Literature Review

FTT definitionThe research on FTT appears to be as inconsistent as practice in regard to the variability in definitions and diagnostic criteria. This section attempts to find common threads from the literature.

Most authors agree that FTT is considered a descriptive term of a diagnostic problem rather than a diagnosis, however confusion arises as it is sometimes also equated with paediatric undernutrition [1, 3]. A review of recent trends in the international medical literature found there was a consensus towards a purely nutritional/ growth based definition. There was agreement on using anthropometric criteria to define FTT, however there was no agreement on which growth parameters to use and whether to use attained values or velocities.

The overall trend in definitions of FTT was towards [4];

the lack of attainment or maintenance of the growth potential expected for a child when the childs growth crosses 2 or more or centile lines on a standard growth chart or when growth falters to below the 5th or 3rd centile for age

In Australia, FTT definitions have followed the above trend. However, Brewster argues that the tendency to use FTT to refer to children below the 3rd centile for weight at a given age risks missing significant weight loss in a bigger child and mis-identifying genetically small children with infection related transient growth deceleration. He argues that FTT should be defined as[3];

growth deceleration or crossing growth centiles, particularly falling through 2 centile spaces on the standard child growth chart

In a paediatric review of FTT Schwartz adds that an age component (younger children and infants) and psychosocial and developmental components are integral to a diagnosis of FTT [20]. It is argued that FTT usually occurs in children under 3 because they normally grow rapidly and depend on their parents for food [3].

Relationship between FTT and CMThere are different opinions in the literature about the relationship between FTT and CM. Undernutrition underlies FTT, and this links FTT with definitions of malnutrition. Some authors argue that CM and FTT are essentially the same condition described in different literatures [1]. Brewster claims that FTT tends to be used when describing children in developed countries like Australia or in middle class families, whereas in developing countries or underprivileged (for example indigenous) families malnutrition is more likely to be used. Other authors see FTT as a syndrome of growth faltering which may or may not result in malnutrition [5]. There is general agreement that all children with FTT have some degree of inadequate nutrition to sustain a normal rate of growth, whatever the cause.

The weight deficits used in diagnosing FTT are equivalent to those used to diagnose malnutrition [24]. The severity of CM/ FTT informs its management. Anthropometric indicators alone are generally used to diagnose malnutrition in populations, whereas an analysis of the growth pattern over time is mainly used to diagnose FTT in individuals [4].

It is interesting that growth assessment tends to continue to dominate definitions and diagnosis of CM/ FTT despite the variability in measures and the capacity for error. Much of the CM/ FTT literature is medical in orientation, and Wright and Talbot argue that weight loss or gain offers an objective and pragmatic measure of change in a complex and confusing area. However the term failure to thrive also implies other aspects of a childs wellbeing and recent research on child development is increasingly highlighting the importance of thriving across the physical, socio-emotional and cognitive domains. McCain and Mustards influential work on the Early Years stresses that children need not only nutrition, but also stimulation, care, security, attachment and love to thrive [6].

Consequences of CM/FTT Early child development can affect health, well-being and competence across the balance of the life course. Even though understanding of the specific contribution of childrens growth as a determinant of health and development is still emerging, The Lancets recent series on maternal and child undernutrition warned that the evidence that growth failure has a huge cost is now overwhelming[6].

This section presents a brief overview of the evidence for short and long term consequences of undernutrition from review articles. The seriousness of the findings is sobering both in terms of the possible impacts on individuals and on human capital.

The short term effects of undernutrition have been found to include; Ongoing growth deficits, severe infection, diminished immunological response, greater risk of death, delayed cognitive and psychomotor development, learning disabilities and behaviour problems, and diminished physical activity. [1,3]

A recent systematic review of the evidence on maternal and child undernutrition in developing countries found overwhelming evidence for long term effects; Poor foetal growth or subsequent stunting (height-for-age z score 80% SWFH and appetite returned 75-80% SWFH and gaining > 5g/kg/day on oral diet, mother educated on appropriate diet for home, hygiene, social issues addressed if required and food supply secure at home If poor social situation/food security issues not in process of being resolved consider remaining an inpatient until weight for height Z score -1.0 of (90% SWFH)

Additionally a nutrition discharge plan should include; Identify need for ongoing provision of paediatric food supplement Education about weaning diets, adequate diet for growth, consequences of ongoing poor growth Recipe for concentrated formula if required and ensure mother able to make up Discharge summaries faxed to the clinic

The effectiveness of hospitalisation for CM/ FTT There is limited evidence for the effectiveness of hospitalisation for FTT. Schwartz claims that meta-analysis has highlighted the efficacy of hospitalisation for physical growth, more than psychosocial improvement [2]. The only Australian study on the effectiveness of hospitalisation for children with malnutrition found mixed outcomes. Hospital admission was effective in re-establishing weight gain but at the cost of high rates of readmission (53% within 6 months) and hospital acquired infections (38%). Children continued to grow 2 months after hospitalisation, but they did not sustain catch-up growth. Hospital was also effective in identifying the organic contributors to malnutrition [3].

Brewster has argued that the emphasis for treatment of malnourished Aboriginal children in the NT needs to change from hospital case management with enteral tube feeding to improved community management in a primary health care setting. He argues that hospitalisation has high relapse rates, is less effective in identifying the underlying causes of malnutrition, and is a costly intervention that is disruptive for the child and carer. He attributes this approach to childhood malnutrition to the affluence of the Australian health care system [1].

Intervention Delay Russell et al found that there was an intervention delay in CA of approximately 6 months between recognition of a child not gaining weight and admission to hospital. The median age at recognition of malnutrition by community clinics was 8.6 months, yet the median age at index admission was 15.1 months. 76% of children in the study had not gained weight for 3 months prior to admission and 24% had crossed down 2 major percentile lines. The study did not review what interventions had occurred in the community or the timeliness of hospitalisation, but did recommend the importance of early intervention. The study only included children who were admitted to ASH and did not identify children for whom community interventions were successful and so were never admitted [3].

A UK community based FTT service found a similar delay between growth faltering and referral to a specialist service. It argued that practitioners need to strike a balance between waiting for positive change to occur and prompt intervention if the child is at risk. Early identification is critical, since the longer and more severe the poor weight gain, the more serious the consequences[5].

Role of parents Little is known about families experience of FTT. A Canadian qualitative study of families of children in hospital with FTT found that parents often felt blamed, isolated and helpless, and were affected by negative attitudes of health care professionals. Families appreciated being included in care team and having their expertise on the child valued [4].

The literature emphasises the importance of the role of the parent or caregiver in hospital. Carers are seen as essential to the diagnostic and therapeutic process. Parental involvement in the multidisciplinary team is considered to promote better follow up post discharge and better parenting. The importance of a non judgemental attitude is emphasised in the literature from developing and developed countries [1].

A Scottish social work study on NOFTT quotes Marcovitch in suggesting that although the community is considered the most appropriate intervention setting for undernutrition, parents may favour hospital intervention as non-medical approaches can imply a failure to care for their children and parents may feel stigmatised [6].

An ARACY review of the research into parent-provider relationships found that developing positive partnerships with parents requires empathy, respect, genuineness and a willingness to work collaboratively with families. There may be organisational constraints to this in ASH where a stigma and history of child removal and legal obligations to report suspected child abuse or neglect can act as a barrier to trust of health professionals. Organisations can enhance positive worker-parent relationships by creating a culture of inquiry and refection that encourages a questioning of assumptions about families needs, problems and resources, and by providing staff supervision and training in cultural competence [5].

REFFERENCE

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