Pediatric Failure to Thrive and Health Care

Afza.Malik GDA

Failure to Thrive in Pediatric Care

Pediatric Failure to Thrive and Health Care

Failure to Thrive (Child)Types or Categories Failure to Thrive,Infant Nutrition And Pediatric Research, Psychosocial Factors ,Economical Factors,Nursing Research,Research Findings

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,

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