Failure to Thrive in Pediatric Care
Failure to Thrive (Child)
Failure to thrive is a term used to
describe a deceleration in the growth pattern of an infant or child that is
directly attributable to undernutrition (Steward, DK, Ryan-Wenger, & Boyne,
2003).
Typically, the deceleration is a growth deficit whereby the rate of the
child’s weight gain is below the 5th percentile for age, based on the National
Center for Health Statistics (NCHS) standardized growth charts.
Undernutrition,
or caloric inadequacy, and thus a deceleration in a child’s growth pattern, can
occur for any number of physiological reasons, such as nutrient malabsorption
or transient weight loss due to acute illness.
When a child’s lack of weight
gain is attributed to psychosocial factors and developmental concerns rather
than organic or disease related factors, the term nonorganic failure to thrive
(NOFTT) is used.
Types or Categories Failure to Thrive
Traditionally, the failure to thrive
syndrome has been classified into three categories: organic, nonorganic, and
mixed. Although the term NOFTT frequently is used in contemporary literature,
most researchers agree that the classification is not so clear, especially
since all cases of failure to thrive have an organic etiology (ie,
undernutrition).
NOFTT is a common problem of infancy and early childhood, and
researchers have documented a dramatic increase in its incidence since the late
1970s. NOFTT accounts for 3%-5% of the annual admissions to pediatric hospitals
and about 10% of growth failure seen in outpatient pediatrics (Schwartz, 1.D.,
2002).
Infants with NOFTT typically present not only with growth failure, but
also with developmental and cognitive delays and signs of emotional and
physical deprivation, such as social unresponsiveness, a lack of interactive
behaviors, rumination, anorexia, and poor hygiene.
Infant Nutrition And Pediatric Research
Infant nutrition has long been the
focus of pediatric research. Holt (1897) was one of the first to describe
marasmus, a significant infant nutrition problem and a condition similar to the
failure to thrive syndrome described in contemporary literature.
It was in 1915
that the term failure to thrive was first used in the pediatric literature to
describe rapid weight loss, listlessness, and subsequent death in
institutionalized infants.
In the early 1900s, the mortality rate for
institutionalized infants was near 100%, and few realized the importance of
environmental stimulation and social contact for infant growth and development.
It was during this time that the first foster home care program for
institutionalized marasmic infants was developed. The home care program
involved the identification and training of families, by nurses, to care for
the ill infants, and included a significant amount of nursing intervention to
monitor the progress of the infants.
Unfortunately, this early work was not
recognized by the pediatric community, despite a 60% drop in the mortality rate
of marasmic infants cared for in the foster homes.
It was not until 1945 that the
concept of failure to thrive captured the attention of the psychiatric and
pediatric communities. In a classic paper, Spitz (1945) described depression,
growth failure, and malnutrition in 61 foundling home infants.
He used the term
hospitalism to describe the syndrome that he observed, and he proposed that a
lack of emotional stimulation and the absence of a mother figure were the main contributors
to infant growth failure. Spitz postulated that with adequate love, affection,
and stimulation, the infants would grow.
Researchers demonstrated weight gain
in infants with hospitalism when stimulation and affection were provided. Thus,
these findings provided a foundation for a failure to thrive theoretical
framework based on maternal deprivation in institutionalized infants.
In the
mid-1950s, a number of case reports were published in the psychiatric
literature that documented depression, malnutrition, and growth failure in
infants living in intact families. These case studies were the first to report
feeding and interactional difficulties between the mothers and their infants.
Feeding episodes for the mothers were anxiety- provoking, which led the mothers
to decrease both the frequency of infant feedings as well as their contact with
the infants. Ethnologists and child development experts began studying
institutionalized and noninstitutionalized infants to further define the
concepts of maternal deprivation and failure to thrive.
On the basis of several
studies, researchers then concluded that decreased maternal contact directly
led to failure to thrive in the infants. From these works, the maternal
deprivation framework for failure to thrive was established, and the mother’s
role in the infant’s well-being became a central focus.
Support for this
framework grew as data accumulated documenting the association between maternal
neglect and failure to thrive in infants.
Psychosocial Factors
The maternal deprivation framework
dominated the literature until the late 1970s, when a transactional framework
was developed to explain the psychosocial correlates of NOFTT. The
transactional framework proposes that an infant’s growth and development is
contingent upon the quality of parental care, the nature of parent and infant
interactions, and the ecological conditions impinging on the family.
Furthermore, the transactional model recognizes that the quality of the
parent-infant interaction reflects infant characteristics as well as parent
characteristics ( Bithoney & Newberger , 1987).
Historically, the emotional
deprivation component of NOFTT has been investigated more than the nutritional
deprivation component. Although NOFTT experts would agree that undernutrition
is the primary biologic insult, systematic studies investigating this element
are lacking.
Economical Factors
Nutritional deprivation again became
the focus of NOFTT research in the early 1970s, when some researchers disputed
the hypothesis that maternal deprivation was the principal cause of NOFTT.
More
recent evidence suggests that the environmental deprivation may occur before
the undernutrition. Although the primary cause of NOFTT may never be fully
understood, it is apparent that nutritional deficits are dependent on the environmental
context in which they occur.
Nursing Research
Nurse researchers developed the
ecological model to describe parent-child interactions, and the model is used
to explain NOFTT (Barnard & Fyres , 1979; Lobo, Barnard, & Coombs,
1992). The ecological model focuses on the three major interaction components
of the parent child relationship: those of the child, the parent, and the
environment.
These interactions are synchronous and reciprocal. Barnard and her
colleagues (1989) emphasized the importance of the parent’s and child’s
physical and emotional characteristics, as well as the supportive or
non-supportive nature of the environment in understanding the interactions.
Research Findings
Researchers have examined
parent child interactions by means of direct, structured observations during
feeding and other situations, and found that NOFTT infants demonstrated more
difficult behaviors, were less vocal, exhibited negative affect, and had more
gaze aversion than infants who were not failing to thrive (Steward, DK, 2001;
Lobo et al., 1992).
Furthermore, parents of NOFTT infants were less able to
determine their infants’ needs, showed a decreased ability to discriminate
infant cues, and exhibited less social instructiveness with their infants when
compared to parents of healthy infants (Steward, DK).
These studies supported
that interference with the reciprocal process of the parent child relationship
disturbs the opportunity to attain optimal growth and development.
Since growth
problems, such as NOFTT, in infancy place a child at significant risk for
developmental delays as a toddler, it is important to recognize the
interactional problems between parents and their infants so that interventions
aimed at improving interactions can begin,