glueck CJ, McGill HC Jr, Lauer RM, at al: The value and Should milk drinking by children be discouraged? Pediatrics
safety of diet modification to control hyperlipidemia in 1974;53:576-582
childhood and adolescence-A statement for physicians. 33. Fomon SJ, Filer U Jr, Ziegler EE, at al: Skim milk in infant
Circulation 1978;58:318A feeding. Acta Paediatr Scand 1977;66:17-30
31. American Academy of Pediatrics, Committee on Nutrition: 34. Hansen A, Steward BA, Hughes G, at al: Fatty acid defi-
Childhood diet and coronary heart disease. Pediatrics ciency. Acts Paediatr Scand 1962;137:1-51

PASSIVE SMOKING OF MARIJUANA

Inadvertent exposure to marijuana is frequently claimed as the basis for a

positive urine test. Passive inhalation of marijuana smoke does occur and can
result in detectable body fluid levels of THC (tetrahydrocannabinol, the primary
pharmacologic component of marijuana) in blood and of its metabolites in urine.
Clinical studies have shown, however, that it is highly unlikely that a nonsmok-
ing individual could inhale sufficient smoke by passive inhalation to result in a
high enough drug concentration in urine for detection at the cutoff of currently
used urinalysis methods. (Employee Drug Screening-Detection of Drug Use by
Urinalysis. Single copies available from the National Clearinghouse for Drug
Abuse Information, P0 Box 416, Kensington, MD 20795.)
Submitted by Alcohol, Drug Abuse, and Mental Health Administration

From AlCOhOL, Drug Abuse, and Mental Health Administration News.

182 NONORGANIC FAILURE TO THRIVE

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 Parental Health Beliefs as a Cause of Nonorganic Failure to Thrive
Michael T. Pugliese, Michelle Weyman-Daum, Nancy Moses and Fima Lifshitz
Pediatrics 1987;80;175

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been published continuously since . Pediatrics is owned, published, and trademarked by the American
Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright ©
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 Parental Health Beliefs as a Cause of Nonorganic Failure to Thrive
Michael T. Pugliese, Michelle Weyman-Daum, Nancy Moses and Fima Lifshitz
Pediatrics 1987;80;175

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/80/2/175

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has
been published continuously since . Pediatrics is owned, published, and trademarked by the American
Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright ©
1987 by the American Academy of Pediatrics. All rights reserved. Print ISSN: .

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