Failure to Thrive and
Nutritional Neglect
The 31st Annual San Diego
International Conference
February 2, 2017
Case Presentation
Suzanne P. Starling, MD
Medical Director
CHKD Child Abuse Program
EVMS Professor of Pediatrics
Growth Failure
• Growth failure occurs in 10% of US
children
• It crosses all socioeconomic levels
• Most FTT is commonly mixed in
etiology
• Non-medical etiology accounts for the
majority of growth failure
Defining FTT
Failure to Thrive
• No consensus on a single best definition
Case Presentation
• Growth pattern below established
standards for age and gender
• Weight loss in a young child is always an
indicator of pathology
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Failure to Thrive
• Descriptive term of a child’s condition
Case Presentation
– Not a diagnosis
– Identification of multifactorial etiologies causing
this malnutrition
• Frequently, malnourished children are not only
growing too slowly, but are truly not thriving
Anthropometric Definition
Other Anthropometric Definitions
• Weight (or weight for length/height) < 2 SD
below mean
• Weight for age <5th % on >1 occasion
• Weight < 80% of median weight for length
• BMI for chronological age < 5th %
• Weight deceleration of > 2 major percentile after previously
established pattern
• Length for chronological age < 5th %
• Relies on the availability of >1 measurement
• Provides a more dynamic view of child’s growth
Quantifying Degree of Malnutrition
To assess severity of
malnutrition, express weight as a
% of median weight-for-age
Median =
50th
% for weight
Age: 42 months (~3.5 yrs )
Weight: 8.7 kg
Median weight (50th %): 16 kg
(8.7kg/16kg) x 100 = 54%
• Normal: 90-110%
of median
• Mild malnutrition: 75-90% of median
• Moderate malnutrition: 60-74% of median
• Severe malnutrition: <60% of median
Severely Malnourished
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Acute Malnutrition
Chronic Malnutrition
Weight declines
• Wasting
• Weight for age drops to greater degree
than the height for age
Height declines
If a child manifests a
different pattern, search
for causes other than
malnutrition
• Associated with a low weight for height
Head circumference
declines
Chronic Malnutrition
Vertical growth stops and inadequate weight gain persists
Height for age percentile falls
Weight for height might normalize
Stunted children do not always appear malnourished
May be proportionally normal
Stunting
Definitions
• Wasted: deficit in weight for age
– failure to gain weight or loss of weight
– develops rapidly and is readily reversed
• Stunted: deficit in height for age
– chronic process, decreased skeletal growth
• Best index of acute risk is weight for height
Case Presentation
Shah, J Clin Gastro, 2002
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Patterns of growth
• HC, Ht, Wt are similarly delayed in
congenital and hereditary disorders
• HC normal, Wt and Ht proportionally
decreased in constitutional delay and
genetic dwarfism
• HC normal and Wt decreased out of
proportion to Ht in acute malnutrition and
malabsorption
Aspects of failure to thrive
Constitutional Growth Delay
• Variant of normal growth
• Normal growth initial 4-12 mo
• Then growth rate slows and
height/weight are < 3rd %
• By 2-3 yrs, growth resumes
• Family history is common
• Bone age mirrors height ages
not chronological age
Failure to Thrive
Etiology
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Medical
Nutritional
Developmental
Social
Inorganic
Organic
Malnutrition caused by major
illness or organ system
dysfunction
FTT Classification
• Classification scheme continues to be
taught
• Over-simplification
• Usually multifactorial etiology
Environmental
Inadequate caloric intake
Inadequate absorption or uptake
Increased metabolism or excretion
Defective utilization
Inadequate calories and nutrients
Failure to Thrive
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Inadequate Caloric
Intake
Dietary
-Breast feeding difficulties
-Diluted formula
-Food fads or restrictions
-Developmental/Neurologic
-Oral motor difficulties
-CNS Abnormalities
Medical
-Adenotonsillar hypertrophy
-Cleft lip and/or palate
-Dental pain and decay
-Congenital cardiac disease
-Gastrointestinal Reflux Disease
-Dysphagia
Inadequate Absorption or
Utilization
Increased Caloric
Requirements
-Food allergies or intolerances
-Hyperthyroidism
-Inflammatory
Bowel Disease
-Chronic infections
-Gastrointestinal
Malformations
-HIV
Case Presentation
-TB
-Pyloric Stenosis
-Pulmonary disease
-Hepatitis
-Cystic Fibrosis
Social
-Unavailability of food
-Parent-child interaction disorders
-MH/behavior disorders
-Mental health of parent
-Disorganized meal times
-Neglect (omitting to feed and/or
create environment conducive to
feeding)
-Parasitic Infections
-Malignancy
-Renal Disease
-Inborn Errors of Metabolism
Risk Factors for FTT
Prenatal Risks
Infancy/Childhood Risks
• Parental height
• No single risk factor uniformly predicts FTT
• FTT involves a multiplicity of overlapping dietary,
developmental, social and medical concerns
• Higher parity
Psychosocial Risks
• Weak sucking in 1st 8
weeks of life
• Mental health issues/IQ of
caregivers
• Duration of breastfeeding
• Poverty
• Medical complications of
pregnancy
• Difficulty weaning
• Family stressors
• Inadequate maternal
weight gain
• Medical illness acute or
chronic
• Lack of social support
• Short gestation
• Recurrent infections
• LBW (symmetric IUGR
a worse prognosis)
• Elevated lead levels
• Feeding difficulties in
nursery
• Child’s temperament
(activity level, adaptability,
distractibility, intensity)
• Social isolation
• Problematic interpersonal
relationships
Poverty
Case Presentation
• Difficulty buying sufficient food
– food shortages at end of month
• Inadequate housing
– lack of cooking facilities
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Crowding, leading to distractions
Increased health problems
Decreased access to health care
Inferior educational opportunities
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Evaluation of growth failure
Developmental History
• Gestational and perinatal history
– Age and parity of mother, pregnancy complications,
substance abuse
• Developmental history
– Birth history, milestones, temperament, routines
• Diet history
– Formula dilution, inappropriate foods, distractions,
struggles
• Family history
– Short parents, family illness/mental illness
• Social history
– Parental stress, family disorganization, violence, poverty
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Developmental milestones
Temperament of child
Daily routine
Child behaviors
– Moody, demanding, rejecting, distractible
• Minor recurrent ailments
• Previous growth records- look for inflection
points
Dietary History
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Over dilution of formula
Large amounts of cereal or food in bottle
Excessive fruit juice, soda, or water
Inappropriate food texture
Infrequent feeds (quiet children)
No set feeding times
No high chair
Grazing
Distractions from feeding
Feeding struggles
Food allergies (factitious food allergies)
Case Presentation
Psychosocial History
Family History
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Familial illness with decelerated growth
Severe childhood deprivation
Developmental impairment
Serious mental illness
Parental eating disorder as a child
Intergenerational substance abuse
Consanguinity
Height of both parents
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Family (dis)organization
Social isolation
Post-partum or other depression
Substance abuse
Violence
Maternal childhood history of child abuse
Parental stress
– Job loss, death of family member
• Poor problem solving abilities
• Poverty
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Observation Points
in NOFTT Parents
Case Presentation
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Lack of physical contact, cuddling
No response to separation from child
Signs of depression, apathy
Loss of self-esteem
Lack of perception of child’s needs
Unusual feeding technique
Mother-Infant Observation
Conflict between needs of mother and needs
of child
Case Presentation
– Group 1: overwhelmed by stress or depression
• When made aware could not figure out how to respond
to child or correct problem
– Group 2: ambivalent- wt gain is baby’s problem
• Responded appropriately when her need and baby’s
need coincided, but not otherwise
– Group 3 hostile: babies are “demanding” or “bad”
• Denied needing help
• Often progress to aggression and abuse
Haynes, CAN, 1983
Diagnostic Considerations in
Growth Failure Before Birth
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Symmetric IUGR
Prenatal infections
Congenital syndromes
Teratogenic exposures
Diagnostic Considerations in
Growth Failure in Neonates
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Incorrect formula preparation
Failed breastfeeding
Neglect
Poor feeding interactions
Less commonly, metabolic,
chromosomal, or anatomic abnormalities
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Diagnostic Considerations in
Growth Failure at 3-6 Months
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Underfeeding
Improper formula preparation
Milk protein intolerance
Oral-motor dysfunction
GE reflux
Celiac disease, HIV, cystic fibrosis,
congenital heart disease
Diagnostic Considerations in
Growth Failure at 7-12 Months
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Physical Examination:
Signs of Malnutrition
Diagnostic Considerations in
Growth Failure After 12 Months
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Coercive feeding
Highly distractible child
Distracting environment
Acquired illness
New psychosocial stressor
Physical Examination
Growth Assessment
Autonomy struggles
Overly fastidious parent
Oral-motor dysfunction
Delayed introduction of solids
Intolerance of new foods
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Decreased pulse, temperature, BP
Decreased activity, apathy, no muscle tone
Decreased fat
Prominent ribs and bone structures
“Old” skin, pale
Sparse fragile hair
Heart murmur from anemia
Protuberant abdomen, big liver
Growth Charts
• CDC 2000 growth charts
• Weight, height (recumbent length < 2 yo),
head circumference
• Plot measurements on proper growth
curves
• Serial measurements are crucial
– based on data collected by NHANES
– revised from 1977 to include larger sample size,
more racially and ethnically diverse sample,
inclusion of more breastfed babies, addition of
BMI
• WHO 2006 growth charts
– for children in all countries regardless of
ethnicity, SES or type of feeding
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Growth Charts
CDC recommends that health
care providers:
•Use the WHO growth
standards to monitor growth
for infants and children ages
0 to 2 years of age in the U.S.
2013 Pediatrics Meyers et al
• Children diagnosed incorrectly as
underweight on CDC 2000
growth charts but normal weight
on WHO 2006
•Use the CDC growth charts
to monitor growth for
children age 2 years and
older in the U.S.
Growth Charts
Laboratory Evaluation
• Specific growth charts for children with
specific health issues (Downs, Turners etc)
• Should be limited and guided by findings on
history and PE
• Premature infants correct for up to
• Lab and radiographic tests are of low
diagnostic yield
– 24 months postnatal age for weight
– 40 months for height
– 18 months for head circumference
Laboratory Evaluation
Screening labs to consider
– CBC
– Serum electrolytes, BUN, Cr
– Albumin, pre-albumin
– ESR or CRP
– Lead level
– UA, urine culture
– Thyroid studies
– TB or HIV (consider in specific populations)
– Sills et al 1978: yield of 1.4%
– Berwick et al 1982: yield of 0.8%
Laboratory Evaluation
• Few medical diseases that can cause growth
failure with no signs or symptoms
– exceptions include silent UTIs and RTA
• Some lab tests to assess the effects of malnutrition
– serum albumin, PAB, zinc, vitamin D and alk phos
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3 Phases of Feeding
Radiographic Evaluation
Phase I: Recognition of hunger,
acquisition of food, and process of
bringing food to the mouth
Consider radiographic studies
– GER
– Oral-motor dysfunction
– Swallowing abnormalities or structural defects
– Concerns for abuse (i.e. skeletal survey)
Phase II: Preparation of ingested food
for swallowing, with safe transfer
of the food bolus to the esophagus
without aspiration
Phase III: Passage of the food bolus
through the esophagus into the
stomach and intestines for digestion
and absorption
Decision to Hospitalize
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Severity of malnutrition
Significant dehydration
Failure of intensive outpatient management
Presence of significant medical problems
Safety of child
Concern about possible re-feeding syndrome
Need for involvement of multiple disciplines and/or
diagnostic procedure
Reporting to CPS/Police
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Frank neglect or physical abuse
Severe malnutrition
Highly dysfunctional families
Families resistant to recommendations
Persistent failure of management attempts
Reunification
Case Presentation
Parent should:
• demonstrate understanding of how the FTT
occurred
• demonstrate understanding of child’s needs
(physical/emotional)
• be willing to receive in-home visits
• cooperate with the medical plan
– Including weekly follow-up for as long as 6-8
weeks
• be willing to make lifestyle changes
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Types of Non-Medical
Failure to Thrive
• Neglectful
– Parent child problems
– Passive child
– Parental stress
Case Presentation
• Accidental
– Poverty-related
– IQ related; literacy
– Lack of parental sensitivity to child
• Deliberate starvation/Deprivational Abuse
Schmitt and Mauro, CAN , 1989
Fatal Starvation
• Meade, J For Sci, 1985
• Kloiber, J For Sci, 2004
• Calculated daily caloric requirements necessary to
prevent death
• Approximated number of days that food was
withheld
Outcomes
• Growth
• Emotional Development
• Intellectual Development
Frank, Ped Clinics of North Am, 1988
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Dendrite formation
Dendrite formation
• At birth, neurons are present, but poorly connected
• A substantial portion of brain growth in early childhood
results from formation of dendrites
– Dendrites sprout from nerve cell
– Dendrites connect (synapse) with other neurons
– Each neuron develops hundreds of dendrites over time
• Exuberant growth period results in massive burst of
synapse formation after birth
• Synapse formation continues into early childhood
• Pruning of synapses begins in middle childhood, continues
through adolescence
Myelination
Brain of malnourished infant
• Myelination is the other process beginning early in
childhood
– Myelin is a fatty coating on the axon of the neuron
• Myelination of nerve cell axons results in faster
signal processing
• Process continues into the early 20s, sometimes up
to age 30
• Malnourishment is the only environmental factor
known to disrupt myelination
Growth
• Treated adequately most children catch up to
some degree
• On follow-up most children are smaller than
peers
Case Presentation
– 25-30% have wts and hts below the 3rd percentile
– Some children reach near normal after intensive
years-long therapy
• Severe growth failure leads to decreased brain
growth and smaller HC
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Emotional Development
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High incidence of emotional disorders
Significantly lower social maturity
Significantly more behavior problems
Increase in psychiatric services
Intellectual Development
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Borderline or retarded intelligence
Significant school difficulties
Delayed speech
Delayed conceptual thinking
Decreased language and reading skills
Decreased math skills
Repeated grades
Poor impulse control
Poor attention span
Poor memory
Other Outcomes
• Impaired immunocompetency
• Combination of neglect and FTT causes
worse cognitive outcome than nutritional
deprivation itself
• Early postnatal FTT is a risk factor for
future serious parenting deficiencies
Investigation of
starvation and neglect
Berwick, Ped Rev, 1980; Drotar, J Dev Behav Peds 1992; Mackner CAN 1997;
Oates, Peds 1985; Corbett, J Psychol and Psychiat, 2004; Alaimo 2001 Peds;
Skuse J Med Screen, 1995
FTT Scene Investigation
• Photos of overall condition of home
• kitchen cabinets, counters, tables, refrigerators
• Evidence of food both for the victim and the adults
• Age appropriate food
• bottles, cans of formula, mixing instructions
• Freshness of food, evidence of recent purchases
• Diapers and dirty laundry
• Toys/sleeping conditions for victim
FTT Scene Investigation
• Photos of victim previously
• Photos or medical evals of other children in the
home
• Photos of the adults
• Evidence of money spent on other things
• Evidence of public assistance for food
• Evidence of parenting classes or books/brochures
indicating how to feed or care for the child
• Prescription, over-the-counter, and other drugs and
chemicals
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Defenses
Medical Investigation
• Medical evaluation for child and possibly siblings
• Underlying medical condition
• Controlled feeding
• Congenital - everyone in family is small
• Document growth for several months
• Poverty, lack of resources such as transportation
and food
• Establish whether parents sought out medical
• Lack of parenting skills - ignorance
intervention; did they keep medical appointments
• Interview physicians
• Caretaker statements to physician
• Interview lay witnesses with access to child
• Another person was responsible for caretaking
• Child healthy until just recently
• Child wouldn’t eat, was vomiting, had diarrhea
Ignorance defense
Rapidity Defense
Child was healthy but lost weight rapidly
• Thorough medical workup should
demonstrate whether malnutrition is
chronic or acute
• Very rare that emaciation occurs rapidly
Poverty Defense
• Evidence that money was spent on nonnecessities: alcohol, drugs, cigarettes,
cable TV
• Evidence of ample food for adult family
members
• Family received public assistance and
had access to resources for the baby
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The parents raised other children successfully
They have attended parenting classes
This child survived fine for a period of time
Other evidence supporting competence
– Parenting books/subscriptions
– Prescriptions
– Parenting discussions with peers
– Previous social service involvement
Intervention
For any given problem, there is a solution
that is simple, direct, and wrong.
H.L. Mencken
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Goals
• Nutritional counseling
– Provide adequate calories
– Monitor growth
• Family evaluation
– Social
– Nurturing skills
– Financial support
• Long term follow-up
– problems are deep-rooted, multiple and chronic
– most families need at least 12-18 months
Medical
• Photographs
• Address acute medical needs/stabilize
• Evaluation/management of medical illness
– may require subspecialty evaluation
• Quantify specific needs for nutritional
repletion
– monitor for re-feeding syndrome
• Supplementation
• OT/Speech/Developmental specialists
Multidisciplinary Evaluation
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Pediatrician
Nutritionist
Lactation consultation
Observation of parent-child interactions
Social work assessment
Developmental evaluation
Behavioral specialist
Psychological evaluation
Occupational therapist
Nutritional Needs
Kcal/kg/day required:
RDA for age (kcal/kg) x Ideal weight-for-height
Actual weight
• Protein requirements can be estimated with a similar
equation
• Concentrate of formulas, use of calorically dense
supplements
• Removal of non-nutritive liquids
• Nasogastric feedings short term
• Long term supplementation or gastrostomy
Re-Feeding Syndrome
• Metabolic disturbances that
occur as a result of
reinstitution of nutrition to
patients who severely
malnourished
• Hypophosphatemia,
hypokalemia, hypomagnesia
• Fluid overloaded with
addition of carbohydrates
CHF, pulmonary edema
• Prevent with slow feeds,
frequent clinical assessment,
and electrolyte monitoring
Bithoney, Peds in Review, 1992
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Behavioral Interactions
• Recognize hunger and satiety clues
• Relax and make meals pleasant/Avoid battles
• Parent decides the food to offer, kid decides how
much to eat
• Accept child’s wish to feed himself (accept mess)
• Positive reinforcement
• Do not withhold food for punishment
• Eat as a family with no distractions
• Allow 1 hour before meal with no food to
stimulate appetite; feed solids first
• Have a meal routine
Psychosocial Issues
• Coordination of care by PCP
• Identify social services needs, transportation barriers,
financial situation, parenting skills, stressors, impulse
control issues, and money management problems
• Parents might benefit from job-finding services,
weight reduction, smoking cessation, marital or
mental health counseling
• Parental education
• Behavioral innervations for children with difficult
temperaments
• Involvement of child protective services
Bithoney, Peds in Review, 1992
Summary
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FTT is multifactorial in origin
History is paramount to diagnosis
Laboratory evaluation is rarely necessary
Hospitalize only selected cases
Outcomes are uniformly poor without
intensive treatment
• Early intervention carries the best prognosis
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