AMERICAN ACADEMY OF PEDIATRICS CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care Robert W. Block, MD; Nancy F. Krebs, MD; and the Committee on Child Abuse and Neglect, and the Committee on Nutrition Failure to Thrive as a Manifestation of Child Neglect ABSTRACT. Failure to thrive is a common problem in cally appropriate,5 because many patients exhibit infancy and childhood. It is most often multifactorial in components of both. See the Pediatric Nutrition Hand- origin. Inadequate nutrition and disturbed social inter- book3 from the American Academy of Pediatrics for a actions contribute to poor weight gain, delayed develop- thorough discussion of FTT. ment, 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 INCIDENCE AND CAUSAL FACTORS pediatrician on the consideration, evaluation, and man- The fundamental cause of FTT is nutritional defi- agement of failure to thrive when child neglect may be ciency. Poverty is the greatest single risk factor for present. Child protective services agencies should be no- 6,7 tified when the evaluation leads to a suspicion of abuse FTT worldwide and in the United States. FTT can or neglect. Pediatrics 2005;116:1234–1237; failure to thrive, be unintentional, occurring with breastfeeding diffi- development, child neglect, abuse, nutrition. culties, errors in formula preparation, poor diet se- lection, or improper feeding technique. FTT can also be caused by organic diseases including but not lim- ABBREVIATION. FTT, failure to thrive. ited to cystic fibrosis, cerebral palsy, HIV infection or INTRODUCTION AIDS, inborn errors of metabolism, celiac disease, renal disease, lead poisoning, or major cardiac dis- ailure to thrive (FTT) in infants and children ease. FTT may result if caregivers who are referred results from inadequate nutrition to maintain for assistance fail to avail themselves of community Fphysical growth and development. An infant or resources and/or assistance.8 FTT is often multifac- child becoming malnourished as the result of paren- torial, involving some combination of infant organic tal or caregiver neglect creates concern about child 1 disease, subtle neurologic and/or behavioral prob- maltreatment. In its extreme form, FTT secondary to lems, dysfunctional parenting behaviors, and parent- neglect may be fatal. This clinical report is not in- child interactional difficulties.9 Feeding difficulties, tended to be a thorough review of FTT but serves as oral-motor dysfunction, food aversion, and/or appe- a guide for the assessment, management, and sup- tite control often compound the problem.10,11 The port of children with FTT as a manifestation of child malnutrition in children with FTT can lead not only neglect. to impaired growth but also to long-term deficits in DEFINITION OF FTT intellectual, social, and psychological function- ing.12,13 FTT is a significantly prolonged cessation of ap- When FTT is caused by child neglect, certain risk propriate weight gain compared with recognized factors are often present. When considering neglect, norms for age and gender after having achieved a the pediatrician should assess each risk factor in the stable pattern (eg, weight-for-age decreasing across 2 context of each family’s unique situation. The par- major percentile channels from a previously estab- Ͻ ent(s) of an infant with FTT may exhibit inadequate lished growth pattern; weight-for-length 80% of adaptive social interactional behavior and less posi- ideal weight). This is often accompanied by normal 2,3 tive affective behavior. The parent may be an ado- height velocity. Despite these accepted definitions, lescent or may have a history of abuse as a child.14,15 caution must be applied when diagnosing FTT on the The infant with FTT is often born preterm or with basis of percentile shifts, because growth variants are 4 Ͻ low birth weight and may have been separated from common. Actual weight 70% of predicted weight- caregivers because of prolonged hospitalization dur- for-length requires urgent attention. It is recognized ing the perinatal period. Family and social factors now that earlier distinctions between organic and that may contribute to neglect include the lack of nonorganic FTT are overly simplistic and not clini- available extended family to help with child rearing, social isolation of the family, substance abuse, family The guidance in this report does not indicate an exclusive course of treat- violence, single parenthood, and employment insta- ment or serve as a standard of medical care. Variations, taking into account bility. Parents in middle-class and affluent circum- individual circumstances, may be appropriate. doi:10.1542/peds.2005-2032 stances or parents engaged in career development or PEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Acad- activities away from home also may lack the emo- emy of Pediatrics. tional strength or maturity to nurture their infants 1234 PEDIATRICS Vol. 116 No. 5 November 2005 appropriately.14,15 Any of these factors may lead to history, feeding history, 72-hour dietary record, gas- inconsistent feeding patterns with decreased nutri- trointestinal symptoms, travel history, feeding rou- tion, decreased growth, and additional family tines, feeding skills, time required to feed, behavior stress.16 In toddlers and older children, decrements during feedings, sleep patterns, developmental his- in the rate of growth in weight and height are more tory, daily routine, gestational and prenatal history, frequently ignored or too easily ascribed to intercur- and history of organic disease. Information obtained rent illness. Pediatricians should be aware of the from all child care providers should include a history potential for neglect of children of any age. of eating patterns, interactions, social skills, re- Infant-caregiver attachment issues may be an im- sponses to the providers, and family concerns. portant component of FTT. Disturbances in attach- ment may predict several problems in infant and Physical Examination child development.17 FTT is not synonymous with The physical examination should include docu- disturbed attachment; many children fail to thrive mentation of past and present growth parameters, without attachment disturbances, and many children including head circumference, using appropriate with attachment disturbances grow normally. Nev- growth charts. General examination should include ertheless, many factors contributing to FTT (poverty, a search for major and minor anomalies, careful neu- maternal depression, neglect) also increase the risk of rologic examination, assessment of suck-swallow attachment disturbances. Because infants with FTT coordination, and observation of the child’s develop- may be at risk of clinical disturbances of attachment, mental skills and responses and interactive behav- pediatricians should consider consultation with iors with parents and examiners. mental health professionals who can assist in evalu- ating infant-caregiver attachment.18–20 Feeding Observation Psychosocial short stature, a variant of FTT, has A feeding observation can be performed in the been described as short stature out of proportion to office but is enhanced as part of a home visit. Feeding the decreased weight. This syndrome is thought to behavior, the child’s oral interest or aversion, and result from major emotional and psychological parent-child interactions before, during, and after trauma. It has been associated with pituitary and feeding should be observed and recorded. hypothalamic dysfunction, possibly with interac- tions with nutrient deficiencies, which is frequently Laboratory Testing reversible when the child is placed in a nurturing When history, comprehensive physical examina- environment.21 tion, feeding observations, and home visitation do not reveal an obvious cause of FTT, laboratory test- ASSESSMENT ing may be performed to rule out organic disease Most children with FTT can be assessed by a gen- and ascertain nutritional deficits. Testing should be eral pediatrician with the help of professionals in performed if there are concerns arising from the other disciplines. The clinical evaluation for FTT history or physical examination; however, the yield should include a comprehensive history, physical of positive laboratory data are Ͻ1%.23 examination, feeding observation, and a home visit by an appropriate health professional. For breastfed RECOGNITION OF FTT SECONDARY TO NEGLECT infants, an observation of feeding should include an OR ABUSE evaluation of the mother’s breastfeeding technique The risk factors that should alert the pediatrician and the infant’s response to feeding and be con- to the possibility of neglect as the cause of FTT in- ducted by a professional specifically trained in lac- clude: tation counseling and assessment. Laboratory and • parental depression, stress, marital strife, divorce; radiologic studies are frequently unnecessary. A • parental history of abuse as a child; multidisciplinary approach involving nursing, social • mental retardation and psychological abnormali- services, and dietetics personnel is essential when ties in the parent(s); children with FTT fail to recover and sustain normal • young and single mothers without social supports; growth velocity after treatment interventions.22,23 • domestic violence; History • alcohol or other substance abuse; • previous child abuse in the family; A thorough review of the child’s family history