Failure to Thrive (Ftt)
Failure of an infant, toddler, or child to grow at a normal rate. Related terms include malnutrition, growth hormone deficiency, low birth weight, and short stature.
Failure to thrive (FTT) occurs when an infant, toddler, or child fails to grow at a normal rate, either due to organic (genetic) or environmental causes. Growth is measured as a combination of factors, including age, weight, height, and sometimes bone age. The height and weight of a child can vary widely at a particular age and still be considered normal. According to the National Center for Health Statistics standards, FTT is formally diagnosed when the child's weight is below the fifth percentile for his age (i.e., he or she is smaller than 95% of others his age) or when the weight drops more than two percentile groups. Low height alone or slightly low height with proportional weight may only indicate short stature. Whenever a child's weight or height falls below the tenth percentile he or she should be observed for other symptoms.
Many factors can cause a child's failure to thrive and grow normally. Traditionally the syndrome is broken down into the categories of organic failure to thrive (OFT) and inorganic or non-organic failure to thrive (NOFT). Organic FTT is caused by a genetic or biological disorder such as diabetes or enlarged adenoids, or most commonly digestive (gastrointestinal tract) disorders. Non-organic FTT is diagnosed when organic causes have been ruled out and some combination of environmental factors prevents the infant or child from taking in sufficient food or nutrients; for example, when infant formula is prepared incorrectly.
Most cases of FTT can be traced to both biological and environmental factors, and the distinction between organic and non-organic FTT is sometimes seen as useless or even harmful because the designation "non-organic" leads people to blame the parents—who may or may not be contributing to their child's disorder. Rather, the point is to determine the combination of causes. For example when a child suffers from a biological problem that goes unnoticed, the parent reacts by being more forceful at feeding time, and then, as the child begins to avoid food, a vicious cycle develops that has both biological and environmental causes (and solutions). This is the case with children who suffer from oral hypersensitivity.
Girls' weight by age percentiles, from ages birth to 36 months.Whatever the combination of causes, FTT is a medical condition that is always accompanied by malnourishment. Malnourishment, especially within the first two years of life, causes serious cognitive and behavioral problems in later life, and can lead to mental retardation. While the factors in non-organic FTT can be difficult to isolate, it is highly responsive to treatment, frequently solved by a period of close observation and subsequent changes in feeding habits. When organic causes exist, the doctor will treat the underlying problem and perhaps give compensatory nutrition.
Boys' weight by age percentiles, from ages birth to 36 months.The first step in treatment is to determine whether a child's weight is in fact below normal. If a child's weight is below 90% of the median weight for age (i.e., the 50th percentile), there is mild FIT. A weight between 75%-60% of the median signifies moderate FTT and below 60% severe FTT. First a child's weight will drop, then his height, so it is essential to know the pattern of weight change over time. The age that FTT first occurs can indicate its causes:
Newborn FTT is frequently organic, often caused by gastrointestinal tract problems such as reflux, parasites, milk intolerance, diarrhea, or another metabolic problem such as diabetes. Incorrect or too infrequent breastfeeding or overdilution of formula can also lead to FTT. Sometimes a mother and child do not bond well, due to postpartum depression or other causes, which leads to feeding problems.
Onset of FTT at around 4 months old often indicates underfeeding, caused by inadequate feeding patterns or circumstances (no highchair, lack of resources for food, etc.).
Onset at around 7-9 months is sometimes a product of struggles over the child's autonomy. Struggles with the child over feeding might be exaggerated due to the parents' overconcern and anxiety. Food intolerance may also occur as solid foods are introduced. Also, the presence of food in the child's bottle can inhibit intake.
Onset in toddlers may again be a struggle over autonomy, and/or a result of the child being able to walk and to be more easily distracted from feeding.
At any age food allergies may be a problem, though just as often parents contribute to deficiencies by diagnosing food "allergies" and withholding certain nutritious foods. Also, excessive drinking of liquids other than formula or milk can constitute empty calories and cause nausea. Watch for signs of organic problems by looking at the skin, nails, and oral cavities for abnormalities. Besides a weight history, the doctor will require a record of exactly what, when, where, and how the child eats and drinks (the dietary history). In addition to digestive problems, the doctor will also test for infections, kidney problems, tuberculosis, and sometimes HIV infection or cystic fibrosis. Tests may also be done for toxins such as lead poisoning, and deficiencies such as those of iron and zinc. After other factors are ruled out, the level of growth hormone in the body may also be measured.
Treatment
To diagnose FTT and assess its causes in a child are significant steps towards treating the syndrome. The immediate goal of treatment is to encourage or induce catch-up growth, defined as a growth rate of 2-3 times the average for the child's age. The feeding and/or eating problems that were identified in diagnosis should be corrected, the child's food should be calorically enriched, and a multivitamin given to make up for deficiencies caused by rapid growth. Infant formula may be concentrated up to no more than 24 calories per ounce (one 13 oz. can plus 8 oz. water). For catch-up growth the child should consume between 120-180 calories per kilogram of weight per day. The desired growth should occur within the first month.
More serious cases of FTT may require immediate hospitalization and artificial feeding/nutrition, followed by the usual testing for organic causes, along with an extensive assessment of the child's total caloric intake and eating or feeding circumstances at home. Medical, nutritional, and social factors should all be observed, preferably in their natural settings, by a "grow" team of a doctor, nurse, social worker, nutritionist, and possibly a psychologist.
For cases of FTT caused by parental neglect, mistreatment, or dysfunctional family dynamics, extensive education and/or therapy is required for the parents. Children who experience catch-up growth while being treated may relapse into malnutrition when they return home or intervention services cease. FTT in these cases is not quickly resolved. Studies have found that, even when corrected for race, gender, and socioeconomic factors, statistical figures indicate that children are at high risk for this type of FTT (non-organic) when they come from families where the parents fight or argue, where there are three or more older siblings, and where very low resources are devoted to care for the child (i.e., compared to the spending habits of other families with the same income). Parents of children who suffer from non-organic FTT due to abuse tend to be more unresponsive, disorganized, harsh, and aggressive with their children than other parents of the same race, gender, and socioeconomic status. Whether it is the cause or effect of FTT, infants and children with non-organic FTT caused by abuse tend also to have withdrawn and irritable temperaments.
For Further Study
Books
Drotar, Dennis, ed. New Directions in Failure to Thrive: Implications for Research and Practice. New York: Plenum Press, 1985. Based on the Proceedings of the National Institute of Mental Health Workshop held October 9-10, 1984.
Periodicals
Frank, Deborah A., Robert Needlmen, and Mary Silva. "What to Do When a Child Won't Grow (Treating Failure to Thrive)." Patient Care 28, May 1994, pp. 107-22.
Goldson, E. "Neurological Aspects of Failure to Thrive." De velopmental Medicine and Child Neurology 31, 1989, pp. 821-26.
Phelps, LeAdelle. "Non-Organic Failure to Thrive: Origin and Psychoeducational Implications." School Psychology Review, January 1,1991, pp. 417-29.
Organizations
The MAGIC Foundation for Children's Growth
Address: 1327 N. Harlem Avenue
Oak Park, IL 60302
Telephone: (708) 383-0808
(National non-profit organization providing support services for families of children afflicted with chronic and/or critical disorders, syndromes, and diseases that affect a child's growth.)
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