Failure to thrive (FTT)

FTT describes infants whose rate of physical growth is declining, or is already
below the 5th centile (Casey, 1999). Although there are various further
refinements in the definition of FTT, the cause is malnutrition. Non-organic
FTT (NOFT) refers to infants for whom there is no identified medical
explanation for poor weight gain. Population-based studies of the incidence of
FTT, when preterm and small for gestational age babies are excluded, indicate a
prevalence of 3 to 4 per cent (Wolke, 1996). The terms FTT and feeding
disorder are sometimes used interchangeably, but feeding difficulties occur
independently of FTT, and they are not necessarily a feature of FTT (Chatoor
et al., 1997; Ramsey, Gisel, McCusker, Bellavance & Platt, 2002). ‘Hospitalism’ is
a term used to describe the extreme of FTT, accompanied by severe emotional
neglect due to maternal deprivation (Spitz, 1945). Maternal deprivation is
synonymous with the absence of consistent caregivers and the lack of physical
contact and stimulation necessary for normal development. This is not a typical feature of FFT (Wolke, 1996).
The term ‘conservation-withdrawal reaction’ is applied to infants failing to
thrive because their nutritional needs have not been recognised or met, who have passed beyond the stage of crying, and passively tolerate inadequate feeding (Menahem, 1994). Such infants have adapted to the futility of protesting, and to
the need to conserve energy. With less frequent feeding the hunger–satiety cycle becomes reprogrammed and hunger is experienced less intensely (Wolke, 1996).
This is seen as a survival strategy.
Even mild FTT, especially during the first six months of life, is associated
with delayed cognitive development, which is likely to arise from poorer brain
development resulting from malnutrition (Corbett, Drewett & Wright, 1996;
Wolke, 1996). Compared with thriving infants, babies with NOFT are
frequently:
• more fussy
• more demanding

• more unsociable
• more inconsolable
• less happy
and they have:
• below average development
• immature or abnormal oral-motor skills, making them more difficult to feed
• more negative affect associated with feeding (Oates, 1996).
Initially, it may not be clear whether these infant behaviours are secondary to
FTT or are primary characteristics of a baby whose temperament and ability to respond to care are mismatched with a discordant parenting style. Studying
interactional feeding behaviours, Drotar, Eckerle, Satola, Pallotta and Wyatt
(1990) compared NOFT babies, after discharge from hospital, with healthy
babies. The mothers whose babies had been underfed demonstrated less positive and appropriate behaviours, and were more likely to arbitrarily terminate feeds.
Such mothers may be less inclined to touch their babies during feeding and play (Polan & Ward, 1998). Parental psychopathology is a frequently reported
association of FTT (for example, Chatoor et al., 1997). This suggests a possible causal link between psychopathology and FTT (Duniz et al., 1996). A distinction also needs to be made between mothers who are capable but
overwhelmed by external factors such as poverty, social isolation or stressful life events, and those with limited emotional resources (Derivan, 1982; Oates, 1996).
Atypical feeding behaviour can also be the overt symptom of intra-psychic
conflicts within the family (Stern, 1985).
Infants with either organic or non-organic FTT may be at increased risk of
insecure attachment (for example, Ward, Lee & Lipper, 2000), however, Chatoor, Loeffler, McGee and Menvielle (1998) also demonstrated high rates of secure
attachment among toddlers with infantile anorexia. While disturbed feeding
relationships are more likely to be a feature of NOFT (Lucarelli, Ambruzzi,
Cimino, D’Olimpio & Finistrella, 2003), feeding problems and FTT can also be present in securely attached infants (Chatoor, Ganiban, Colin, Plummer &
Harmon, 1998). NOFT and hospitalism are sometimes classified as
psychosomatic disorders of attachment (Brisch, 2002). In contrast to DSM-III,
DSM-IV no longer includes FTT as a defining feature of reactive attachment
disorder (Casey, 1999). NOFT has been shown to be frequently associated with oro-motor dysfunction, suggesting that a diagnosis of NOFT may sometimes in
fact have an unrecognised organic basis (Ramsay et al., 2002; Reilly, Skuse,
Wolke & Stevenson, 1999).
Wolke (1996) suggests that there are several subgroups in infants with
NOFT, reflecting multiple pathways to malnutrition:
• undemanding, sleepy babies, possibly hypotonic and with weak suck, who are not woken for feeds • infants with subtle oro-motor dysfunction who do not negotiate the transition
to more textured and varied food, remaining exclusively breastfed beyond six
months, and therefore likely to be undernourished
• infants who refuse to feed, possibly because of oro-motor problems, although refusing food does not necessarily lead to poor weight gain
• a small group of infants on restricted diets because their overweight mothers prefer slimmer babies
• a very small group of infants, exposed to neglect and deprivation, and likely
to be referred to clinical services.