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Child Abuse & Neglect: Failure to Thrive: Follow-up

Author: Andrew P Sirotnak, MD, Department Head, Child Abuse and Neglect, Director, Kempe Child Protection Team
Coauthor(s): Antonia Chiesa, MD, Senior Instructor of Pediatrics, University of Colorado at Denver Health Sciences Center
Contributor Information and Disclosures

Updated: Jul 14, 2008

Follow-up

Further Inpatient Care

• Failure to thrive (FTT) is considered a medical emergency in infants or toddlers who weigh less than 70% of the predicted weight for length.
• Watch for refeeding syndrome.
• Most infants and children younger than 1-2 years can be treated with a coordinated outpatient care plan. Far fewer patients are hospitalized as inpatients today because of the development of appropriate and focus-specific outpatient care clinics and poor reimbursement for inpatient care.
• Patients with severe malnourishment who have had either no previous workup or for whom outpatient care has failed may require hospitalization.
• Hospitalization may be required in cases of suspected abuse or neglect, as well as for patients who are perceived to be in an unsafe environment. Foster care placement may be a subsequent requirement.
• Nasogastric and gastrostomy tubes should be reserved for the most severe cases.

Further Outpatient Care

• Carefully monitor growth parameters and overall development. Continue weekly weight checks using the same clinic scale until sustained growth is documented for months.
• Provide home visitation services either through public health resources or through a hospital/clinic program as the situation warrants.
• Monitor support services aggressively in conjunction with the involved agencies, in particular, local child protection services.
• Use the care team regularly and include the family and all involved specialists at team meetings.
• Closely document the child’s clinical course.

Deterrence/Prevention

Prevention of growth failure related to parental neglect and family and/or social dysfunction can be viewed on primary, secondary, and tertiary levels.

• Primary prevention involves careful assessment and monitoring of all families in primary care practice for any risk factors as reviewed above.
• Secondary prevention involves monitoring and intervention when these risk factors or situations are identified in a family or child. Consider early intervention as a mode of prevention in cases in which the goal is preventing the potential morbidity of growth failure.
• Tertiary prevention involves cases that have been identified and where intervention has begun to address the growth failure. Prevent further growth failure, with the resultant developmental disability and poor outcome morbidity, by creating and implementing a care plan that involves detailed review (see Treatment).

Prognosis

• Early diagnosis is crucial.
• Growth, development and behavior can be affected.
• Prognosis should be guarded for infants and children with severe malnutrition. If abuse and neglect are comorbid in a case of FTT, the degree of risk and risk factors for poor outcome increase in complexity and potential for poor outcome increases.
• With early intervention and treatment, the overall outcome can be promising for infants and children who respond to the nutritional and environmental interventions needed.
• Nutritional and growth improvement alone does not mean that all problems are resolved.

Patient Education

• As noted above, patient education is one of the most crucial elements of the care plan for these patients. It involves education dealing with nutrition, feeding, and normal child behavior and development.
• Also shared with caregivers are the interventions and therapy needed for the patient and those needed to address the family or caregiver pathology or dysfunction.
• Consider such education a long-term requirement throughout the early years of the child's growth and, in some situations, for the entire childhood.

Miscellaneous

Medicolegal Pitfalls

• The most significant pitfall occurs when the focus is exclusively on a medical differential diagnosis and the complex psychosocial factors that can affect pediatric growth are disregarded.
• The clinician must consider the recognition of failure to thrive (FTT) or growth failure as a possible presentation of child neglect that requires intervention when constructing a differential diagnosis. Mandated reporting laws for child abuse and neglect are in effect in all states but may differ in the requirement or definition of neglect and may not specifically state FTT as a reportable form of neglect.

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