FAILURE TO THRIVE

Children who fail to grow properly have always existed. In earlier times when many children did not survive the first few years, small or sickly children were a fact of life. More recently, medicine has increasingly turned its attention to the unique problems of children, among them the problems of growth failure and most interestingly to the problem of malnutrition and growth failure in children without obvious organic illness. The case of so-called nonorganic failure to thrive, growth failure without apparent medical cause, is the main focus of this discussion.

The medical concept of "failure to thrive" in infants and young children dates back about a century.L. Emmett Holt's 1897 edition of Diseases of Infancy and Childhood included a discussion of a child who "ceased to thrive." Chapin correctly recognized in 1908 that growth failure was primarily caused by malnutrition, but that temporarily correcting caloric in-take and improving growth often proved futile after the child returned to her (often impoverished) environment. By 1933 the term "failure to thrive" formally entered the medical literature in the tenth edition of Holt's text.

Failure to thrive is not a discreet diagnosis or a single medical condition (such as chicken pox), but rather a sign of illness or abnormal function (as a rash or fever may be a sign of chicken pox virus infection). In infants and young children, the term "failure to thrive" is most broadly defined as physical growth that for whatever reason falls short of what is expected of a normal, healthy child. Statistical norms have been published for the growth patterns of normal children. Plotting a child's height, weight, and head circumference on such charts yields valuable diagnostic information. In children younger than age two, inadequate growth may be defined as falling below the third or fifth percentile for the age, where weight is less than 80 percent of the ideal weight for the age, or where weight crosses two major percentiles sequentially downward on a standardized growth chart.

The concept of failure to thrive, however, encompasses not just disturbances of the more obvious aspects of physical development but the more subtle aspects of psychosocial development in infancy and early childhood. "Thriving" is a concept that implies that a child not only grows physically in accordance with published norms for age and sex, but also exhibits the characteristics of normal progress of developmental milestones in all spheres—neurological, psychosocial, and emotional.

Early observations that an organic illness could not be found in many cases of failure to thrive led to the categorization of failure to thrive into the subclasses of organic and nonorganic causal factors. This classification ultimately proved too simplistic, both organic and environmental factors acting together may cause poor growth, but it served to sharpen thinking about the nonorganic causes.

Organic versus Nonorganic Failure to Thrive

Organic failure to thrive is that caused by the harmful effects on growth of organic disease. Growth failure can be an extremely sensitive marker for unsuspected systemic disease, revealing illness long before it would normally be detected. Likewise, the progress of therapy is often dramatically mirrored by improvement in growth. Any significant illness in an infant or young child can cause growth failure. Thus growth failure alone alerts the physician to search for possible medical causes. Nevertheless, the search for organic disease in young children with an initial diagnosis of failure to thrive most often finds no physical (organic) condition to explain the growth failure; the failure is therefore termed nonorganic.

The modern understanding of this disorder views it as a fundamental failure of maternal-infant attachment. In fact, it is referred to in psychiatric literature as feeding disorder of attachment, as well as maternal deprivation, deprivation dwarfism, and psychosocial deprivation. Nonorganic failure to thrive reflects a failed relationship between a mother and her infant during the first year of life. Its chief characteristic is a lack of engagement or bonding between mother and infant in the daily routine of care, most dramatically with respect to feeding.

Diagnosis

Nonorganic failure to thrive can be understood in terms of both physical and emotional deprivation of the child, and has both physical and behavioral signs. Caloric deprivation of an infant may be caused more or less innocently by lactation failure, extreme poverty, parental ignorance of proper infant feeding, or strange nutritional beliefs. Parents of children with nonorganic failure to thrive, however, typically give a history of adequate or often exaggerated amounts of nutritional intake belied by the child's obvious malnourished state.

By interviewing and observing the mother, it is noted that feedings are marked by a lack of the mutual pleasurable relationship of giving and receiving that is the hallmark of normal feedings. In contrast, the mother may admit that she props the bottle or even sometimes forgets regular feedings.

There may be other evidence of poor caregiving and physical neglect, such as unwashed skin, diaper rash, skin infections, and dirty clothing. The back of the baby's head may be flat with a bald patch over the flattened area, implying that the child is left unattended for long periods of time lying on his back in the crib. The baby may exhibit a lack of appropriate social responsiveness, with an expressionless face and classic avoidance of eye contact. Normal vocal responses, such as cooing and blowing raspberries, may be absent. In children older than five months, there may be no anticipatory reaching for interesting objects. Motor milestones may be delayed. When held, instead of cuddling normally, the baby characteristically arches his back and scissors his legs, or lies limp as a rag doll in the examiner's arms. By contrast, babies with organic failure to thrive typically do not show the characteristic withdrawal behaviors of non-organic failure to thrive infants, and respond best to their mothers.

Prominent features in the mother's history may include symptoms of acute or chronic depression, personality disorder, substance abuse, and a generally high level of psychosocial stress related to poverty, social isolation, or spousal abuse. Often the mother was abused or neglected as a child, producing an apparently transgenerational pattern of insecure attachment. Parents of infants with nonorganic failure to thrive are often initially evasive. They usually take the baby to an emergency room for another illness, whereupon the baby's malnutrition attracts attention. Upon the child's admission to the hospital, the parents may disappear for several days.

Treatment

Inpatient investigation and initial treatment is warranted for infants under a year in the following cases: when the infant is suffering from more severe growth failure; when there are signs of emotional deprivation; when the parents have not sought medical intervention; when the infant shows signs of physical abuse; when the infant's hygiene has been seriously neglected; when the mother appears severely disturbed or is abusing drugs or alcohol or is living a chaotic lifestyle overwhelmed with stresses; or when the mother-infant interaction appears uncaring and includes feelings of anger.

During hospitalization, a primary-care nurse is assigned to establish a warm and nurturing relationship with the baby. The baby typically begins to blossom in its social interactions and rapidly gains weight. As the baby begins to improve both in terms of weight gain and psychosocially, hospital personnel can help the mother engage with her baby, teaching her to receive and express the mutual signals of mother-infant bonding. Understanding and addressing the mother's needs for emotional support and encouragement is essential to rehabilitating the mother-infant relationship. The degree to which parents are aware of the cause of the problem and actively cooperate in their baby's reattachment has been found to be predictive of the long-term outcome. Appropriate referrals to child protective services agencies must be made both to ensure the child's continued safety and to monitor the efforts to help the parents learn needed skills.

Long-Term Prognosis for Recovery

Severe nonorganic failure to thrive is a potentially fatal illness. Nutritional deprivation can lead to death from starvation or overwhelming infection due to a weakened immune system. With detection and intervention, infants can in some cases recover from the effects of their condition. Brain size as measured by head circumference may be permanently reduced, especially if the failure to thrive occurred in the first six months of life. During this time of its most rapid growth, the brain is very susceptible to permanent damage from the effects of poor nutrition.

Later emotional and learning problems are common in these children. A 1988 Case Western Reserve University study found that the mean IQ score for three-year-old children with a prior history of failure to thrive was 85. A follow-up study of children from this group showed that even those who subsequently participated in early intervention programs had problems of personality development, deficient problem-solving skills, and more behavioral problems in general as compared to the controls. These problems included impulse control, gratification delay, and the ability to adapt behaviorally to new situations. An Israeli study found that at age five, about 11.5 percent of children with a history of failure to thrive had some manifestations of developmental delay, compared with no delays in the control children. They likewise found an 18 percent incidence of poor school performance compared with a 3.3 percent rate in the control group. Another follow-up study of children diagnosed with nonorganic failure to thrive found that at age six, half of the children in the study sample of twenty-one had abnormal personalities and two-thirds learned to read at a later-than-normal age. Two of the twenty-one had died under suspicious circumstances, pointing up the vulnerability of children with psychosocial failure to thrive. Another study determined that out of fifteen children initially diagnosed with growth failure caused by emotional deprivation, only two were functioning well three to eleven years after diagnosis. Infants hospitalized with failure to thrive prior to six months of age exhibited decreased cognitive development, despite long-term outreach intervention programs. Earlier age of onset of growth failure, lower maternal education level, and lower family income all predicted lower cognitive level.

Summary

Failure to thrive in young children represents significantly suboptimal growth due to intrinsic medical (organic) or environmental (nonorganic) factors. Nonorganic failure to thrive in particular represents a recognizable syndrome of poor growth in infants and young children with specific diagnostic features. Nonorganic failure to thrive in early infancy poses a significant risk of adverse long-term developmental effects.