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Home , Failure to thrive, Short stature, Stunted growth

PEDIATRICDENTISTRY/Copyright © !990 by The AmericanAcademy of Pediatric Dentistry Volume 12, Number3

Failure to thrive: review of the literature, case reports, and implications for dental treatment Craig E. Elice, DDS Henry W. Fields, DDS, MS, MSD

Abstract The symptomfailure to thrive (FTT) is increasing in the dressed in comparative growth charts. No single meas- general population, and has a prevalence of 9.6% among ure accurately characterizes the degree of growth fail- in the UnitedStates. Other factors occur in associa- ure. tion with growthfailu re such as medicaland dental anomalies For these reasons, a complete medical examination, and developmental delays that influence the managementof social and family history, and midparental height these children. Four cases are presented to demonstratethe (average for both ) are required for an accurate spectrum of proble~ns and interdisciplinary management evaluation (Smith et al. 1976; Levine 1978; Accardo required to provide successful dental treatment. 1982). Three growth descriptors -- height, weight, and head circumference -- help estimate the timing of the Introduction etiologic insult and the effects of treatment (Lubchenco (FTT) is an increasing symptom 1976). Manytimes, these data are available, but have not our population because more infants with serious been plotted prior to referral to a tertiary care facility. medical problems are surviving the pre- and postnatal The processes associated with FTToccur pre- period and because more well-intentioned parents are or postnatally and can involve most pediatric feeding their infants an inappropriate, restrictive diet of (Riley et al. 1968; Beck and van den Berg 1975; Lubch- questionable nutritional value. Mitchell et al. (1980) enco 1976). Several authors (Hannawayet al. 1970; Sills reported a 9.6% prevalence of growth failure among 1978; Homer and Ludwig 1981) described FTT as or- infants. Up to 5%of all pediatric hospital admissions ganic (18-50% of cases), nonorganic (35-60% of cases), maybe related directly to failure to thrive (Levine 1978). or mixed (0-25% of cases). The purpose of this paper is to provide a literature Organic FTTrequires identification of an associated review and present a series of case reports to illustrate organic disease or other condition, i~cluding: neurol- problems these patients can present to the pediatric ogic (7-18%), gastroenterologic (8-14%), or endocrine dentist. (2-5%) disorders; malignancy (1%); congenital heart (2-4%), renal (2-5%), or hepatic (2-4%) diseases; Review of Literature mosomal abnormalities (2%); HIV (1%) or intrauterine (2%) infections; or dental caries (Sills 1978; Hannaway The symptom FTT was described in the textbook al. 1980; Accardo 1982). Diseases of Infancy and Childhood (Holt 1899) and tradi- Nonorganic FTTrefers to the exclusion of an organic tionally has been reserved for infants and toddlers etiology and findings consistent with an adverse envi- younger than 3 years of age. Older children with similar ronment, such as: inadequate maternal information in symptomsare labelled as "failure to grow" or "short caring for the , disturbance in attachment (4%), stature" (Reinhardt 1979). By definition, FTTconsists of: and problems in separation/individuation which re- 1. Weight or height below the third percentile for age flect abnormal infant behavior (25%) (Egan et al. 1978; 2. Weight less than 80%of ideal weight for age Cupoli 1980). 3. Failure to maintain a previously established Homer and Ludwig (1981) defined mixed FTT growth pattern; and/or patients with both organic and nonorganic causes. 4. Growth failure of unknownorigin (Accardo 1982). Gordon and Vasquez (1984) subdivided mixed FTT into This definition has shortcomings because racial, envi- three different types. The first involved an adverse ronmental, and hereditary differences are not ad- environment that precipitated organic symptoms. The

PEDIATRICDENTISTRY: MAY/JUNE, 1990~ VOLUME12, NUMBER3 185 second type required a diseased infant and an adverse both height and weight velocity increased and ap- environment that magnified growth failure. In the third proached the third percentile. type, the affected infant caused an adverse environment A number of factors were significant for this 's (e.g.: negative parental reactions). dental treatment. He had nursing bottle caries, defiant Although description of the etiologies of FIT ap- behavior, and poor motivation. The patient's inappro- pears straightforward, clinicians often confuse causa- priate behavior was managed using conscious sedation tive agents with environments. Case histories that in- and restraint. His inadequate oral hygiene practices and volve multiple medical problems amplify this point. cariogenic dietary habits were addressed with his par- ents during restorative visits. The restorative care in- Case Reports cluded placement of stainless steel crowns and alloys on The following case reports illustrate some of the the posterior teeth and extraction of the primary ante- medical and environmental problems associated with rior teeth. Diet counseling measures and oral hygiene FTT and the problems that occur when managing these instruction were coordinated with the referring pedia- patients' dental needs. In all cases, the chief complaint, tricians. The patient was lost to follow up because of past medical history, etiology of FTT, and dental treat- poor compliance with dental appointments. ment are described. Case 2 Casel This 3 year, 11 month black female was referred by a This 7-year-old black male was referred from a pedi- clinic because of enamel hypoplasia. She was atric clinic for treatment of extensive a 3 kg product of a 41-week gestation period and was dental caries believed to be contributing to his FTT. delivered by Cesarean section because of fetal distress. and hypothyroidism were diagnosed The patient had seizures at 8 days of age. Subsequently, at 4 years of age. The child had frequent upper respira- the child was diagnosed with hepatomegaly, pulmonic tory infections and was experiencing separation diffi- stenosis requiring SEE precautions, sleep apnea, and culties, behavior problems at school, and crowded liv- developmental delays. A karyotype was performed ing conditions at home. This combination was classified because of her dysmorphic features, which revealed an as mixed etiology FTT. extra autosomal segment on the short arm of her X The growth charts (Figs 1 and 2) illustrated that chromosome. This confirmed the diagnosis of a chro- between ages 4 and 5 years growth was below the third mosomal abnormality (46XXP+) and FTT of organic percentile. After was implemented, etiology.

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1 234567 9 10 11 12 1 1 4 5 6 7 8 9 10 11 12 1- Fig 1. This patient with growth hormone deficiency was below Fig 2. This patient with growth hormone deficiency was below the third percentile (lowest curve plotted) and deviated to lower the third percentile (lowest curve plotted). Following growth percentiles an increasing amount between 4 and 5 years of age. hormone therapy (indicated by arrows), the child's weight Arrows indicate the time span of approximated the third percentile. during which the curve progressed toward the third percentile.

186 FAILURE TO THRIVE: ELICE AND FIELDS Growth data indicated that the child did not grow in Case 4 height between I year, 11 months and 2 years, 4 months, This 3-year, 4-month-old white male was referred by which mayhave been related to either chronic illness or pediatric endocrinology because of extensive dental the chromosomal abnormality. Her weight gain during caries suspected of contributing to his FTT. His past the same period was very low. medical history indicated only normal childhood dis- Because of the multiple dental lesions, inability to eases. No family history for was apparent, communicate, and multiple medical problems, the and the patient’s older brother was of normal stature. dental treatment was performed under general anesthe- Initially, the patient was referred to the hospital sia. Her hypoplastic carious teeth were susceptible to because of loss of appetite at 1 year, 10 months. A recurrent decay; therefore, all of her posterior teeth were physical examination, blood test, and endocrine screen restored with stainless steel crowns, and the anterior were negative for organic disease, and subsequently the teeth were extracted. Preventive oral health measures child was placed on a frequent follow-up schedule. were instituted and maintained successfully by the Later, bone age was determined radiographically to be parents. In the two years since the patient’s initial exam, at 2 years of age, despite his 3 year, 6 monthchronologi- she has continued to grow at a velocity below the third cal age. NonorganicFTT was the etiologic classification percentile. based on exclusion of organic disease. Case 3 Up to 4 months of age, this patient maintained This patient was an ll-year, 10-month-old white growth at the fiftieth percentile. Beginning at 6 months male referred by a pediatric endocrinology clinic for an of age, growth curves deviated to the twenty-fifth per- orthodontic evaluation. At 3 years of age the patient was centile. The pediatrician suspected juvenile , admitted to the hospital because of right knee pain that but a glucose test ruled out diabetes as a cause of was diagnosed subsequently as atypical nonHodgkins deceleration in growth. Between 1 year and 2 years, 6 lymphoma.As a result, the patient received CNSradia- months, the patient demonstrated almost no weight tion and chemotherapy. At 10 years, 2 months a testicu- gain. At 2 years of age, he began growth hormone lar biopsy indicated malignancy, and an orchiectomy therapy, and his stature was maintained at the third was performed. At that time, an indwelling catheter was percentile while his weight showed a more dramatic placed, and chemotherapy and local radiation were improvement with the growth hormone therapy. reinstituted. The child was referred to the pediatric dental clinic During radiation therapy, growth curves deviated because the physicians suspected a relationship be- across percentiles, and the height curve shifted from the tween the dental caries and the child’s FTT. A diet seventeenth percentile at 3 years of age to below the analysis indicated that the child was breast fed for 22 third percentile at 7 years of age. Pediatric endocrinol- months with limited solid food supplementation. The ogy subsequently madea diagnosis of organic failure to child ate snack foods throughout the day, but refused to grow secondary to cranial radiation. At 9 years of age, eat at meal time when balanced meals were served. In growth hormone therapy was instituted for 3 months this case, the nonorganic etiology may relate to the with no effect. Chemotherapy following diagnosis of patient’s refusal to eat and lack of parental understand- the testicular lesion probably was responsible for a ing of proper dietary management. The pediatric endo- second shift to below the third percentile in stature. crinologists counselled the parents on diet modification Growth hormone was reimplemented at 11 years, 10 and behavior managementto improve the child’s eating months, and his growth rate improved. Predictably, the habits. A dental examination revealed moderate nurs- growth hormone therapy had an even greater effect on ing bottle caries with incipient decay on the posterior weight. teeth. Although normal motor and mental development Because of the patient’s severe malocclusion, he was were achieved, he required chloral hydrate and hy- referred for an orthodontic evaluation at 11 years, 10 droxyzine pamoate sedation for his dental treatment months, and was monitored for facial growth changes because of his inability to cooperate. The child received during the next 18 months. The lateral cephalometric .fluoride supplementation and was placed on a three- radiographs obtained at 11 years, 10 months and 12 month recall. Despite instituting preventive measures, years, 8 months were superimposed and demonstrated the conservative alloys required replacement with downward and forward growth with reasonable veloc- stainless steel crowns due to recurrent decay. In the 18 ity, but not a velocity usually expected during the ado- monthsafter his first visit, the patient’s growthvelocity lescent growth spurt. Orthodontic treatment for growth accelerated to approach the third percentile. Whether modification was begun based on the sustained positive this growth acceleration was due to growth hormone growth velocity. therapy, improveddiet, or dental treatment is not clear.

PEDIATRICDENTISTRY: MAY/JUNE, 1990- VOLUME12, NUMBER3 187 Discussion (e.g.: tell-show-do and positive reinforcement) often The prevalence of children whofail to thrive is re- require more extraordinary means (i.e. conscious seda- markably high. Because several diseases in children, tion, restraint, or general anesthesia). Some of these especially H1Vand related infections, are rising at an children may be older than patients who normally extraordinary rate, FTTwill contribute more to medical, might require restraint or sedation and/or require psychological, and developmental problems than it has modification of drug regimens and restraining devices in the past and will influence the appropriate manage- and techniques. Sometimesthe older child simply is too ment of these children’s dental needs. Although the strong or large to handle safely in an outpatient setting. symptomFTT does not cause disease, it contributes to The first case demonstrated (as did the fourth) that the severity. severe dental decay can be a contributing etiologic agent Pediatric dentists treat manyseverely ill and debili- in FTT. Both children were referred for treatment of tated patients; therefore, these patients will become severe dental caries that can inhibit adequate . more prominent in specialty practice. Our responsibil- Often it is overlooked that teeth, although not necessary ity is to recognize the manytypes of etiologic factors that for adequate nutrition, make efficient, pleasurable nu- can be active, including dental caries, and be prepared trition possible. Oral pain and discomfort, on the other to treat these children in an interdisciplinary manner. hand, can reduce nutritional and fluid intake to danger- ous levels. Data from a recent survey revealed that Treatment between medical and dental specialties needs to be coordinated to meet a patient’s complex children with chronic and needs. Cases 3 and 4 illustrate this fact in several ways. have a higher caries prevalence, suggesting a relation- The third patient needed an evaluation of the present ship to FTT(Alverez 1988). malocclusion and a determination of whether dentofa- Reliable growth records can help identify children cial growth modification was feasible. Records obtained who are suffering from FTT. Most often these data need by the endocrinologist were not useful in determining to be plotted to be meaningful. Growthcharts are avail- the effects of growth hormone on the craniofacial com- able and are illustrated in contemporary pediatric den- plex. Facial growth can be gauged accurately only by tistry texts (Casamassimoet al. 1988). Because the pedi- evaluating facial structures. When growth hormone atric dentist usually maintains an aggressive recall therapy is judged successful for the patient’s somatic schedule, this type of monitoring can be accomplished and dentofacial problems, it can be continued and more readily in the dental setting at the semiannual (or orthodontic treatment instituted. One health care disci- more frequent) recalls than by the physician. pline alone cannot evaluate adequately the state of the patient’s complete health status. Conclusions Multidisciplinary care also is required for patients The symptom of FFT is recognized in 9.6% of the with inappropriate dietary habits. Dietary counselling pediatric population, and given, the. dramatic rise in and intervention by the pediatric dentist alone can lead some of the diseases contributing to FTT, can be ex- to problems with behavior modification regimes and pected to rise in prevalence. nutritional criteria set by the physician and dietitian. For 1. Pediatric dentists should expect to encounter example, high-calorie snack foods can be appropriate these medically or developmentally impaired and even part of an initial reinforcement schedule for patients. some children. Conflicting, or more often confusing, 2. Developmental delays resulting from FTT may information can undermine or stop progress. Adjust- require special behavior management techniques ment can be made in medical and dental treatment including restraint, sedation, or general anesthe- regimens to work toward mutually satisfactory goals as sia. treatment progresses. 3. Medical and dental treatment must be coordi- Treatment can alter the child’s status dramatically. nated for routine restorative care or orthodontic Appropriate cardiac surgery, a transplant, counselling, growth modification because of the complex prob- medication, or better nutrition can alter the child’s lems these patients have and their changing treat- physical and psychological status dramatically. In these ment situations. cases, the practitioner must be able to evaluate these 4. Dental caries can be a symptomor etiology of FTT. changes and alter treatment methods as needed. This 5. Height and weight should be recorded periodi- will require additional interdisciplinary communica- cally during dental exams as an adjunct to identi- tion. fying or confirming the symptom FFT. Because of their low developmental level, children whose chronological age would ordinarily dictate treat- The authors acknowledge the review of this manuscript by Drs. F.T. ment by conventional behavior management means Mclver and W.F. Vann, Jr. and the assistance in manuscript prepara- tion of Ms. Carolyn Gravely.

188 FAILURETO THRIVE:ELICE AND FIELDS Dr. Elice is a resident in the departmentof pediatric dentistry at the Research and Practice. Drotar D, ed. NewYork: PlenumPress, Schoolof Dentistry, University of North Carolina, ChapelHill. Dr. 1984, pp 69-77. Fields is assistant dean for academicaffairs and professor in the departmentsof pediatric dentistry and orthodontics, also at the Uni- HannawayPJ: Failure to thrive: a study of 100 infants and children. versity. Reprintrequests should be sent to: Dr. Craig E. Elice, Dept.of Clin Pediatr 9:96-99, 1970. Pediatric Dentistry, Schoolof Dentistry, Universityof NorthCarolina, Holt LE: The Diseases of Infancy and Childhood. (1899) Reprinted CB7450, 205 Brauer Hall, Chapel Hill, NC27599-7450. 1980. NewYork: D Appletonand Co., 1980, p 661. AccardoPJ: Failure to Thrive in Infancy and Early Childhood: A HomerC, LudwigS: Categorizationof etiology of failure to thrive. Am Multidisciplinary TeamApproach. Baltimore: University Park J Dis Child135:848-51, 1981. Press, 1982,p 119. Levine MI: Failure to thrive: an introduction. Pediatr Ann7:737-42, Alverez JO, Lewis CA, SemanC et al: Chronic malnutrition, dental 1978. caries, and tooth exfoliation in Peruvianchildren aged 3-9 years. AmJ Clin Nutr 48:368-72,1988. LubchencoLO: The High Risk Infant. Philadelphia: WBSaunders Co, 1976, pp 125-51,233-81. BeckGJ, van den BergBJ: The relationship of the rate of intrauterine growthof low infants to later growth. J Pediatr Mitchell WG,Gorrell BW,Greenberg BA: Failure to thrive: a study in a primarycare setting. Pediatrics 65:971-77,1980. 86:504-11,1975. CasamassimoP, ChristensenJ, Fields H: Examination,diagnosis, and Reinhardt JB: Disturbances of development, in Basic Handbookof ChildPsychiatry, Vol. II. JosephD. Noshpitz,ed. NewYork: Basic treatment planning for general and orthodontic problems, in Pediatric Dentistry: Infancy ThroughAdolescence. Pinkham JR, Books,1979, pp 593-99. CasamassimoPS, Fields HW,McTigue DJ, NowakAJ, eds. Phila- Riley RL, LandwirthJ, KaplanSA: Failure to thrive: an analysis of 83 delphia: WBSaunders, 1988, pp 463-66. cases. Calif Med108:32-38, 1968. Cupoli JM, Hillock JA, Barness LA: Failure to thrive. Curr Probl Sills RH:Failure to thrive: the role of clinical and laboratory evalu- Pediatr 10:1-41,1980. ation. AmJ Dis Child 132:967-69,1978. EganJ, Chatoorl, RosenG: Nonorganicfailure to thrive: pa thogenesis SmithDW et al: Shifting linear growthduring infancy. Illustration of and classification. Clin Proc Child HospNMC 36:173-81, 1980. genetic factors fromfetal life throughinfancy. J Pediatr 89:225-30, GordonEF, VasquezDM: Failure to thrive: an expandedconceptual 1976. model, in NewDirections in Failure to Thrive: Implications for

Older female teens more likely than male teens to be HIV-infected

Although U.S. teenagers rarely have AIDS, their rate of HIV infection may be higher than previously thought, warns a study that appeared in the April 18, 1990 issue of the Journal of the American Medical Association. About one of every 3,000 teenaged applicants for U.S. military service tests positive for the human immunodeficiency virus (HIV), according to the authors, Col. Donald S. Burke, MC, USA, of the Division of Retrovirology, Walter Reed Army Medical Center, Washington, DC, and colleagues, Older female teens (aged 17 and 18) are more likely to have been infected with HIV than their male counterparts, whereas adolescent male AIDS cases outnumber female cases by a four to one margin, they said. "Adolescents typically have little understanding regarding risks of infection with HIV," the authors wrote. "The data presented in this study suggest that HIV is a real and immediate threat to teenagers throughout the United States." Since October 1985, all applicants for U.S. military service have been tested for HIV. Between October 15, 1985 and March 31, 1989, more than 1.1 million teenagers applied for military service. Of these, 393 (345 males, 48 females) were found to be seropositive. The prevalence of HIV among black teenagers (1.06 per 1,000 applicants) was greater than among whites (0.18 per 1,000) or Hispanics (0.31 per 1,000), researchers found. The rate of HIV seropositivity varied markedly in different geographic locales. The most populous states had the greatest number of infected teenagers (California, 52; New York, 45; and Texas, 38). Throughout the north-central states, there was less than 0.1 per 1,000 applicants with HIV, compared with 2.0 per 1,000 in urban counties of Maryland, Texas, New York, and the District of Columbia. The overall prevalence of HIV infection was similar among teenaged males and females, although

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PEDIATRICDENTISTRY: MAY/JUNE, 1990 - VOLUME12, NUMBER3 189