A Look Back to Go Forward
I came across an article published by Elizabeth Tenety in Motherly on July 19, 2022 where the subtitle read: ““Failure to thrive” kids aren’t failing at anything”.
It had me thinking of all the times I walked into an appointment or a patient room and saw that look of worry or panic, or worse, guilt, stricken on parents’ faces. Had we, the medical professionals, caused these emotions? With our choice of words?
It got me thinking of failure to thrive (FTT)’s history, its varying definitions often based on weight alone, the often negative connotation it has and its future. Here’s what I found.
A Look Back at the History of Failure to Thrive
Emmett Holt was the first to describe an infant who “ceased to thrive” in 1897 in the text book The Diseases of Infancy and Childhood. The term FTT was introduced in medical journals a few decades later in the 1930’s. Generally, the term is used to describe infants or children that are under nourished, resulting in insufficient weight gain or growth deviation.
Since there is no universal consensus on its definition, estimating its prevalence is challenging and there are concerns with under or over recognition.
Gretchen J. Homan, MD, describes the following conventionally accepted definitions of FTT in her article Failure to Thrive: A Practical Guide:
Weight for age consistently below the 5th percentile for sex and corrected age
Weight for length below the 5th percentile or BMI below the 5th percentile
Sustained decrease in growth velocity, in which weight for age or weight for length/height falls by two major percentiles (percentile markers 95, 90, 75, 50, 25, 10, and 5) over time
WHO and UNICEF have moved to recommending defining severe acute malnutrition as:
Weight for height < -3 standard deviations
And a mid-upper arm circumference (MUAC) <115 mm (in those between 6-59 months of age)
ASPEN’s 2013 landmark article Defining Pediatric Malnutrition A Paradigm Shift Toward Etiology-Related Definitions, has provided an updated framework, using a variety of indicators rather than weight alone, to more accurately diagnose the presence of malnutrition and its degree. The article guides us through how to use the indicators to help assess and understand:
Chronicity (acute vs. chronic)
Degree (mild, moderate, severe)
Etiology (illness vs. non-illness)
Presence or absence of inflammatory state
And mechanisms (decreased nutrient intake, increased energy requirement, malabsorption) and outcomes affected
Growth failure is not a diagnosis, it highlights a concern that calls for further evaluation into a child’s possible indicators for malnutrition.
Terminology and How It’s Changing
Our job as health professionals is to support our patients and their families. In this new era where words matter, where the focus is changing to inclusive language, we should rethink the use of the old term FTT.
As Elizabeth wrote in her article, “My happy healthy toddler was deemed a “failure to thrive”. It was a crushing blow […].To be clear: He was gaining weight and growing, just slowly and on a lower curve.[…] hearing that your child is “failing”, that YOU’RE “failing” after months of worrying and strategizing and focusing to help your child grow, it’s an unnecessary crushing blow.”
Daymont et al in Academic Pediatrics 2020 described emotional distress for children and caregivers as a potential harm with the evaluation and treatment of FTT.
Rethinking Our Language
Proposed new terms in the literature:
Weight faltering, faltering growth, growth failure, undernutrition, malnutrition
“The term weight faltering has been proposed to more appropriately emphasize that problems with appropriate weight gain are the initial and most reliable clinical finding of undernutrition. The term weight faltering is also perceived to be less negative or alarming, and less potentially critical of parents or caretakers.” AAFP 2016
“The term “faltering growth” is now used widely to refer to a slower rate of weight gain in childhood than expected for age and sex. The term faltering growth is preferred as periods of slow growth may represent temporary variation from the expected pattern and the word “failure” may be seen as pejorative.” NICE 2017
Action Steps You Can Take in Your Practice
Ensure that accurate, reliable serial measurements of weight and length/height are obtained
Plot on the an appropriate growth chart:
- WHO <2 years of age
- CDC for 2-20 years of age
- Specialized growth charts are to be used in addition to standard charts to supplement data collection
Use clinical judgment to assess an infant or child’s growth pattern
Update your language
Measure MUAC in those that are 6 months – 59 months of age
Assess for malnutrition using ASPEN’s Pediatric Malnutrition Indicators
Helpful Resources and Tools
ASPEN’s Pediatric Malnutrition Indicators
ASPEN’s New Growth Failure Tool
For more information on MUAC, refer to our blog Mid-Upper Arm Circumference in Pediatric Malnutrition
For more information on growth failure, check out our free webinar Growth Failure – A New Roadmap for a Common Problem
As always, we’d love to hear from you. Have you started using ASPEN’s Pediatric Malnutrition Indicators? How do you feel about the terms being proposed to replace FTT?
Charlene and Julie
P.S. Missed the link to join our next free webinar, sign up here: Growth Failure – A New Roadmap for a Common Problem
P.P.S. If you’d love to know more about infant nutrition, check out our flagship course Infant Nutrition Essentials