Failure to thrive

Sociodemographic Differences of Hospitalization and Associations of Resource Utilization for Failure to Thrive

OBJECTIVES

This study examines the sociodemographic differences between elective and nonelective admissions for failure to thrive (FTT). We investigate associations between admission type and hospital resource utilization, including length of stay and feeding tube placement.

METHODS

We included children <2 years old with FTT in the nationwide Kids' Inpatient Database. We described differences between elective and nonelective admissions using Fisher exact and t tests. To assess associations of admission type and hospital resource utilization, we used negative binomial and logistic regression for length of stay and feeding tube placement, respectively.

RESULTS

In this study of 45,920 admissions (37,224 nonelective vs 8696 elective), we found differences by race and ethnicity, income, and insurance type, among other factors. Compared to elective admissions, nonelective admissions had higher proportions of infants who were Black, Hispanic, and of lower-income. Nonelective admissions were associated with longer lengths of stay (incidence rate ratio 1.46; 95% CI: 1.37-1.55), independent of child age, sex, neighborhood income, insurance, admission day, chronic conditions, and location. Nonelective admissions were associated with lower odds of feeding tube placement compared to elective admissions (adjusted odds ratio 0.62; 0.56-0.68). In the stratified analyses, children of racial and ethnic minority groups admitted nonelectively versus electively had relatively higher odds of feeding tube placement, while White children had relatively lower odds of feeding tube placement.

CONCLUSION

There are various sociodemographic differences between elective and nonelective FTT admissions. Future research is warranted to elucidate drivers of these differences, particularly those related to racial and ethnic disparities and structural racism.

How Lifestyle Factors Affect Cognitive and Executive Function and the Ability to Learn in Children

In today's research environment, children's diet, physical activity, and other lifestyle factors are commonly studied in the context of health, independent of their effect on cognition and learning. Moreover, there is little overlap between the two literatures, although it is reasonable to expect that the lifestyle factors explored in the health-focused research are intertwined with cognition and learning processes. This thematic review provides an overview of knowledge connecting the selected lifestyle factors of diet, physical activity, and sleep hygiene to children's cognition and learning. Research from studies of diet and nutrition, physical activity and fitness, sleep, and broader influences of cultural and socioeconomic factors related to health and learning, were summarized to offer examples of research that integrate lifestyle factors and cognition with learning. The literature review demonstrates that the associations and causal relationships between these factors are vastly understudied. As a result, current knowledge on predictors of optimal cognition and learning is incomplete, and likely lacks understanding of many critical facts and relationships, their interactions, and the nature of their relationships, such as there being mediating or confounding factors that could provide important knowledge to increase the efficacy of learning-focused interventions. This review provides information focused on studies in children. Although basic research in cells or animal studies are available and indicate a number of possible physiological pathways, inclusion of those data would distract from the fact that there is a significant gap in knowledge on lifestyle factors and optimal learning in children. In a climate where childcare and school feeding policies are continuously discussed, this thematic review aims to provide an impulse for discussion and a call for more holistic approaches to support child development.

Maternal Common Mental Disorder as Predictors of Stunting among Children Aged 6-59 Months in Western Ethiopia: A Case-Control Study

Background

Child malnutrition in low- and middle-income countries still continues to be an alarming. Africa and Asia bear the greatest share of all forms of malnutrition. The association between maternal common mental disorder and stunting has not been studied well even in developed countries; much less in developing countries and even the findings are conflicting. Thus, the purpose of the present research was to investigate the relationship of maternal common mental disorder and child stunting.

Methods

Institution based unmatched case-control study design was employed from March to April 2017. Two hundred thirty-four sampled children (78 cases and 156 controls) were randomly selected. Anthropometric measurements (height/length and weight) were taken by calibrated instruments. Maternal common mental disorder (CMD) was measured by using the locally validated Self-Reporting Questionnaire (SRQ-20). Data entry was done by Epi data version 3.1 and analysis was done by SPSS 21.0 statistical software.

Result

Finding of this study found out about three-fourths of cases (71.8%) and three-fourths of controls (69.9%) were residing in rural and urban areas, respectively. Regarding maternal common mental disorder, more than half of cases mother (53.8%) and more than one-tenth of controls mother (13.5%) were found to have common mental disorder. The study showed that children of mothers who had common mental disorder were found to be three times more likelihood of developing stunting than children whose mothers had not common mental disorder.

Conclusion and Recommendation

The study indicated that maternal common mental disorder was significantly associated with stunting. Therefore, emphasis should be given in preventing, managing, and maintaining maternal mental health in order to prevent stunting.

Hospitalization for Failure to Thrive: A Prospective Descriptive Report

Failure to thrive (FTT) is a common symptom leading to hospitalization of children. Most literature describing this population is from 30 years ago. Since that time the hospitalized population has become more medically complex. We aimed to describe children hospitalized for FTT in a tertiary care pediatric hospital. We prospectively collected demographic, anthropometric, evaluation, and outcome data for 92 consecutive children admitted with FTT. The majority of children grew with behavioral interventions alone (primary nonorganic FTT) and had negative evaluation (n = 63). Children with primary organic FTT had longer hospital stays (7 vs 4 days; P < .001) and lower daily weight gain (35 vs 58 g/d; P < .001). Laboratory, radiological, and endoscopic evaluation rarely led to a diagnostic etiology of FTT in hospitalized children. We conclude that children hospitalized with FTT should be observed for weight gain prior to pursuing diagnostic investigation.

Comparison of Percentile Weight Gain of Growth-Friendly Constructs in Early-Onset Scoliosis

STUDY DESIGN

Multicenter retrospective cohort.

OBJECTIVE

To compare improvement in nutritional status seen in early-onset scoliosis (EOS) patients following treatment with various growth-friendly techniques, especially in underweight patients (<20th weight percentile).

BACKGROUND

Thoracic insufficiency resulting from EOS can lead to severe cardiopulmonary disease. In this age group, pulmonary function tests are often difficult or impossible to perform. Weight gain has been used in prior studies as a proxy for improvement and has been demonstrated following VEPTR and growing rod implantation. In this study, we aim to analyze weight gain of EOS patients treated with four different spinal implants to evaluate if significant differences in weight percentile change exist between them.

METHODS

Retrospective review of patients treated surgically for EOS was performed from a multicenter database. Exclusion criteria were index instrumentation at >10 years old and <2 years' follow-up.

RESULTS

287 patients met the inclusion criteria and etiologies were as follows: congenital = 85; syndromic = 79; neuromuscular = 69; and idiopathic = 52. Average patient age at surgery was 5.41 years, with an average follow-up of 5.8 years. Preoperatively, 55.4% (162/287) fell below the 20th weight percentile. There was no significant difference in preoperative weight between implants (p = .77), or diagnoses (p = .25). Among this group, the mean change in weight percentile was 10.5% (range: -16.7% to 88.7%) and all implant groups increased in mean weight percentile at final follow-up. There were no significant differences in weight percentile change between the groups when divided by implant type (p = .17).

CONCLUSIONS

Treatment of EOS with growth-friendly constructs resulted in an increase in weight percentile for underweight patients (<20th percentile), with no significant difference between constructs.

LEVEL OF EVIDENCE

Level III.

Empty sella syndrome in a male child with failure to thrive

Empty sella syndrome (ESS) is commonly seen in adult and is considered as an infrequent finding in childhood. It may be diagnosed incidentally on imaging in asymptomatic children. However, most of the children with ESS present with features of hypothalamic-pituitary dysfunction. We report a case of ESS in a child with features of failure to thrive as well as hypopituitarism and review the literature briefly on the subject.

Behavioural Parent Training Versus Dietary Education in the Treatment of Children with Persistent Feeding Difficulties

This controlled treatment-outcome study compared the effects of behavioural parent training (BPT) and standard dietary education (SDE) on the mealtime interaction, feeding behaviour, nutritional status, and adjustment of children with feeding disorders. Participants were 20 children (aged between 18 months and five years) with persistent feeding difficulties, and their families. Children underwent initial screening (involving medical assessment, behavioural observation of mealtime interaction, nutritional intake analysis, and self-report measures of parent and child adjustment) and were randomly assigned to BPT or SDE. Results indicated that children in both treatment conditions showed improvement on the child behaviour measures (e.g. food refusal, disruptive behaviour during mealtimes) at home and in mealtime observations in the clinic. Children in both conditions also showed an increase in the variety of foods sampled by follow-up. Following treatment, mothers who received BPT showed more positive mother–child interaction during mealtimes, and both parents were more satisfied with treatment than parents in SDE. Mothers in both conditions showed slight elevations in mood at posttest and follow-up, and increased marital satisfaction at posttest (which decreased by follow-up). All other treatment effects were maintained at a three- to four-month follow-up assessment.

Maternal perceptions of toddler body size: accuracy and satisfaction differ by toddler weight status

OBJECTIVES

To examine (1) accuracy of maternal perceptions of toddler body size; (2) factors associated with accuracy of toddler body size; and (3) how maternal satisfaction relates to accuracy/toddler body size.

DESIGN

Cross-sectional.

SETTING

Low-income community sample from suburban Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)/urban pediatric clinics.

PARTICIPANTS

Two hundred eighty-one mother-toddler dyads (toddlers: 54.1% male; mean age, 20.2 months; 70.8% African American; 8.5% underweight [<15th weight-for-length percentile]; and 29.2% overweight [≥85th weight-for-length percentile]).

MAIN EXPOSURE

Measured anthropometry (mother/toddler) and demographics.

OUTCOME MEASURE

Validated toddler silhouette scale (accuracy and satisfaction).

RESULTS

Nearly 70% of mothers were inaccurate in assessing their toddler's body size. Compared with mothers of healthy-weight toddlers, mothers of underweight toddlers were 9.13 times more likely to be accurate (95% CI, 2.94-28.36) and mothers of overweight toddlers were 87% less likely to be accurate (95% CI, 0.05-0.33); accuracy did not differ by toddler age, sex, or race or mother's education or weight status. More than 70% of all mothers and 81.7% of mothers of overweight toddlers were satisfied with their toddler's body size. Accurate mothers of underweight toddlers were less likely to be satisfied than accurate mothers of healthy-weight toddlers (30.0% vs 76.8%; P < .001).

CONCLUSIONS

Mothers of overweight toddlers had inaccurate perceptions of their toddler's body size and were highly satisfied, suggesting a view of heavy toddlers as normative. Mothers of underweight toddlers had accurate perceptions yet were dissatisfied, suggesting recognition of their child as outside the norm. Because inaccurate perceptions begin early in toddlerhood, pediatric providers should help improve families' understanding of healthy body size. Future studies should examine how satisfaction and accuracy relate to parenting behaviors.

Nutritional approach to failure to thrive

Failure to thrive (FTT) is a term generally used to describe an infant or child whose current weight or rate of weight gains is significantly below that expected of similar children of the same age, sex and ethnicity. It usually describes infants in whom linear growth and head circumference are either not affected, or are affected to a lesser degree than weight. FTT is a common problem, usually recognized within the first 1-2 years of life, but may present at any time in childhood. Most cases of failure to thrive involve inadequate caloric intake caused by behavioral or psychosocial issues. The most important part of the outpatient evaluation is obtaining an accurate account of a child's eating habits and caloric intake. Routine laboratory testing rarely identifies a cause and is not generally recommended. FTT, its evaluation, and its therapeutic interventions are best approached by a multi-disciplinary team includes a nutritionist, a physical therapist, a psychologist and a gastroenterologist. Long term sequelae involving all areas of growth, behavior and development may be seen in children suffering from FTT. Early detection and early intervention by a multi-disciplinary team will minimize its long term disadvantage. Appropriate nutritional counseling and anticipatory guidance at each well child visit may help prevent some cause of FTT.

Comparison of changes in growth percentiles of US children on CDC 2000 growth charts with corresponding changes on WHO 2006 growth charts

Longitudinal data with 37 964 length and weight measurements from 10 844 children who participated in the California Child Health and Development Study was used to compare the proportion of children aged ≤24 months who crossed major percentile lines on the Centers for Disease Control and Prevention (CDC) 2000 growth charts with the percentage who crossed corresponding lines on the World Health Organization (WHO) 2006 growth charts. Percentage of children aged ≤24 months who crossed at least 2 major percentile lines for length-for-age, weight-for-age, and weight-for-length according to CDC 2000 charts were compared with the percentage who did so according to WHO 2006 charts. The results from this analysis suggest that pediatricians who monitor children's growth on the basis of WHO 2006 growth charts may be more likely to refer children aged <6 months and less likely to refer those aged 6 to 12 months for further evaluation for failure to thrive.

[The role of life events in mothers of malnourished children: the other side of malnutrition]

The objective of this article is to describe the life story of mothers of malnourished children and their possible associations to socio-demographic and psychosocial aspects. It is a cross sectional study carried out in a public health basic unit in Porto Alegre (RS, Brazil), with a total of 82 mothers. It was used a structured questionnaire with socio demographic, reproductive variables and mothers' live events. A descriptive analysis and chi-square were used to investigate possible associations among the selected variables. Mothers had low schooling, low income and were multiparous besides, suffered parental abuse, had negative experiences with alcoholic parents (67%), were neglect in infancy (65%), have rejected the undernourished baby during pregnancy (70%). They related depression symptoms during pregnancy (70%) and postpartum (60%). The study showed a difference of proportion between mothers who suffered abuse in childhood and those who not suffered according to pregnancy rejection (p<0,001), depression during the pregnancy and after delivery (p<0,001). This study associated mother's life stories with live events that, beyond the social and economic disadvantage, could develop a weak interaction between mother-baby that contribute to malnutrition.

Risk factors for weight faltering in infancy according to age at onset

The aim of this study was to identify risk factors for failure to thrive (FTT) or weight faltering according to age of onset. The study is part of a Danish longitudinal population study of early risk mechanisms in child psychiatric disorders, The Copenhagen Child Cohort, which consists of a birth cohort of 6090 children born during the year 2000 and followed prospectively from birth. Weight faltering/FTT was defined as slow conditional weight gain, and divided into subtypes according to age of onset in the first year of life: birth to 2 weeks, 2 weeks to 4 months, and 4-8 months. Regardless of the age of onset, slow weight gain was found to be strongly associated with feeding problems, but the risk factors involved differed according to age of onset. Thus, onset within the first weeks of life clearly differed from faltering later on, the former being strongly associated with low birthweight and gestational age, with single parenthood and with mother having smoked during pregnancy. Onset between 2 weeks and 4 months was associated with congenital disorders and serious somatic illness, and with deviant mother-child relationship, whereas, onset between 4 and 8 months seemed to represent a group of children with feeding problems arising de novo in otherwise healthy children. In conclusion, weight faltering in infancy is clearly associated with contemporary measured feeding problems, but the risk mechanisms involved differ in early vs. late onset.

Feeding and eating disorders in childhood

OBJECTIVE

To review the literature related to the current DSM-IV-TR diagnostic criteria for feeding disorder of infancy or early childhood; pica; rumination disorder; and other childhood presentations that are characterized by avoidance of food or restricted food intake, with the purpose of informing options for DSM-V.

METHOD

Articles were identified by computerized and manual searches and reviewed to evaluate the evidence supporting possible options for revision of criteria.

RESULTS

The study of childhood feeding and eating disturbances has been hampered by inconsistencies in classification and use of terminology. Greater clarity around subtypes of feeding and eating problems in children would benefit clinicians and patients alike.

DISCUSSION

A number of suggestions supported by existing evidence are made that provide clearer descriptions of subtypes to improve clinical utility and to promote research.

Short-term cyproheptadine therapy in underweight children: effects on growth and serum insulin-like growth factor-I

BACKGROUND

Cyproheptadine, an appetite stimulant, has been used in poor-appetite underweight children. Its beneficial effects on enhancing growth rate have been demonstrated. In contrast, an adverse effect on blunting growth hormone (GH) secretion has also been reported. To date, however, its effect on insulinlike growth factor-I (IGF-I), a GH-mediated growth factor, has not been documented.

AIM

To examine the effect of cyproheptadine therapy on growth and serum IGF-I in underweight children.

METHODS

Twenty-one underweight, otherwise healthy children were recruited. They were randomly assigned into cyproheptadine administration (n = 10) and placebo (n = 11) groups. The former received cyproheptadine for 4 months. Serum IGF-I levels were measured in both groups.

RESULTS

Weight and height velocities and IGF-I z-scores during cyproheptadine therapy were significantly greater in the intervention group than those of the placebo group.

CONCLUSION

Cyproheptadine therapy in underweight children increased caloric intake and serum IGF-I concentration and consequently enhanced growth velocity.

Postdischarge growth and development in a predominantly Hispanic, very low birth weight population

OBJECTIVES

The goals were to assess postdischarge growth and developmental progress of very low birth weight (birth weight: <1500 g) premature infants in a predominantly Hispanic population and to identify predictors for neurodevelopmental impairment at 3 years of age.

METHODS

A cohort of 135 very low birth weight infants (gestational age: 23 to 35 weeks) were monitored to 3 years of age. Maternal and neonatal characteristics, anthropometric z scores, and developmental performance (using corrected age until 24 months) were analyzed collectively and according to gestational age groups. Specific criteria for failure to thrive and microcephaly were used.

RESULTS

A characteristic pattern of poor weight gain in the first 12 months was followed by accelerated weight gain starting at 18 months, whereas head growth decreased at 18 months, with recovery beginning at 30 months of age. Infants born at gestational age of <or=26 weeks remained growth-impaired at 3 years of age, whereas infants born at gestational age of >or=27 weeks achieved catch-up growth by 30 months of age. Mean developmental scores also decreased in infancy, with improvements in motor development emerging at 18 months and cognitive skills at 30 months. Growth z scores, particularly for head growth, correlated with developmental scores. Infants born at gestational age of <or=26 weeks were most likely to have neonatal morbidities, failure to thrive, and neurodevelopmental impairment. With adjustment for gestational age and neonatal morbidities, Hispanic acculturation, failure to thrive, and microcephaly were predictive of neurodevelopmental impairment.

CONCLUSIONS

Very low birth weight infants exhibited growth patterns that coincided with developmental progress in the first 3 years of life. Birth at gestational age of <or=26 weeks was associated with greatest risk for developmental impairment, whereas failure to thrive and microcephaly increased neurodevelopmental impairment risk regardless of gestational age.

Diagnosis on a positive fashion of nonorganic failure to thrive

AIMS

To study the predictive value of predefined symptoms and signs for allocating children into one of two groups: nonorganic and organic failure to thrive.

PATIENTS AND METHODS

Two hundred eight outpatients (6 months-14 years old) suffering from failure to thrive (FTT) were included in the study. Predefined symptoms and signs were considered as potential predictors of organic/nonorganic failure to thrive. All patients underwent an established diagnostic work up in order to exclude organic causes of FTT.

RESULTS

The percentage of patients without any organic symptom (negative predictive value), who were diagnosed as NOFTT was 92%; the percentage of patients having nonorganic symptoms only (positive predictive value), who were diagnosed as NOFTT was 96%, while their absence does not exclude a NOFTT diagnosis as well (negative predictive value = 41%).

CONCLUSION

The detection of at least one nonorganic symptom or sign, with the exclusion of any organic symptom, can support a diagnosis of nonorganic FTT and therefore only few laboratory investigations seem to be warranted.

'It's not just about food': mother-infant interaction and the wider context of nutrition

In recent years, attention has increasingly focused on the wider context of nutrition, rather than simply on calorie and nutrient intake. Recent estimates put the figure of people in the world living in extreme poverty (an income of less than $1 a day) at 1.1 billion. This has significant implications for nutritional deficiencies in infants and young children. In this paper, we will show how the physical growth and psychological development of infants and children are intimately linked, and how many of the same aetiological factors (such as caregiver sensitivity, psychosocial support, communicative exchange between infant/child and their caregiver) are implicated in both domains. Preliminary evidence indicates that community-based interventions impact on the mother-infant relationship as well as infant physical growth, and contribute to the increasing sense of how aspects of the early relationship between infants and their caretakers are crucial to any complete understanding of infant growth and development. The paediatric food-based dietary guidelines (PFBDGs) include guidelines relating to the mother-infant relationship and may thus prove to be a significant tool in community interventions.

Psychosocial predictors of being an underweight infant differ by racial group: a prospective study of Louisiana WIC program participants

OBJECTIVES

In order to prospectively identify psychosocial predictors of infants being underweight, we followed 3,302 low-income infants. These infants received well-baby care in health departments and were enrolled in the Women, Infants, and Children (WIC) Supplemental Food Program from the newborn period to 12 months of age.

METHODS

We linked risk factor data collected from newborn medical history records to anthropometric data from a WIC database. The unadjusted relative risk of being underweight at 12 months of age, defined as weight for recumbent length below the 5th percentile, according to current Centers for Disease Control and Prevention growth charts, for each group was calculated for the study population and for black and white racial groups. Using logistic regression, we calculated odds ratios measuring the effect of the newborn risk factors on underweight status at 12 months of age.

RESULTS

There were no psychosocial risk factors that were significantly associated with being underweight simultaneously in both racial groups. Among black infants, those whose mothers had an eighth grade education or lower were at greater risk of being underweight at 12 months of age (OR=3.7, CI=1.5-4.8), as were those whose mothers were married (OR=2.7, CI=1.5-4.8). Among white infants, those whose mothers initiated prenatal care in the third trimester were significantly more likely to have underweight infants at 12 months of age (OR=4.5, CI=1.6-12.4).

CONCLUSIONS

Predictors of being underweight at 12 months of age in a low-income population differ by racial group. Further research of public health interventions targeting families of infants with the significant psychosocial risk factors is needed.

Image or reality: why do infant size and growth matter to parents?

Perspective on the paper by Lucas et al(see page 120)

Failure to thrive: the prevalence and concurrence of anthropometric criteria in a general infant population

BACKGROUND

Failure to thrive (FTT) in early childhood is associated with subsequent developmental delay and is recognised to reflect relative undernutrition. Although the concept of FTT is widely used, no consensus exists regarding a specific definition, and it is unclear to what extent different anthropometric definitions concur.

OBJECTIVE

To compare the prevalence and concurrence of different anthropometric criteria for FTT and test the sensitivity and positive predictive values of these in detecting children with "significant undernutrition", defined as the combination of slow conditional weight gain and low body mass index (BMI).

METHODS

Seven criteria of FTT, including low weight for age, low BMI, low conditional weight gain and Waterlow's criterion for wasting, were applied to a birth cohort of 6090 Danish infants. The criteria were compared in two age groups: 2-6 and 6-11 months of life.

RESULTS

27% of infants met one or more criteria in at least one of the two age groups. The concurrence among the criteria was generally poor, with most children identified by only one criterion. Positive predictive values of different criteria ranged from 1% to 58%. Most single criteria identified either less than half the cases of significant undernutrition (found in 3%) or included far too many, thus having a low positive predictive value. Children with low weight for height tended to be relatively tall.

CONCLUSIONS

No single measurement on its own seems to be adequate for identifying nutritional growth delay. Further longitudinal population studies are needed to investigate the discriminating power of different criteria in detecting significant undernutrition and subsequent outcomes.

Physical and emotional development, appetite and body image in adolescents who failed to thrive as infants

BACKGROUND

Previous studies suggest that failure to thrive in infancy may be associated with adverse sequelae in childhood. Although cognitive abilities have been extensively investigated, little systematic research is available on other aspects of development.

METHODS

Eighty-nine children who failed to thrive as infants and 91 controls were followed up when twelve years old and examined using anthropometric measurement, self-ratings of appetite and body image, the Dutch Eating Behaviour Questionnaire, the Self-perception Profile for Children, The Revised Children's Manifest Anxiety Scale, the parent and child form of the Mood and Feelings Questionnaire and the parent and teacher's form of the Child Behavior Checklist.

RESULTS

The children who failed to thrive were significantly shorter and lighter at twelve and had significantly lower BMIs, but they did not go into puberty any later. They were more likely to rate their appetite as lower than their best friend's, were generally more satisfied with their body shape, and had significantly lower restraint score on the Dutch Eating Behaviour Questionnaire. They were not significantly different from controls on any of the measures reflecting anxiety, depression or low self-esteem.

CONCLUSIONS

Failure to thrive in infancy is not associated with adverse emotional development in childhood.

The influence of maternal socioeconomic and emotional factors on infant weight gain and weight faltering (failure to thrive): data from a prospective birth cohort

AIMS

To study the influence of maternal socioeconomic and emotional factors on infant weight gain and weight faltering (failure to thrive) in the first year of life.

METHODS

The Gateshead Millennium Baby Study is a population birth cohort in northeast England studied prospectively from birth, via parental questionnaires and a health check aged 13 months. Data were collected on maternal education, deprivation, eating attitudes, and depression, using the Edinburgh Post Natal Depression Scale (EPDS) at 3 months. Weight gain was assessed using change in weight SD score, conditional on birth weight (Thrive Index); weight faltering was defined as conditional weight gain below the 5th centile.

RESULTS

Of 923 eligible infants born at term, 774 (84%) had both weight and questionnaire data. Replicating a previous finding, both the highest and the lowest levels of deprivation were associated with weight faltering; this was independent of the type of milk feeding. No relation was found with maternal educational status. Maternal eating restraint was unrelated to weight gain. Infants of mothers with high depression symptom scores (EPDS >12) had significantly slower weight gain and increased rates of weight faltering up to 4 months (relative risk 2.5), especially if they came from deprived families, but by 12 months they were no different from the remainder of the cohort.

CONCLUSIONS

In this setting, social and maternal characteristics had little influence on infants' weight gain, apart from a strong, but transient effect of postnatal depression.

How does maternal and child feeding behavior relate to weight gain and failure to thrive? Data from a prospective birth cohort

OBJECTIVES

The aim of this study was to study the influences of child and maternal feeding behavior on weight gain and failure to thrive in the first year of life.

METHODS

The Millennium Infant Study recruited a population birth cohort in Northeast England shortly after birth and studied them prospectively to the age of 13 months. Parents completed questionnaires at 6 weeks and 4, 8, and 12 months. Appetite was rated on a 5-point scale at each age, and a core group of questions was used to generate scores of oromotor dysfunction, avoidant eating behavior, maternal feeding anxiety, and response to food refusal. Routinely collected weights were used to assess weight gain using the thrive index (TI); weight faltering was defined as TI below the 5th percentile from birth to age 6 weeks or 4, 8, or 12 months.

RESULTS

Of 923 eligible infants, 75% of the mothers returned at least 1 questionnaire and > or =2 weights. Weight gain to 6 weeks was independently related to appetite and oromotor dysfunction rated at 6 weeks. Appetite rated at 6 weeks and 12 months both independently predicted weight gain to 12 months. Some avoidant eating behavior was seen in most children by 12 months old, but there was no relationship with weight gain or faltering after adjustment for appetite. However, the extent to which caregivers responded to food refusal was a significant inverse predictor of weight gain, even after adjustment for appetite.

CONCLUSIONS

Inherent child appetite characteristics seem to be an important risk factor for weight faltering and failure to thrive, but high maternal promotion of feeding may also have an adverse influence.

Failure to thrive as a manifestation of child neglect

Failure to thrive is a common problem in infancy and childhood. It is most often multifactorial in origin. Inadequate nutrition and disturbed social interactions contribute to poor weight gain, delayed development, and abnormal behavior. The syndrome develops in a significant number of children as a consequence of child neglect. This clinical report is intended to focus the pediatrician on the consideration, evaluation, and management of failure to thrive when child neglect may be present. Child protective services agencies should be notified when the evaluation leads to a suspicion of abuse or neglect.

Shifts in percentiles of growth during early childhood: analysis of longitudinal data from the California Child Health and Development Study

OBJECTIVE

To document growth-velocity changes across major percentiles during the preschool years.

DESIGN

Analyses of longitudinal data using height-for-age, weight-for-age, weight-for-height, and body mass index (BMI)-for-age percentiles were performed to examine crossing of major percentiles of the Centers for Disease Control and Prevention 2000 growth charts. The 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles were defined as the major percentiles.

SETTING

Data from the California Child Health and Development Study were used.

SUBJECTS

A total of 10,844 children up to 60 months of age, with 44,296 height and weight measurements, were included in our final analysis.

RESULTS

For height-for-age, 32% of children between birth and 6 months of age, 13% to 15% of children between 6 and 24 months of age, and 2% to 10% of children between 24 and 60 months of age crossed 2 major percentiles. For weight-for-age, 39% of children between birth and 6 months of age, 6% to 15% of children between 6 and 24 months of age, and 1% to 5% of children between 24 and 60 months of age crossed 2 major percentiles. In contrast, for weight-for-height, 62% of children between birth and 6 months of age, 20% to 27% of children between 6 and 24 months of age, and 6% to 15% of children between 24 to 60 months of age crossed 2 major percentiles. Similar to the pattern observed for weight-for-height, 8% to 15% of children between 24 and 60 months of age crossed 2 major BMI-for-age percentiles. During the preschool years, weight-for-height had the highest percentages of children who crossed 2 major percentiles, and weight-for-age had the lowest percentages of children who crossed 2 major percentiles among these 3 indices.

CONCLUSIONS

Shifts in growth rates were very common for children from birth to 6 months of age, somewhat less common for children 6 to 24 months of age, and least common for children 24 to 60 months of age. Shifts in weight-for-height occurred more frequently than did other growth changes. Pediatricians must consider the prevalence of growth rate shifts during infancy and early childhood before they counsel parents regarding growth or refer children for additional evaluations of growth.

Gastrointestinal motility and sensory abnormalities may contribute to food refusal in medically fragile toddlers

BACKGROUND

In chronically ill children who refuse to eat, surgery to correct anatomic problems and behavioral treatments to overcome oral aversion often succeed. A few patients fail with standard treatments. The aims of the study were to: 1) investigate motility and gastric sensory abnormalities and 2) describe treatment that was individualized based on pathophysiology in children who failed surgery and behavioral treatments.

METHODS

We studied 14 patients (age 1.5-6; mean 2.5; M/F: 7/7). All had a lifelong history of food aversion and retching or vomiting persisting after feeding therapy and fundoplication. All were fed through gastrostomy or gastro-jejunostomy tubes. We studied esophageal and antroduodenal manometry, and gastric volume threshold for retching. We identified when gastric antral contractions were associated with retching and pain. A multidisciplinary treatment program included a variable combination of continuous post-pyloric feedings, drugs to decrease visceral pain, drugs for motility disorders, and behavioral, cognitive, and family therapy. We interviewed parents 2-6 months following testing to evaluate symptoms, mode of feeding and emotional health.

RESULTS

We found a motility disorder alone in 2, decreased threshold for retching alone in 5 and both motility and sensory abnormalities in 7. After treatment, 6 of 14 (43%) began eating orally and 80% had improved emotional health. Retching decreased from 15 episodes per day to an average of 1.4 per day (p <0.01).

CONCLUSIONS

Upper gastrointestinal motor and/or sensory disorders contributed to reduced quality of life for a majority of children and families with persistent feeding problems. A multidisciplinary approach improved symptoms and problems in these children

Diet and nutrition in pediatric dentistry

Optimal growth and development are the primary objectives of pediatric nutrition. Dietary habits and food choices to support both oral health and systemic health are similar. Each emphasizes structured meal patterns and food choices. The oral health professional has a responsibility to screen for diet-related disorders and to treat or refer as appropriate.

Feeding behaviour in young children who fail to thrive

One-year-old children who failed to thrive in infancy were identified through a specialist clinical service using a conditional weight gain criterion which identified the slowest gaining 5%. Control children of the same age and sex were recruited from the same local geographical area and had the same primary care physician. The food intake and feeding behaviour of the groups was compared using a detailed observational micro-analysis of a lunchtime meal, using a behavioural coding scheme developed for use over the weaning period. Both food and fluid intake at the test meal were significantly lower in the children who failed to thrive than the controls. There was no significant difference in the energy density of the foods they consumed. As recorded in the behaviour counts at the meal, the mothers of the children who failed to thrive fed them as much as or more than the control mothers fed their children. The children who failed to thrive tended to refuse or reject the offered food more, and also fed themselves significantly less often than the controls. These behavioural differences during the meal accounted for about one third of the difference in energy intake between the groups.

Selection of growth parameters to define failure to thrive

Failure to thrive (FTT) is a syndrome of growth failure due to undernutrition. Determining whether an infant has FTT is based on the use of an anthropometric indicator and a selected cutoff value for that indicator. These anthropometric indicators include weight for age, weight for length, and length for age, and the cutoff values include the 10th, 5th, and 3rd percentiles. Each indicator and selected cutoff value provide unique information about an infant's growth. However, these parameters are often used interchangeably to explain the same growth phenomenon. The sensitivity and specificity of each anthropometric indicator are a function of the cutoff value selected and dictate which infants will be classified as having FTT and which infants will be classified as healthy. Depending on the sensitivity and specificity of the indicator, some infants with FTT will be classified as healthy, and some healthy infants will be classified as having FTT. A clear rationale for the selection of an anthropometric indicator and a cutoff value for defining FTT are important for increasing the generalizability of research findings and thereby expanding the current knowledge base related to FTT.

Failure to thrive in children

Optimal nutrition in early infancy is the success behind good health, growth, and development of children. This article presents an overview of failure to thrive in children younger than 2 years of age. This article reviews normal growth, growth indices, common etiology, and an approach to evaluation and management of failure to thrive.

Energy compensation in young children who fail to thrive

BACKGROUND

Failure to thrive is generally attributed to undernutrition, but little is known about the appetite or eating behaviour of children with the condition. The hypothesis that young children who fail to thrive lack a normal sensitivity to internal hunger or satiation cues was tested in this study using an energy compensation procedure.

METHOD

Twenty-seven children under assessment by a community-based service for failure to thrive, with weight gain in the lowest 5% for their age, were studied at one year of age with 26 controls of the same age and sex with normal weight gain, resident in the same local geographical area. Test meals were given in the child's own home on two separate days. The test meals were preceded by either a high energy (402 kJ) drink, or by a low energy (1 kJ) drink on a control day. The order was randomised, and the study conducted double blind, without the experimenter or the mother knowing which drink was which. Energy intake at the test meal was measured.

RESULTS

There was no significant difference in the birth weight of the children in the two groups but by the time of the test the cases weighed significantly less than controls, with mean (SD) weight 9.06 (1.05) kg and 11.59 (1.59) kg respectively. In relation to the British Growth Reference for weight this is a difference of 2.2 SD. Mean (SD) energy intake at the meal on the control day was significantly lower in the case children than the controls (FTT 687.5 (334.3) kJ; controls 1065.9 (431.8) kJ; p < .001). After the high energy drink, controls reduced their energy intake at the meal by a mean (SD) -257.3 (383.3) kJ while the cases showed a slight average increase of +78.1 (365.9) kJ; t = 3.26, df 51, p < .001. Per kJ of the pre-load, the average change was -1.18 kJ in controls and +0.80 kJ in cases.

CONCLUSIONS

The controls compensated as expected for their high energy load at the subsequent meal, but the case children did not, showing that they lack the normal responses to internal hunger/satiation cues. High energy snacks may improve the nutritional status of children who fail to thrive.

The effects of infant feeding decisions on infant growth

ISSUES AND PURPOSE

To determine the effects of feeding decisions on infant growth in the first 6 months of life.

DESIGN AND METHODS

Growth measurements were collected twice during the first 6 months of infancy as part of a larger investigation of infant feeding practices (N = 52).

RESULTS

Infants who received solid foods before the age of 4 to 6 months weighed less than those who received solid foods after 4 to 6 months. There were no differences in growth measurements between formula-fed and breast-fed infants, although breast-fed infants weighed more at birth.

PRACTICE IMPLICATIONS

Emphasize the importance of feeding breast milk (preferably) or formula only for the first 6 months. Advise parents to withhold fruit juices until the infant is at least 6 months old.

Functional magnetic resonance imaging of the pediatric swallow: imaging the cortex and the brainstem

OBJECTIVE

To design and implement a functional magnetic resonance imaging (fMRI) protocol to investigate the cortical and brainstem patterns of activity in children with regard to the act of swallowing.

STUDY DESIGN

Pilot study to assess the clinical feasibility of the project.

METHODS

Using a 3T Bruker Biospec 30/60 MRI scanner, images were obtained using the Behavior Interleaved Gradient/Blood Oxygen Level Dependent (BIG-BOLD) image acquisition method. Initially, regions of interest (ROI) were developed to identify the mean time from the onset of a swallow to maximum cortical blood flow in the motor cortex. Using this data to design the BIG-BOLD acquisition method followed by postprocessing of the data, images from two volunteer adults and four volunteer children were obtained.

RESULTS

The average time from the onset of a swallow to maximum cortical blood flow was 6 to 8 seconds. Regions of cortical activity include pre- and post-central gyrus (Brodmann's areas 3 and 4), superior motor cortex (B.A. 24), insula, inferior frontal cortex (B.A. 44 and 45), Heschl gyrus (B.A. 41 and 42), putamen, globus pallidus, and the superior temporal gyrus (B.A. 38). Of particular note is the first mapping of the functional activity of swallowing at the level of the brainstem; activity was seen in the region of the nucleus ambiguous.

CONCLUSIONS

fMRI provides a novel means of studying the central processes of both normal swallowing and its various pathologic forms in children. Further understanding of how a child coordinates a swallow and how this coordination can be altered at the level of the brainstem and cortex may aid in the development of novel rehabilitative strategies.

FAILURE TO THRIVE

Failure to thrive is a commonly encountered problem in Paediatric practice. This essentially generic term refers to children whose attained weight or rate of weight gain is significantly below that of other children of similar age and same sex. Several defining criteria have been proposed and help to differentiate true failure to thrive from other conditions causing apparent growth failure. There are numerous organic causes of failure to thrive, but non-organic failure to thrive is also an important entity and is caused by social, psychological and environmental factors. The clinical features are those of malnutrition, signs of underlying organic cause and specific manifestations of environmental/psychosocial deprivation. Indiscriminate laboratory investigations are usually non-contributory and have no role in evaluation. Management requires a multidisciplinary approach and hospitalization has a specific role. Although nutritional rehabilitation is the cornerstone of therapy, treatment of underlying factors-medical, psychological, social and environmental-should receive equally important attention. Long term physical, developmental and behavioural sequelae are known to occur in children with failure to thrive.

Reversing growth deficiency in children: the effect of a community-based intervention

INTRODUCTION

The effect of a community health nursing intervention on children with growth deficiency (also called nonorganic failure to thrive or growth failure) was examined in a pretest and post-test experimental study. This study evaluated the impact of the intervention on growth quotients, children's diets, parent-child interaction, home environment, and mothers' perceived stress.

METHODS

The sample consisted of 39 children (ages 3 months to 3 years) with growth deficiency in weight or height for age, weight for height, or a decrease in growth across two percentiles. The children were enrolled in Special Supplemental Feeding Program for Women, Infants and Children (WIC) clinics in county health departments and were randomly assigned to experimental or control groups. After preliminary data were collected for the entire sample, a community-based intervention was administered to the experimental group during home visits. The intervention included education about nutrition and about parenting and community skills.

RESULTS

Data collected after the intervention by a research assistant blind to group assignment indicated positive changes (P < or = .05) in the experimental group's growth quotients, home environments, and their mothers' perceived stress.

DISCUSSION

This study supports the community health nursing practice of teaching nutrition and child care during home visits to families of children with growth deficiency.

Classifying complex pediatric feeding disorders

BACKGROUND

This study defines the multiple characteristics associated with complex pediatric feeding problems and determines the relative frequency of each classification in a population referred to an interdisciplinary feeding team.

METHODS

The written reports from team evaluations on 103 children (64 males, 39 females; age range 4 months to 17 years) were reviewed. Prematurity and/or presence of developmental delay was coded. Identified factors related to current feeding problems were coded according to five categories: structural abnormalities, neurological conditions, behavioral issues, cardiorespiratory problems, metabolic dysfunction.

RESULTS

Interrater reliability for the classification coding was 88%. Thirty-eight percent of the children had a history of pre- maturity and 74% were reported to have evidence of developmental delay. The following five categories or combinations were coded most frequently: structural-neurological-behavioral (30%), neurological-behavioral (27%), behavioral (12%), structural-behavioral (9%), and structural-neurological (8%). Overall, behavioral issues were coded more often (85%) than neurological conditions (73%), structural abnormalities (57%), cardiorespiratory problems (7%), or metabolic dysfunction (5%).

CONCLUSIONS

Data analysis using this classification system revealed that the majority of children in this sample had a behavioral component to their complex feeding problem, regardless of concurrent physical factors. These findings suggest that complex pediatric feeding problems are biobehavioral conditions in which biological and behavioral aspects mutually interact, and both need to be addressed to achieve normal feeding.

Follow-up study of children with growth deficiency

This follow-up study revealed that all the children with growth deficiency in the original study had slower growth velocity after termination of the study. Two years later, 56% of the sample was located and the measures were repeated. The experimental group had diets significantly higher in fat and zinc than did the control group. The amount of fat, calories, zinc, and protein intake in all the children's diets was significantly related to their percentile level for weight. The stress of all the mothers, both experimental and control, had increased, and there was a significant increase in stress in the experimental mothers. There was no difference in the children's home environments, but the parent-child interactions were significantly more positive between the experimental children and their mothers. This follow-up study demonstrates that children with growth deficiency benefited over time from the original intervention but need continued intervention for positive significant changes to persist.

Nonorganic failure to thrive: a theoretical approach

Nonorganic failure to thrive (NOFTT) is a significant health problem of infancy. Although NOFTT is thought to be a result of multiple factors, exactly what these factors are is unclear. Explaining the development of NOFTT has been hindered by a lack of a theoretical approach. The purpose of this article is to provide a review of the literature and the discussion of a theoretical framework to guide future research in the area of NOFTT.

A community based study of failure to thrive in Israel

OBJECTIVE

To examine the characteristics of infants suffering from failure to thrive in a community based cohort in Israel and to ascertain the effect of failure to thrive on their cognitive development.

METHODS

By review of records maintained at maternal and child health clinics in Jerusalem and the two of Beit Shemesh, epidemiological data were obtained at age 15 months on a cohort of all babies born in 1991. For each case of failure to thrive, a matched control was selected from the same maternal and child health clinic. At age 20 months, cognitive development was measured, and at 25 months a home visit was carried out to assess maternal psychiatric status by questionnaire, and the HOME assessment was performed to assess the home environment.

RESULTS

3.9% of infants were found to have fallen below the third centile in weight for at least three months during the first year of life. Infants with failure to thrive did not differ from the general population in terms of obstetric or neonatal complications, birth order, or parents' ethnic origin, age, or years of education. The infants with failure to thrive did have lower birthweights and marginally smaller head circumferences at birth. Developmental assessment at 20 months of age showed a DQ of 99.7 v 107.2 in the matched controls, with 11.5% having a DQ below 80, as opposed to only 4.6% of the controls. No differences were found in maternal psychiatric problems as measured by a self report questionnaire. There were, however, significant differences in subscales of the HOME scale.

CONCLUSIONS

(1) Infants who suffered from failure to thrive had some physiological predispositions that put them at risk; (2) failure to thrive may be an early marker of families providing suboptimal developmental stimulation.