A postural sign in the sensory deprivation syndrome in infants

Transient diplegia in children who fail to thrive

We describe a group of eight children seen over a 4-year period. After a few months of apparently normal health and development, the children developed feeding difficulty, failed to thrive and had mild diplegia. No other underlying pathology was demonstrated. After a period of careful attention to feeding in the stimulating environment of a child development centre, the feeding difficulty, developmental delay and diplegia all disappeared, but, by school age, the children showed learning or behavioural difficulty. It is suggested that these children suffered a subtle neurological insult during the intra-uterine period and that this predisposed them to the neurological difficulty and failure to thrive. It is important to distinguish this small group of children from those in whom non-organic failure to thrive is found and parental neglect is suspected.

Failure to thrive

Malnutrition is the primary biologic insult in most cases of failure to thrive. A transactional model of infant development provides a framework for understanding the psychosocial context in which such malnutrition occurs. Each child who fails to thrive should receive a multidisciplinary evaluation to address the diagnostic and therapeutic implications of nutritional, medical, psychosocial, and developmental factors contributing to growth failure.

Non-organic failure to thrive

Non-organic failure to thrive is a clinical diagnosis which should be considered in parallel with other causes of failure to thrive in infants. It has not been resolved as to whether the condition is due to a lack of stimulation or to deprivation of calories, although both these factors, as well as a contribution from the child in some cases, are likely to be responsible. There is no typical profile of the parent whose child develops non-organic failure to thrive. The condition can occur in all social classes but is more common in situations of poverty, poor marital relationships, chaotic family lifestyle and when there is a history of deprivation in the parents' own childhood. Although the majority of these children eventually show catch-up growth, long-term follow-up studies show a high incidence of emotional and cognitive problems. Treatment should go beyond nutritional rehabilitation in the hospital and should include practical, supportive help for the mother together with measures to improve the level of stimulation and the quality of interpersonal relationships for the child.

Similarities and differences between nonorganic failure to thrive and deprivation dwarfism

Although the terms, nonorganic failure to thrive and deprivation dwarfism, are sometimes used interchangeably, and while the family pathology is similar in both conditions, the clinical features differ. The majority of children with nonorganic failure to thrive are under 2 years and often 18 months of age. Weight loss is the most marked feature and they are often withdrawn and apathetic. In contrast, the documented ages of children with deprivation dwarfism range from 2 to 15 years although the history may reveal earlier feeding and behavior problems. Short stature is the most striking feature, their weight often being in proportion to their height. They may steal and hoard food and have bizarre eating habits. In some cases reversible hypopituitarism has been documented. It is suggested that deprivation dwarfism constitutes a subgroup within the nonorganic failure to thrive syndrome. Management in both conditions is similar. It should emphasize a practical, supportive approach and be on a long-term basis.

Failure to thrive

Reviewing the chronological evolution of our understanding of why some children fail to thrive without obvious organic cause permits us to develop a rational contemporary approach to diagnosis and management. Originally recognized as a phenomenon of children living in institutions, it later became clear that it could occur in children living with their families. While emotional deprivation was at first emphasized as the principal determinant of growth failure, it is now apparent that the major mediating mechanism is insufficient caloric intake. Thus prior to nutritional recovery it may be difficult to segregate whether emotional symptoms in the child reflect the causes or effects of malnutrition. With rare exceptions, an etiologic diagnosis can be suspected on the basis of history, physical examination, and family assessment. Nonspecific investigative screening of such children has proved to be without value. Successful management depends on recognition of the supernormal caloric intake required to induce rapid catch-up growth. Aggressive hyperalimentation combined with intensive emotional stimulation and often with active family participation offer the best chances of a successful outcome.