eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Child Abuse & Neglect: Failure to Thrive

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

Introduction

Background

Although the discussion of pediatric growth failure can be traced back over a century in the medical literature, the term failure to thrive (FTT) has only been used in the past several decades. The previously used dichotomy of nonorganic (environmentally related) and organic growth failure is the result of either inadequate calorie absorption, excessive calorie expenditure or inadequate intake of calories. 

The objective parameter is usually the deceleration of growth height and weight. If FTT is severe, the parameter is poor brain growth as evidenced by head circumference. The diagnosis is based on growth parameters that (1) fall over 2 or more percentiles, (2) are persistently below the third or fifth percentiles, or (3) are less than the 80th percentile of median weight for height measurement. Growth failure is now generally accepted to be overly simplistic and obsolete.

A good working definition of growth failure related to aberrant caregiving is the failure to maintain an established pattern of growth and development that responds to the provision of adequate nutritional and emotional needs of the patient. Most cases of FTT are not related to neglectful caregiving, although it may be a sign of maltreatment and should be considered during an evaluation for growth failure.¹  A joint clinical report by the American Academy of Pediatrics Committee on Child Abuse and Neglect and the American Academy of Pediatrics Committee on Nutrition outlines 3 indicators of neglect: “Intentional withholding of food from the child; strong beliefs in health and/or nutrition regimens that jeopardize a child’s well-being; and family that is resistant to recommended interventions despite a multidisciplinary team approach.”²

Frequency

United States

Incidence of true growth failure of children in the United States is not accurately known. However, nearly 20% of children younger than 4 years live in poverty, and the inability to obtain adequate food is directly related to such conditions.

International

International problems of poverty and hunger occur in many nations. The death rate from malnutrition and infection for these countries can be high.

Mortality/Morbidity

The morbidity of malnutrition as a separate clinical entity is discussed in Malnutrition. Malnutrition that accompanies FTT can lead to significant developmental delays in children. The first 2 years of a child’s life are a sensitive period of rapid brain growth when neurodevelopmental outcomes can be influenced. Motor, fine motor, speech, language, and cognitive delays have been documented. The resultant poor cognitive ability can lead to emotional and behavioral problems as well. Children die each year in the United States from malnutrition; some severe cases are directly related to intentional child neglect.

Race

No racial predilection is noted because growth failure related to aberrant caregiving can affect people of all races.

Sex

No sex predilection is important to note.

Age

Growth failure for this discussion is described in children from infancy through the toddler period.

Clinical

History

The history for evaluating pediatric growth failure and malnutrition is addressed in detail elsewhere. This discussion addresses the infant with failure to thrive (FTT) primarily related to nonmedical (eg, environmental, psychosocial) causes.

• Maternal medical history should include the following:
  • Maternal age
  • Gravidity
  • Parity
  • Abortions
  • Pregnancy health history, including a detailed history of weight gain, prenatal care, substance or cigarette use, nutrition and unusual nutritional practices, general complications, bleeding, infections, fevers, and toxemia
  • Labor and delivery and complications, if any
• Neonatal medical history should include the following:  
  • Gestational age determined at birth
  • Intrauterine growth rate (IUGR)
  • Apgar scores
  • Birth weight, length, and head circumference with percentiles
  • Neonatal course and complications, including sepsis, jaundice, feeding intolerance, or feeding difficulties
  • Detailed medical history of newborn period
  • Completed review of newborn screens (eg, phenylketonuria [PKU], other inborn errors of metabolism)
• The infant's or child's history should include the following: 
  • Medical-based history to exclude medical causes
  • Feeding and nutritional history
  • Growth and developmental progress
• Postnatal medical history should include the following:
  • Immunizations
  • Allergies
  • Medications
  • Food intolerance
  • Formula intolerance
  • Weight loss
  • Diarrhea
  • Vomiting
  • Dysphagia
  • Snoring
  • Sleep apnea
  • Recurrent respiratory or other bacterial and viral infections
  • Signs of immune deficiency
  • Malabsorption symptoms and signs
  • CNS abnormalities
  • Developmental delay or delayed or regressed milestones
• A detailed history of food intake from infancy through the current period is vital, and feeding history should include the following:
  • Age-adjusted and age-dependent dietary details - Milk, formula, solids, vitamins, other supplements, food allergy or intolerance
  • Feeding behaviors - Sucking, chewing, and swallowing difficulty; limited food preference or negative responses to food and feeding; frequency and timing of meals
  • Caregivers' knowledge - Nutrition and feeding, dietary beliefs, religious and cultural beliefs about food, any unusual diets that might be inappropriate for a child
  • Basic food and nutritional needs - Anything that prevents the family from (or assists the family with) getting food (eg, finances, transportation, subsidized programs); appropriate and safe preparation of food by the caregiver (eg, clean water, housing or shelter, cooking facility, refrigeration, cooking knowledge)
  • Issues of nutritional ignorance (inadequate amounts or types of food, unusual dietary beliefs)
  • Review of all developmental milestones for infancy and childhood, looking for either failure to attain or regression from the norm at specific ages
• The details of the psychosocial history are vital and should include the following:
  • Finances, poverty risk factors (In 2004, food insecurity was identified in 42% of low-income houses with children younger than 6 y.² )
  • Environment (eg, 1 bedroom apartment, 4 adults, 4 children)
  • Family structure
  • Caregiver identity and responsibility
  • Daycare use
  • Beliefs about child rearing
  • History of abuse or neglect
  • Prior child with growth problems
  • Family substance abuse or addiction
  • Violence or chaotic family structure
  • Risks for or signs of maternal postpartum depression
  • Educational level of parent or caregiver
  • Employment with caregiver arrangements
  • Food subsidy (eg, food stamps, Women, Infants, and Children [WIC] Program)
  • Transportation problems
  • Welfare or other aid programs
  • Health insurance
  • Family or cultural concepts on feeding and specific foods

Physical

The physical examination must be detailed and carefully performed to detect any disease or syndrome that might affect growth and development. The examination most often reveals a rather small and undernourished infant with normal vital signs and with most developmental milestones either intact or mildly delayed. Hospitalization is only needed for the rare infant with signs of severe malnutrition as evidenced by cachexia or marasmus.
 
Plotting growth parameters on the appropriate growth chart is essential. Multiple data points are helpful to evaluate trends in growth. Weight should be measured with the child unclothed. Length (not height), head circumference, weight for height and body mass index should also be plotted. Some conditions, such as Down syndrome, achondroplasia, and Turner syndrome, require specific growth charts.

• Vital signs - Temperature, blood pressure (in 4 extremities in an infant or one arm and one leg in young child), pulse, respiration
• General - Appearance, activity, affect
• Skin and hair - Poor hair texture and amount, nails, alopecia, hygiene, rashes, birth marks, trauma (eg, bruises, burns, or scars as signs of physical abuse)
• Head - Size, frontal bossing, fontanel size and patency, dysmorphia
• Eyes - Dysmorphia, ptosis, sunset sign, palpebral fissures, pallor, trauma, optic discs, fundi for evidence of chorioretinitis (toxoplasmosis, other infections, rubella, cytomegalovirus infection, and herpes simplex [TORCH]), cataracts (TORCH or inborn errors of metabolism)
• External ears - Size, shape, position, infection
• Middle ears - Infection, acute or chronic
• Mouth and pharynx - Palate deformity, submucous cleft, tongue, teeth, caries, glossitis, mucous membrane hydration or lesions, thrush, bleeding, unusual odors to the breath
• Neck - Shape, web, masses, nodes, thyroid abnormalities
• Chest - Breath sound, cardiac examination for murmurs or cardiomegaly or arrhythmias
• Abdomen - Protuberance, organomegaly, masses, bowel sounds, normal umbilicus healing in infant
• Genitalia - Normal for age, malformations, ambiguous in quality, hygiene, trauma
• Extremities - Edema; digit malformations; examination of the nails, joints, spine, and back
• Neurologic function - Cranial nerves, reflexes (increased or decreased), tone, infant reflexes present or extinguished at appropriate age, gait, suck/swallow coordination
• Muscles - Muscle development and quality and texture of muscle mass
• Adversive behaviors - Gaze avoidance, arching, hypertonicity, refusal to attach or respond appropriately, unusual body movements

Causes

See History.

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