[Psychosocially stunted growth masked as growth hormone deficiency]

Short stature is a common reason for presenting a child to the pediatrician. Emotional deprivation may cause short stature and may simulate growth hormone deficiency. Diagnosis of emotional deprivation as the cause of growth retardation is difficult and misdiagnosed frequently despite of suspicious clinical signs. We report on 2 patients with growth retardation because of emotional deprivation. At the age of 5 years both children had a severe growth hormone deficiency. They received therapy with growth hormone and showed an increase of growth velocity to > or = 8 cm in the first year of treatment. But in the third year of treatment both patients showed a diminished response to the growth hormone therapy. During the period of observation the features of emotional deprivation became obvious through the extreme behavioural abnormalities. Both children showed disturbances in their social behaviour, and striking disorders concerning eating and digestion. The families of these children had severe social problems; alcoholism, low income and rejection of the child were risk factors. Removal from the current environment led to a characteristic increase of the growth velocity. Growth hormone deficiency was spontaneously reversible, so that treatment with growth hormone was terminated. The social environment and the psychical prosperity are essential growth factors in childhood and adolescence. The common features and risk factors of emotional deprivation are described. Spontaneous catch-up growth after removal from the current environment distinguishes this form of short stature from the other organic growth disorders.

Medical assessment. Its role in comprehensive psychiatric evaluation

This article describes the role of a medical evaluation in the overall developmental assessment of a young child. General guidelines for conducting the evaluation and practical issues to consider in dealing with young children and their families are provided. To illustrate these points, hypotonia and failure to thrive, two broad categories of pathology with numerous potential underlying medical causes, are addressed specifically. The involvement of genetics in developmental pathology is also outlined in some detail. Finally, issues to be aware of when considering pharmacologic management of psychiatric symptoms in young children are discussed.

Dyadic psychotherapy for early relationship disorders: a case study

Specific treatment modalities, such as dyadic psychotherapies, have emerged, based on the notion that in cases of very early relational disorders, the patient is the parent-infant relationship. The aim of this paper is to present a case study of such a relational disorder which took place as the result of a complex interplay between the infant's biological risk factors and the parents' psychological risk factors. The emphasis is on the technique and the course of the dyadic psychotherapy of the mother and her three-year-old child, where the main goal was to change some of the intrapsychic and interpersonal processes specifically related to pathological motherhood. The theoretical background is briefly presented, while emphasizing the criteria for choosing one approach among the different kinds of dyadic psychotherapy.

Attachment and feeding problems: a reexamination of nonorganic failure to thrive and attachment insecurity

OBJECTIVE

To examine the relationship between attachment patterns, degree of security, and feeding problems.

METHOD

Three groups of toddlers (age range = 12-37 months) were included: toddlers with infantile anorexia (n = 33), picky eaters (n = 34), and healthy eaters (n = 34). Participants in each group were matched for age, socioeconomic status, gender, and ethnicity. Attachment patterns and degree of attachment security were assessed through the Ainsworth Strange Situation.

RESULTS

The infantile anorexia group exhibited a higher rate of insecure attachment relationships than the picky eater and healthy eater groups. When measured on a continuous scale, the infantile anorexia group also displayed a higher degree of insecurity than the other groups. Contrary to previous research, elevated rates of type D attachments were not present within the infantile anorexia group.

CONCLUSIONS

Feeding problems and growth deficiencies can occur within the context of organized and secure attachment child-parent relationships. However, insecure attachment relationships may intensify feeding problems and may lead to more severe malnutrition. Implications for the treatment of specific feeding problems are discussed.

Short stature at school entry--an index of social deprivation? (The Wessex Growth Study)

This study was carried out to examine the biological and environmental variables associated with non-organic short stature. We observed an unselected population of very short normal children (SN) and their age- and sex-matched controls (C) within the community. All 14,346 children in two health districts entering school during 2 consecutive years were screened for short stature, and those whose height lay below the 3rd centile, according to Tanner and Whitehouse standards (n = 180) were identified. Excluding 32 with pathology, five from ethnic minorities and three who refused to take part, the remaining SN children (mean height SDS-2.26) were matched with 140 age- and sex-matched controls (C) of average height (mean height SDs 0.14). Birth weight, target height and predicted adult height (based on parental height and bone age respectively), medical and social background (obtained from parental interviews), and school performance (assessed by class teachers) were the main outcome measures. Mean birth weight of the SN children was significantly lower than C (SN = 2845 g, C = 3337 g, P < 0.001). Mean mid-parental target height was also very different (SN = 162.0 cm, C = 170.9 cm, P < 0.001). Thirty-five per cent of SN children (C = 6%) had height SD scores below parental target range, though only 10% had predicted heights below target range (mean delay in bone age 0.68 years). There was a significant difference between SN children and C in the number of children in the household (SN = 2.8, C = 2.4 (P = 0.007) and in socio-economic status (P < 0.002). Many more SN children were in social classes IV and V (SN = 31%, C = 13%, P < 0.002), and had an unemployed father (SN = 22%, C = 10%, P < 0.010), highlighting the importance of environmental influences on growth. One in four SN children was judged to have serious psychosocial problems. However, the lower the socio-economic class, the less likely the SN children were to be inappropriately short for parents. Significantly more SN children were reported to have asthma (SN = 18%, C = 7%, P < 0.007) and eczema (SN = 19%, C = 5%, P < 0.001), though only the latter was significantly associated with stature below target height for both SN and C groups. Biological variables are often insufficient to explain short stature. No child, whatever the parental height, should be dismissed as normal without careful evaluation, as poor growth in the early years may be an important pointer to an adverse but potentially remediable environment.

Nonorganic failure to thrive: a theoretical approach

Nonorganic failure to thrive (NOFTT) is a significant health problem of infancy. Although NOFTT is thought to be a result of multiple factors, exactly what these factors are is unclear. Explaining the development of NOFTT has been hindered by a lack of a theoretical approach. The purpose of this article is to provide a review of the literature and the discussion of a theoretical framework to guide future research in the area of NOFTT.

Functional, social, and psychological disability as causes of loss of weight and independence in older community-living people

This article reviews functional, social, and psychological disabilities that relate to weight loss and independence in older community residents and suggests possible ways in which these factors may be alleviated. Although these disabilities clearly interact with one another as causes of failure to thrive, this article is organized into three major sections: functional disability, psychological and social factors, and malnutrition. In-depth geriatric assessment provides directions to reverse or halt failure to thrive. Using case materials, possible interventions are presented; these include dietary changes, a carefully planned program of physical exercise, treatment for depression, and a combination of social and environmental "prescriptions" designed to reduce social and emotional isolation. Appropriate social supports are also necessary, as is careful attention to how caregiver stress may be reduced through suitable interventions.

Neuropsychiatric aspects of failure to thrive in late life

Both depression and dementia can lead to failure to thrive (FTT). Depression can lead to FTT by two routes: a direct path related to decreased appetite as a symptom of depression; and an indirect path related to the effect of depression in increasing disability. Depression associated with FTT should usually be treated with antidepressant medication. In Alzheimer's patients with FTT, the thrust of treatment is the identification and treatment of the medical and psychiatric comorbidities and the appropriate titration of environmental supports.

Non-organic failure to thrive complicated by benign intracranial hypertension during catch-up growth

Severe non-organic failure to thrive associated with physical and emotional abuse including food deprivation was diagnosed in a 9-y-old boy. Rapid catch-up growth (weight and height) followed change of carer. Recovery of poor growth hormone response to clonidine stimulation was associated with benign intracranial hypertension accompanied by headaches and vomiting. Possible mechanisms are discussed.

Risk status and home intervention among children with failure-to-thrive: follow-up at age 4

Examined the moderating effects of risk status on the impact of home intervention in a follow-up study of children with failure-to-thrive (FTT). Two types of risk (demographic and maternal negative affectivity) and two levels of intervention were examined. In this randomized clinical trial, all children received services in a multidisciplinary growth and nutrition clinic, and half the children also received home visits from a lay home visitor for 1 year. There were no effects of demographic risk, maternal negative affectivity, or intervention status on child outcome at the close of the home intervention. However, at age 4, more than 1 year after the home intervention ended, there were effects of the home intervention on motor development among all children and on cognitive development and behavior during play among children of mothers who reported low levels of negative affectivity. Results highlight the importance of conducting follow-up assessments in the evaluation of home intervention services, and suggest that among low-SES families of children with FTT, home intervention may be most useful among mothers with low negative affectivity.

The cumulative effect of neglect and failure to thrive on cognitive functioning

OBJECTIVE

A cumulative risk model was used to examine the relationship among neglect, failure to thrive (FTT), and cognitive functioning in low income children.

METHOD

A sample of 177 children 3 to 30 months old was recruited from a pediatric clinic serving low-income, primarily African American families. Four groups were formed based on neglect and FTT status: Neglect and FTT, Neglect Only, FTT Only, and No Neglect or FTT. FTT was defined as weight-for-age below the 5th percentile on growth charts. To avoid the biases associated with Child Protective Service reports as definitions of neglect, the HOME scale (Caldwell & Bradley, 1984) was used to define neglect.

RESULTS

The cognitive performance of the group with neglect and FTT was significantly below that of the children in the Neglect Only, FTT Only, and No Neglect or FTT groups.

CONCLUSIONS

These findings support a model in which the accumulation of risk factors is detrimental to cognitive functioning. The results also underscore the need for thorough evaluation when one risk factor has been identified. Growth failure may come to the attention of medical personnel, but neglect may not be detected. However, a child experiencing both neglect and FTT may be at risk for significant deficits in cognitive functioning.

A community based study of failure to thrive in Israel

OBJECTIVE

To examine the characteristics of infants suffering from failure to thrive in a community based cohort in Israel and to ascertain the effect of failure to thrive on their cognitive development.

METHODS

By review of records maintained at maternal and child health clinics in Jerusalem and the two of Beit Shemesh, epidemiological data were obtained at age 15 months on a cohort of all babies born in 1991. For each case of failure to thrive, a matched control was selected from the same maternal and child health clinic. At age 20 months, cognitive development was measured, and at 25 months a home visit was carried out to assess maternal psychiatric status by questionnaire, and the HOME assessment was performed to assess the home environment.

RESULTS

3.9% of infants were found to have fallen below the third centile in weight for at least three months during the first year of life. Infants with failure to thrive did not differ from the general population in terms of obstetric or neonatal complications, birth order, or parents' ethnic origin, age, or years of education. The infants with failure to thrive did have lower birthweights and marginally smaller head circumferences at birth. Developmental assessment at 20 months of age showed a DQ of 99.7 v 107.2 in the matched controls, with 11.5% having a DQ below 80, as opposed to only 4.6% of the controls. No differences were found in maternal psychiatric problems as measured by a self report questionnaire. There were, however, significant differences in subscales of the HOME scale.

CONCLUSIONS

(1) Infants who suffered from failure to thrive had some physiological predispositions that put them at risk; (2) failure to thrive may be an early marker of families providing suboptimal developmental stimulation.

Resolving the feeding difficulties associated with non-organic failure to thrive

Since 1991 The Children's Society's Infant Support Project has been working in Wiltshire with the families of under 3 year olds identified as failing to thrive non-organically. Research has shown that the only common factor in children with this problem is the presence of feeding difficulties. The service concentrates on helping parents/caregivers to resolve the problems which are allowing the difficulties to continue. The multidisciplinary staff team work on a domiciliary basis, using working practices founded on social learning theory. A recent evaluation indicated that for more than two-thirds of the children with whom the project had worked, a satisfactory or very satisfactory outcome was achieved. Funding for the service is received from the Health Commission for Wiltshire and Bath, Wiltshire Social Services Department and the Children's Society.

What do we know about children who fail to thrive?

It is the aim of this article to provide an overview of difficulties in children with poor growth enrolled in an intensive community intervention trial for failure to thrive (FTT). Children were assessed for developmental delay (Bayley test), inadequate diet, iron deficiency, eating and other behavioural problems, and maternal anxiety and depression (HAD Scales). Sixty-three children aged 6 months to 2 1/2 years were studied. The majority of children were from families living in poverty with many from divorced, separated or single families. On developmental testing (Bayley Developmental Scales) 55% were delayed, 27% severely. Seventy-seven per cent had caloric intakes below the expected average requirement (EAR) with 19% reported at less than 50% of requirements. Iron intakes were similarly low and one-third had iron deficiency anaemia on testing. Sixty per cent of children were reported to have eating difficulties, principally in terms of responding negatively to food. Eating difficulties had commonly presented within the first weeks of life. Other behavioural and sleeping difficulties were also common. Children identified as failing to thrive in the community are likely to have associated developmental, dietary and behavioural problems which may not be immediately evident and to an extent which may require intensive multidisciplinary involvement.

Changes in psychopathology of parents of NOFT (non-organic failure to thrive) infants during treatment

This clinical case-study of 50 infants suffering from NOFT (non-organic failure to thrive) and their parents supports the idea that the feeding problem is intimately related to parental disorders. We find a high rate (70%) of parental psychopathology (axis I diagnosis applying DSM-III-R) at the time of referral and a significant reduction (to 37%) during treatment of the infants and their parents. After a year only 12% of the parents were diagnosed with psychiatric disorders. In contrast personality disorders (axis II diagnosis applying DSM-III-R) show more stability and can be regarded as a trait variable, whereas the psychiatric disorders are of a more reactive nature. These conclusions may be influenced somewhat by the strictly hospital based design of our pilot study (infants and parents contacted only after clinical referral) and by inclusion only of firstborn infants. Nevertheless, they point to the psychopathology of parents as a main cause for non-organic failure to thrive. Psychopathological traits such as severe attachment behavior problems and primary bonding difficulties may have been latent and only became manifest due to the task of nurturing an infant for the first time.

Failure to thrive: an ambulatory approach

The diagnosis and management of failure to thrive, a multifactorial condition, can be a challenge for the primary care provider. This article deals with organic failure to thrive and nonorganic failure to thrive in ambulatory settings. The complex etiology of failure to thrive is addressed relative to maternal/paternal and infant/child characteristics. Physical assessment is addressed with special attention on critical growth measurements, feeding and eating patterns, developmental delays, and psychosocial issues. Interventions in the areas of nutrition, development, and psychosocial interactions are examined with an emphasis on team management. Long-term effects of failure to thrive and primary and secondary preventive interventions are addressed.

Infant growth in the context of maternal eating disorders and maternal depression: a comparative study

There is evidence of growth faltering in infants of mothers with eating disorders. The aim of the current study was to examine whether this is a specific relationship. Thus, the infants of mothers with eating disorders were compared with infants of mothers with post-natal depression and a large comparison group. This study also aimed to explore possible mechanisms whereby growth disturbance comes about. It was found that the infants of mothers with eating disorders were smaller, both in terms of weight for length and weight for age, than either comparison group infants or infants of mothers with post-natal depression. There was little evidence, however, that mothers with eating disorders preferred smaller children or were dissatisfied with their children's shape or that they misperceived their children's size. On the contrary these mothers seemed highly sensitive to their children's shape and, compared with the other two groups, were more likely to judge their children's size accurately. None of these maternal measures significantly predicted the child's growth. The mechanism whereby growth disturbance arises in the context of eating disorders does not appear to be by means of a direct extension of the maternal psychopathology to the infant.

Markers of failure to thrive among older hip fracture patients

OBJECTIVES

To determine whether there is a group of recent hip fracture patients who exhibit the signs of failure to thrive and to identify potential precursors to their decline in physical functioning.

DESIGN

Prospective (nonintervention) study of hip fracture recovery; patients were assessed in the hospital and at 2, 6, 12, 18, and 24 months post-fracture.

SETTING

Hip fracture patients admitted to one of eight Baltimore area hospitals from the community with a new fracture of the proximal femur between January 1, 1990, and June 15, 1991.

PARTICIPANTS

Patients were 65 years of age and older and lived in the community before the fracture. A total of 804 patients were eligible for the study; the present study analyses were restricted to the 252 patients who survived 1 year and had a self-report assessment at 6 and 12 months post-fracture.

MEASUREMENTS

A questionnaire administered during hospitalization assessed pre-fracture functional and health status and current affective and cognitive status. In-home interviews post-fracture ascertained dependence and difficulty with physical and instrumental activities of daily living. Abstraction of the medical records provided information about comorbidities, surgical procedure, and hospital length of stay.

RESULTS

Patients who declined in ability to walk from 6 to 12 months post-fracture had greater use of health resources (more hospitalizations) and poorer physical functioning up to 2 years post-fracture. Impaired function in physical activities of daily living at 6 months, high glucose, calcium, and CO2 at admission, and low BUN and creatinine at admission were more prevalent among decliners than among non-decliners.

CONCLUSIONS

Findings indicate that certain older hip fracture patients begin to exhibit signs and symptoms of failure to thrive. About 10% of patients who survived at least 1 year after fracture could not retain their recovery level of functioning after 6 months and began to decline further. High glucose and CO2 and low BUN and creatinine on hospital admission were associated with later functional decline among hip fracture patients, but their clinical significance is uncertain.

[Child abuse--diagnostic methods and therapy. Diagnosis of neglect, deprivation and psychosocial short stature--therapeutic consequences]

The terms child abuse, neglect and sexual abuse overlap; while child abuse, neglect and sexual abuse can often be diagnosed on the basis of somatic symptoms, deprivation and other psychological sequelae can be identified only in interviews and by observing the interaction of children with their mothers/fathers. Social difficulties are reflected in a disturbance of the mother/doctor interaction in the doctor's office. The main task of the physician is to establish contact with the family and gain the parents' trust. An important aspect is expressing appreciation of the positive characteristics and achievements of both the child and its parents. In addition, provision of concrete information and counseling can be useful.

Infant-mother attachment and nutrition in children with cystic fibrosis

The association between nutritional status (percentage of weight for height) and infant-mother relationship was studied over 4 years in 38 children diagnosed with cystic fibrosis in the first year of life. Infant-mother relationship was assessed in a standardized laboratory observation. Although they could not be distinguished medically from the others at the time of diagnosis, infants showing a specific form of insecure relationship with their mothers (insecure-avoidant) differed from the others in: (1) failure to improve in nutritional status in the first year; (2) continuing decline in weight for height in the first 3 years; and (3) significantly lower weight for height at 1, 2, and 3 years of age. These data suggest that attention to mother-infant relationships, particularly feeding interactions, may improve nutritional status in children with cystic fibrosis.

[A case of Munchausen syndrome by proxy with digestive symptoms and severe growth retardation]

A case of Munchausen syndrome by proxy in an infant presenting with recurrent vomiting and severe failure to thrive is described. Only very few cases of this syndrome have been reported in the italian literature in comparison to those described in the Anglo-Saxon countries. The factitious symptoms and signs fabricated or induced by parents lead to unnecessary medical investigation, hospital admissions and treatment. The Authors emphasize the difficulties in reaching a diagnosis and the risks of this potentially very dangerous behaviour in terms of morbidity and mortality. Since only one third of parents recover following psychotherapy, the offending parent should be sometimes separated from the child and promptly reported and closely supervised by the legal Authorities. Bizarre and otherwise peculiar, unexplained symptoms should always suggest the possibility of the Munchausen syndrome by proxy.

Very early onset nonorganic failure to thrive in infants

Nonorganic failure to thrive (NOFTT) occurs in absence of any gastrointestinal, endocrine, or other chronic diseases. It is usually associated with psychosocial deprivation, although behavior problems may also contribute to its occurrence in absence of maternal pathology. We report seven infants and children between the ages of 13 and 30 months at the time of presentation, who failed to consume adequate calories and suffered from delayed growth. All were born at term after normal pregnancies with birth weights and lengths between the 50th and 95th percentiles except in one. None had any history of perinatal problems. Decreased intake was encountered almost immediately after birth, with lack of interest in consuming adequate calories. The evaluations performed did not reveal any specific etiology for the decreased intake. None had any developmental delay nor were there any psychiatric conditions in mothers. Changes in formulas or psychologic intervention were unsuccessful in modifying feeding habits except in two infants. All were supplemented with enteral supplements (Pediasure-five, Ensure-one, and Osmolite-one). Three did not consume enough orally and needed nasogastric tube infusions with eventual placement of gastrostomy tubes in two, and the third one has continued with nasogastric infusions. A significant increase in caloric intake caused improvement in growth percentiles. Height and weight percentiles improved in all and crept into the normal curve in four and five patients, respectively. Head circumference of two stayed at < 5th percentile despite nutritional rehabilitation. Attempts at weaning off the supplements actually resulted in weight loss in all. Our data suggest that there is a critical need for early, aggressive nutritional intervention in such infants.