What Is Failure To Thrive?
From the day a baby is born, parents will focus their attention on the child’s growth and development; their major preoccupation will be connected with the baby’s nutrition, health, growth, and contentment. Parents will be eager to see how much weight the baby gains, how well the baby feeds, how the baby responds to their nurturing, and what developmental progress the baby makes.
To grow satisfactorily, the baby needs sufficient nutrition on a regular basis and a quality of care that will make the child feel at ease, comfortable, and secure. In a secure and caring home, and fueled by adequate nutrition, children will thrive, giving parents pleasure and confidence in their parenting. In homes riddled with conflicting stress, chaos, or poverty, or where parents are poorly informed about children’s developmental needs, the children’s progress may be impaired if nutritional intake and the quality of nurturing are inadequate for the child’s age.
During the first year after birth, human growth is quicker than at any other period during childhood, decreasing rapidly until the end of the third year, then continuing at about one third of its postnatal rate until puberty. However, there are some children who do not grow according to expected norms and who are cause for concern. These children have been described as failing to thrive and, compared with their peers, are significantly smaller and can be expected to have poor outcomes. They can be found in all social classes and levels of society. Without help, one can expect their physical growth, cognitive progress, and emotional development to be negatively affected, and they may be at risk for neglect, abuse, or even death.
Trends And Prevalence
The term failure to thrive is applied to infants and young children whose weight, height, head circumference, and general psychosocial development are significantly below age-related norms and whose well-being causes concern. In the United Kingdom, children who fall below the second centile on the Growth and Developmental Charts (and remain there for more than a month) are investigated. In the United States, common practice is to use the fifth centile as a cutoff point for weight. Children who drop down two or more percentile curves on the weight chart over a short period of time need to be assessed to determine whether there is a medical or psychosocial problem, such as development of a serious illness or trauma (e.g., abandonment, abuse, loss of parents).
The term failure to thrive describes a condition rather than a specific disease, and consequently it can have many causes that can be organic, psychosocial, or a mixture of both. It is conceived as a variable syndrome of severe growth retardation, delayed skeletal maturation, and problematic psychomotor development, which is often associated with illness, inadequate nutrition for normal growth, feeding difficulties such as oral-motor dysfunction, disturbed mother-child interaction (especially during the act of feeding), poor relationships, insecure attachment, family dysfunction, and poverty. Whatever the reason, these children are undernourished in terms of adequate caloric intake. Undernutrition during early infancy can have detrimental effects because the nutritional requirements at that time are most crucial. Given the rapid growth, particularly brain growth, that occurs during the first few years, particular attention should be given to sufficient provision of food.
Failure to thrive is normally diagnosed within the first 2 years of life, although its effects can be seen much later than this. Estimates of prevalence have varied from as many as 10% of children seen in outpatient clinics to 1% of all pediatric hospitalizations.
Several risk factors have been identified that tend to trigger failure to thrive and maintain the problem if helping strategies are not put in place early on. They are as follows: inadequate intake of food; feeding difficulties; poverty; family stress, such as parental chronic illness; divorce or separation; family violence; substance misuse; single unsupported parenting; low maternal education; limited knowledge about child rearing; social isolation; maternal depression; low parental self-esteem; distorted perceptions about the child; and poor interaction between child and mother.
Program Of Intervention
Intervention with failure-to-thrive cases usually falls into two basic categories: (a) immediate (crisis intervention); and (b) longer-term therapeutic and supportive work with more complex cases.
During the assessment period, attention is paid to urgent needs of the child and parents. It is sometimes necessary to arrange day care (e.g., day nursery for a child if there are developmental delays due to the lack of stimulation or when a child is at risk for being neglected or maltreated). Some families might need assistance with housing, welfare provision, health and addiction problems, employment, family frictions, and financial difficulties. These issues should be dealt with early on to reduce stress and to create an atmosphere in which further therapeutic intervention can take place.
Treating Inadequate Intake Of Food
The primary objective of all failure-to-thrive cases is to increase nutritional intake by children in order to achieve subsequent weight and height expansion. Because many children have feeding difficulties, these are treated first in order to help the child to take more food and for the parents to manage better the process of feeding. Some children are simply not given a sufficient amount of food, the feeding formula is wrong, or the interpretation of the child’s signals of hunger or satiation is incorrect; therefore, they are instructed and shown how, when, and what to feed. Parent training, in terms of developmental and cognitive counseling, plays an important role in problem solving in such cases.
Frequent home visits by a public nurse to support and monitor the case are very helpful. Much effort is put into making mealtime more relaxing for everybody in the family, but in particular, emphasis is put on the mother-child feeding interaction. Feeding behavior is modeled by the therapist, and food is presented in an attractive, appetizing way to encourage interest in eating and enjoyment of taking food. Because food avoidance behavior is common among failure-to-thrive children, the process of change tends to be slow. Assisting parents for a considerable time to reach successful results is necessary.
Some failure-to-thrive children are insecurely attached to their mothers, and there is lack of maternal bonding to the child. Interaction in some cases is limited to the bare essentials of care and control and tends to be negative in nature. The child’s fear and apprehension when in the mother’s company is observable, as is anxiety, anger, or helpless despair on the part of the mother. To bring them closer together and to reduce negative feelings, structured interaction in the form of play, increasing in time, is introduced. Rejective mothers, and those who have a poor relationship with the child, are encouraged to hold a child, sit the child on the lap for a few minutes several times a day, and talk to the child warmly while doing so. Frequent exposure to close proximity, conducted in a calm and soothing way, tends to reduce anxiety and apprehension in the child and anger or resentment in the parents.
Video Recording And Feedback
Video recording is a useful technique to increase parents’ awareness and understanding of what is happening and how to correct inappropriate responses to the child. Examples of aversive parental behavior are videotaped and then played back to parents so they can see and hear how they behaved. Parents are asked to imagine how they would feel if they were treated in the way they are treating their child. By doing so, it is hoped that they will be able to get in touch with their own and their child’s feelings, which, in turn, will help them to recognize the pain and hurt inflicted on the child. Parents are asked to observe the role-play conducted by a therapist demonstrating warm, encouraging, and caring behavior with the child. Then they are asked to play with the child again, using better interaction, which is videotaped, played back, and discussed.
Cognitive Work With Parents
Cognitive therapy is used to identify and correct negative dysfunctional or maladaptive cognitions relating to the parenting of the failure-to-thrive child. An essential component of cognitive therapy is that the parents are actively involved. Thus, parents must participate in the exploration of the manner in which their behavior is guided by their own beliefs and information processing. Modeling of alternative methods of interaction or feelings may help parents widen the scope of self-imposed and child-related expectations. Cognitive work points to the successful aspects of parents’ lives so that they can take comfort from those aspects and redirect their thinking to constructive strategies to solving problems and feel good about them, thus reinforcing the conviction that they are able to achieve positive change.
Monitoring Failure To Thrive
The cases of failure to thrive have to be followed until satisfactory growth velocity is acquired and maintained for at least 2 months. Additionally, parental confidence on how to deal with various problems and who to turn to if in difficulty is needed for the satisfactory outcomes.
Failure to thrive is a multifactorial syndrome that has many routes and, if not identified and dealt with early on, can lead to serious physical and psychosocial consequences. Once a child’s weight begins to falter and parent-child interaction is causing concern, action needs to be taken to preempt further deterioration and possible harm.
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