Failure to Thrive

A basic lack—and maldistribution—of food is the major factor in undernutrition in developing countries. Even in wealthy countries, however, food may not be readily available to all people, especially the poor. Surveys in the United States have shown that as many as 12 percent of households experience inadequate access to food at some time during a year.

Cultural beliefs and practices around the world influence young children's nutritional intake. Cultures differ with respect to the nutritional value of foods given to children of different ages, prestige and status of food types, healing values that people attribute to food, religious customs such as fasting, who is responsible for feeding children, caregiver versus child control of eating, and toddler-weaning practices (Sturm and Gahagan 1999). Even in developing countries where poverty is widespread, nutrient intake can be affected by differences in cultural norms and parents' beliefs.

Families' choices of foods for their infants may impair their nutrition. For example, parents may give soda pop or too much fruit juice, so that infants take less milk and solid foods. Some parents, in an effort to be healthy by avoiding fat in their diet, unduly limit their infants' intake of fat, which is especially needed in the first two years for brain and bodily growth.

Infants may themselves have difficulties in feeding. These difficulties may be obvious in infants with problems in moving the body, like cerebral palsy, or they may be subtle in children who have trouble chewing and swallowing. Such children may, for example, lose excessive amounts of food or milk from the mouth, pocket food in the mouth, be unable to move their tongues well, or refuse foods with rough textures. Children's eating behavior can also contribute to poor intake and is often a focus of parental concern. Probably the most common behavioral problem is food refusal, in which children close their mouths, turn their faces away, and cry. All these factors can make meals take a long time.

During the first two years, infant-parent relationships change, and so does child feeding. During the first two months, parents help babies establish a regular schedule of eating and sleeping. If parents do not learn to tell when a baby wants to be awake or asleep, or is hungry or full, the baby many not get enough milk or formula. Between approximately three and eight months, babies look for more social interaction with their caretakers. If parents have trouble recognizing, interpreting, or responding appropriately to their cues, feeding may be affected. At the end of the first year and during the second year, babies seek more and more independence from their parents during feeding and other parts of everyday life. This process of psychological separation and individuation may lead to control struggles over the child's becoming an autonomous self-feeder (Birch 1999; Satter 1987).

Lack of daily structure can result in an absence of predictable mealtime and sleep routines, two processes intrinsically interrelated for babies and toddlers (Yoos, Kitzman, and Cole 1999). Toddlers who are allowed to snack and drink caloric beverages without a reliable schedule of mealtimes and snacks may not develop the internal cycles of hunger and satiety that are the basis for self-regulation of eating and good growth. Adequate amounts of sleep at night and daytime naps are necessary for the child to attend to the task of eating during meals. Appetite can be limited because of inappropriate timing and size of meals across the day (Kedesdy and Budd 1998).

Many aspects of family functioning can affect how much a child eats and the nutritional value of what is eaten. Within the family unit, general life stressors and worries can interfere with the primary caretakers' ability to monitor the child's nutritional intake, to provide regular meals, and to respond attentively and sensitively during meals (e.g., with encouragement and praise). Parental psychological disorders, family interaction problems such as marital conflict, and problems in parent-child relationships can impair caloric intake. Although research has been inconclusive as to whether there are more psychiatric problems in parents of babies with failure to thrive compared to parents of babies with normal growth, clinical case reports indicate that such problems can damage the feeding relationship. Maternal depression, social isolation, alcohol use and substance abuse, domestic violence, and a history of problematic parental childhood can make it harder for parents to have good relationships with their young children (Drotar and Robinson 2000).

Infants with low birth weight (less than 5.5 pounds or 2500 grams) start out life small and are more likely than others to be small later on. If their growth rate is normal, there may be no problem, although it is important to make sure they receive good nutrition. Many illnesses can impair children's growth. Most of those illnesses are common infectious diseases, such as repeated ear infections, respiratory infections, and diarrhea. Less commonly, infants may gain weight poorly because they have a cleft palate, their intestines fail to absorb nutrients, stomach contents slide up the esophagus (gastroesophageal reflux), or they have a long-term medical disorder like Down's syndrome or fetal alcohol syndrome.