Failure to Thrive Syndrome Effects on the Physical and Cognitive Development of Children - Essay Example

Running Head: FAILURE TO THRIVE SYNDROME EFFECTS ON CHILDREN Failure to Thrive Syndrome Effects on the Physical and Cognitive Development of Children. Your Name Your Uni Abstract Failure to thrive (FTT) is a syndrome that most often associated with malnourishment of a person. Amongst children, FTT can have numerous serious negative effects on both physical and cognitive development. For example, children who experience FTT may be consistently shorter than their peers, or consistently way considerably less than their cohort. Developmentally, literature points to FTT resulting in cognitive deficits such as lower than average IQ scores, or speech and motor delays. Additionally, FTT children may experience socioemotioanl difficulties that put them at risk of poor interpersonal relationships in later life. This research paper drew on current secondary data to establish the effects of FTT on the physical and cognitive development of children. Prior results were supported. It is anticipated that this research will contribute to the body of knowledge investigating the effects of FTT on children. Failure to thrive (FTT) in early childhood is associated with developmental delays and is conceded to be associated with under-nutrition. The term FTT was used to replace a description of a syndrome of delayed growth and development called the 'maternal deprivation syndrome' (Wright, 2000). FTT, also known as growth failure, is not an actual diagnosis in itself, rather a descriptive term to identify a child or adult who does not meet established standards of healthy growth. In general, the term FTT is used when growth appears to be low, or has decreased over a period of time (Bassali & Benjamin, 2006). Wright (2000) defines this low growth rate in terms of growth chart percentiles, a fall of two centile spaces indicating mild to moderate FTT, and of three centile spaces to indicate severe FTT. A recent definition of FTT includes low weight-for-age, low BMI, low conditional weight gain, and Waterlow's criterion for wasting (Olsen, Peterson, Skovgaard, Weil, Jorgenson, & Wright, 2006). It is evident that a combination of measurements is required to ascertain nutritional growth delays, and current longitudinal research is investigating the strength of different criteria to differentiate FTT and its subsequent outcomes (Olsen et al., 2006). Due to current medical technology there appears to be an increase in the numbers of children surviving an extremely low birth weight (ELWB; < 1000g), and this increases the numbers of children at risk of cognitive dysfunction during development (Mikkola, Ritari, Tommiska, Salokorpi, Lehtonen, Tammela et al., 2006). The aim of this paper is to identify the long term physical and cognitive outcomes in children diagnosed as having failure to thrive (FTT). First, a general background of FTT will be outlined. Second, recent studies that have investigated cognitive and or physical affects of FTT with children shall be presented. Next a discussion will provide a synthesis of the findings and the implication for children who survive FTT. Finally, a conclusion shall make recommendations for future research. FTT can be conceptualized as a failure of a child to meet expected weight, height, developmental and well-being standards (Wright, 2000). Predominantly, the FTT child is relatively undernourished and does not show a temperament or constitutional pattern that would be considered as within the norm for a child of their age. Organic disease, abuse and neglect, deprivation (i.e., low socio-economic status), and under-nutrition are all possible causes of FTT. n series of USA reports dated between 1980-1989 attributed FTT to 1-5% of the hospital admissions of children less than a year old (Bassali & Benjamin, 2006). It was also estimated that about 10% of children receiving primary care exhibited signs and symptoms of FTT. Although, internationally, developing nations tend to have much more common rates of malnutrition as compare to the USA. It is evident that FTT occurs across all socioeconomic classes. However, the prevalence of FTT does appear to be more frequent in families who are living in poverty. The literature indicates that there are higher rates of FTT amongst children who receive Medicaid, who live in a rural area, or who experience homelessness. To date, FTT tends to be more common among female children, than male (Bassali & Benjamin, 2006). The average birth weight of a term newborn is 3.3kg. However, during the first days of life the infant's weight drops by as much as 10%, most likely due to the loss of excess fluid. Within a fortnight it is expected that the infant regain its birth weight. In general, it is the breastfed babies who regain their weight at a later period as compared to those who are bottle-fed. On average, an infant will put on 1kg per month over the first 3 months, and then 0.5 kg/mo between the ages of 3-6 months, after that, 0.33 kg/mo from 6-9 months, and 0.25 from 9-12 months of age. As such, term newborns will double their birth weight by the time their age 4 months of age, and their weight will triple by 12 months of age. Term newborns will grow about 25 cm during their first year, 12.5 cm in their second years, slowing to an estimated 5-6 cm between 4 years of age and the beginning of puberty (usually between 9-11 years of age). During puberty, an adolescent can grow as much as 12 cm per year (Bassali & Benjamin, 2006). Additional growth indicators include the head circumference of the newborn, which for a term infant is on average 35 cm (Bassali & Benjamin, 2006). By one year of age the average infant has a head circumference of 47 cm, whereupon growth slows dramatically, and the head circumference measuring about 55 cm by the age of 6 years. Also growing is the upper-to-lower body ratio. At birth, the average ratio is 1.7, at three years of age it tends to be around 1.3, and by seven years old the ratio is generally 1.0. The National Center for Health Statistics in the USA last revised their growth charts based on data from the Third National Health and Nutrition Examination Survey (NAHANES III), conducted over a period between 1988 to 1994 (Bassali & Benjamin, 2006). The probability sample collected survey, interview and physical examination data from 33, 994 people aged 2 months and over. Growth charts are available for females and males between the ages of 0-36 months, and 2-20 years. All have seven percentile curves (i.e. 5th, 10th, 25th, 50th, 75th, 90th, and 95th). A complimentary 'thrive index' has been constructed by Wright and colleagues (1998) to compensate for the conventional growth charts lack of guidance as to when a fall down centiles is actually a cause for concern. Traditional cross sectional charts are limited by their regression to the mean, so that large babies tend to have falls toward the average, whilst small babies tend to move upwards. The thrive-index is recommended for selective use with children whose weight appears to deviate from the expected range to determine if additional investigation and or intervention are required. Additionally, the thrive-index can provide reassurance when falls are within the normal range. Wright et al. note that a distinct limitation of the thrive-index is that it was constructed to monitor patterns in weight over at least six month periods from baseline. Additional to growth chart measurements, an important aspect of the evaluation of children with FTT requires the questioning of parents or caregivers to obtain a comprehensive history of the child (Bassali & Benjamin, 2006). Prenatal if history, if it is known, is critical, especially information that indicates a biological mother's smoking, alcohol consumption, medication use, and or illnesses during the pregnancy. Indications of chromosomal abnormalities should also be checked. The postnatal history should question the dietary habits of the child, such as their appetite levels, or an inability to suck and swallow as an infant; evidence of poor absorption of nutrients, such as experiences of gastro-intestinal disorder/s, endocrine disorder or chronic infection such as parasites of HIV; and indications of an increased metabolic demand, as with chronic disease or malignancy (Bassali & Benjamin, 2006). Overall, it is the decreased physical growth that is the most salient feature of FTT children. However, cognitive development is also affected, especially in children who experience FTT before the age of 3 years (Bassali & Benjamin, 2006). It has been reported that significant cognitive deficits of between 7 and 10 developmental quotient (DQ) points were found at one year of age for children with FTT (Wright, 2000). Significant developmental deficits of between 7and 10developmental quotient (DQ) points have been found at the age of 1year in two well conducted population based studies each of approximately 50children with FTT. It is contended by Wright (2000) that improving the nutritional status of the child will reverse the negative cognitive effects of FTT. She attests that her review of FTT literature indicates that the cognitive developmental delays appear to be short-term, and that a permanent effect is unlikely (Wright, 2000). However, Berg and Stafford ( ) and Bassali and Benjamin (2006) disagree, arguing that some cognitive developmental delays cannot be completely reversed. On the whole, therefore, the evidence suggests that although FTT probably influences development in the short term, a permanent effect on brain growth is less likely. In general, the research has indicated that non-organic forms of FTT result in a higher incidence of cognitive deficits as compared to organic forms. Psychosocial stimulation such as play has been found to greatly benefit FTT children, although it should be noted that nutritional support is also required. FTT children who receive a combination of nutrition and psychosocial stimulation may be able to enhance their mental development. As well, children who have been part of these programs have been found to have enhanced feelings of happiness, friendliness, and to be more cooperative and to express more vocal behaviors. Associated with cognitive deficits are emotional and behavioral withdrawal of some infants and who experience FTT (Berg & Stafford, 2006). FTT has been associated with an insecure attachment style, so that the child withdraws from social contract, and experiences great distress on separation from the caregiver. The child is also unlikely to be overly curious about its environment, nor keen to explore it, tending to remain close to the caregiver. An insecure attachment style at infancy has been associated with interpersonal difficulties during later childhood, adolescence and adulthood. It may happen that emotional withdrawal occurs before a deceleration in growth rates. Although brief periods of infant withdrawal are normal, at sustained levels it can be an indicator of infant depression. An ongoing study by Berg & Stafford (2006) aims to identify if infant withdrawal can be used as a warning sign of FTT or developmental delay. It is anticipated that determining at risk infants at the early stages of FTT, using the Alarm Distress Baby Scale (ADBB) during routine immunizations, can facilitate early intervention and so avoid further developmental delays. Management and treatment of FTT can incorporate a range of interventions. However, the literature tends to support the clinical effectiveness of interventions that incorporated a health visitor led intervention, or intensive home-based support (Wright, 2000). Such interventions include education of parents as to the nutritional, psychological and socioemotional needs of the FTT child. In regards to nutrition, it is necessary that parents or caregivers become aware of the energy balance equation and that if the child remains underweight for their height that it is likely the child is not consuming enough energy to meet activity their needs. A child that continues to grow steadily at two centiles below the standard may not require further intervention. However, an FTT child with a larger centile fall or more variable pattern may need to be referred to a medical specialist (Wright, 2000). Results Recent literature continues to support the conclusion that FTT has negative physical and cognitive consequences for the child. Mackner, Black and Starr (2003) investigated the cognitive development of children in poverty with normal growth, and compared this sample with children who had a history of FTT from infancy through to 6 years of age. In total, their 226 participants all had reported normal birth weight, with no perinatal complications, congenital problems or experiences of chronic illnesses. Of the participants, 128 children experienced FTT, and were treated at an inter-disciplinary clinic. Results showed that cognitive development had declined across both groups, being 1.0-1.5 standard deviations (SD) below the norm. However, children who had experienced FTT had, on average, lower scores on cognition tests as compared with children who had experienced adequate growth through to four years of age. By the ages of five and six years, there appeared to be no differences in cognitive scores on based on the history of the children's growth rates. It was also established through statistical analyses that the child-centered home environment and or a small family size were positively related to better cognitive performance, as compared to non child-centered and or larger family sizes. It was concluded that the overall low scores of both groups was indicative of the essential need to develop intervention programs that educated parents and caregivers to provide a child-centered approach within the home. A more recent study in 2005 by Rudolf and Logan was a meta-analytic review of 13 cohort studies of children aged less than three years old who had or had not experienced FTT. Four of the included studies had reports of IQ scores that showed significant differences between average IQ scores, with FTT children scoring on average 3 IQ points below that of children who had not experienced FTT. Two of the studies had reported growth rate data, with FTT children found to be 1.24 SD below the mean for weight as compared to the control groups, and 0.87 SD below the mean for height. It was concluded that although the differences in means on the IQ scores were significant, that the slight difference may not be of clinical significance. However, weight and height differences between means were larger, although most children who had experienced FTT were above the 25th percentile. It was also considered to be questionable as to what extent the observed differences actually represented causal relations, or if extraneous variables that had not been accounted for had confounded the results. As such, Rudolf and Logan strongly recommend an evaluation of the processes for identifying FTT. Early in 2006 Mikkola and colleagues assessed the five-year outcomes for a national early low birth weight (ELBW) infant cohort in Finland. Of the original 351 live-born ELBW infants, 206 (59%) survived until 5 years of age. Of these, 103 had been born at less than 27 weeks. In total, 172 children were evaluated with both neurocognitive and motor tests: Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R) and a Developmental Neuropsychological Assessment (NEPSY), and a modified Touwn test. Nine participants were not cognitively capable of taking part in the cognitive tests. Results found that 9% of the ELBW survivors experienced some form of cognitive impairment. Of the ELBW infants born at less than 27 gestation weeks, 19% were diagnosed with cerebral palsy. The mean full-scale IQ was 96+/- 19, although for children born at less than 27 weeks it was 94 +/- 19. Overall, the children rated poorly on measures of attention, language, sensorimotor, visuospatial, and verbal memory indices, as compared to means of the normal population. Of the participants 4% required use of a hearing aid for daily living, and 30% had poor eye health. Twenty-one children had received laser treatment for retinopathy of prematurity. As a group, 39% of the children experienced a disability of some form (i.e., 41[20%] experienced a major disability and 38 [19%] experienced a minor disability). Of the remaining children, 124 (61%) who did not exhibit functional abnormality did display slight departures from the norm. There were only 53 children (26%) who were found to have normal cognitive and physical outcomes. Additionally, ELBW survivors were found to have suboptimal growth rates at least until the age of 5. It was concluded that such high rates of cognitive dysfunction are indicative of the increased likelihood for learning difficulty. It was also recommended that ELBW survivors need extended follow-up across the lifespan to ascertain the effects of FTT on social and academic behaviors later in life. Discussion It is evident that childhood experiences of FTT can have serious negative consequences on physical and developmental growth. However, the present studies did not establish if may of such consequences are likely to be long-term. Essentially, it appears that FTT affects height and weight of a child in later life, so that they tend to be below the average norm. Additionally, developmental delays tend to be salient with IQ ratings, although studies do not support a clinical significant difference in IQ means between FTT children and those who have not experienced FTT. It should be noted though, that the literature available on the effects of FTT is limited beyond the year 2000, whereupon research tends to focus on modes of effective assessment and management interventions and their evaluation. This may be due to the general consensus that evidence exists to support the conclusion that FTT negatively affects both physical and cognitive development in children. The current research cited provides a greater cross-cultural appreciation for the effects of FFT on children, whereas many studies of FTT effects in the past have focused on samples from within North America. A limitation of the present paper was that it did not aim to answer its research question using an empirical study, so that the use of secondary data constrains the ability for the results to be generalized to a wider population. Hence, it is recommended that future research into the effects of FTT on children incorporate a longitudinal-control group design with random selection of participants. It is also suggested that a more comprehensive investigation of the socio-emotional effects of FTT on children is required, perhaps exploring associations between interpersonal difficulties and parenting/caregiver skills of the previously FTT child. It is anticipated that this current research paper will provide a conglomeration of the literature to date as to the effects of FTT on children's physical and cognitive development. References Bassali, R. W., & Benjamin, J. (2006). Failure to thrive. Retrieved May 11th, 2006, from eMedicine Website: http://www.emedicine.com/PED/topic738.htm Berg, A., & Stafford, B. (2006). Early withdrawal and failure to thrive. Retrieved May 11th, 2006, from the Infant Institute Website: http://www.infantinstitute.com/research.htm Mackner, L. M., Black, M. M., & Starr, R. H. Jr. (2003). Cognitive development of children in poverty with failure to thrive: a prospective study through age 6. Journal of Child Psychology and Psychiatry and Allied Disciplines, 44(5), 743-751. Mikkola, K., Ritari, N., Tommiska, V., Salokorpi, T., Lehtonen, L., Tammela, O. et al. (2005). Neurodevelopment outcome at 5 years of age of a national cohort of extremely low birth weight infants who were born in 1996-1997. Pediatrics, 116(6), 1391-1400. Olsen, E. M., Petersen, J., Skovgaard, A. M., Weile, B., Jorgensen, T., & Wright, C. M. (2006). Failure to thrive: the prevalence and concurrence of anthropometric criteria in a general population. Archives of Disease in Childhood, 94. Rudolf, M. C. J., & Logan, S. (2005). What is the long term outcome for children who fail to thrive A systematic review. Archives of Disease in Childhood, 90, 925-931. Wright, C. (2000). Identification and management of failure to thrive: a community perspective. Archives of Disease in Childhood, 82, 5-9. Wright, C., Avery, A., Epstein, M., Birks, E., & Croft, D. (1998). New chart to evaluate weight faltering. 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