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nal deprivation (Whitten, Pettit, & Fischhoff, 1969). This and subsequent research led to our current understanding of the multifactorial nature of FTT, with some suggesting that the emphasis on parental culpability in FTT in the absence of direct evidence of neglect is wrong (Skuse, 1985) and that FTT is “distinct” from neglect (Black et al., 2006). As described in this chapter, it is now recognized that medical, dietary, psychosocial, and behavioral factors all need to be considered when assessing children for FTT. Consistent with FTT’s diverse etiologies, a multidisciplinary approach to treatment is necessary to address ways to enhance caloric intake in each of these domains. The chapter presents some specific recommendations for the assessment and treatment of FTT. EPIDEMIOLOGY Despite the lack of current data on the prevalence of FTT, older published data are available from a variety of clinical settings. Historically, children with FTT were often admitted for an extensive workup to determine the etiology. In a retrospective review of charts, FTT accounted for 1%–5% of admissions to tertiary care hospitals (Berwick, Levy, & Kleinerman, 1982; English, 1978; Shaheen et al., 1968). A more recent review found that anywhere between 2% and 24% of patients admitted to the hospital have symptoms of FTT (Joosten & Hulst, 2008). There are limited epidemiological data from outpatient settings, but the incidence of FTT in primary care clinics was found to be as much as 10% of outpatient visits (Frank & Zeisel, 1998; Mitchell, Gorrell, & Greenberg, 1980; Zenel, 1997). In addition, as many as 30% of visits to some emergency departments are for children with FTT (Frank & Zeisel, 1998; Zenel, 1997). Some studies suggest that one-third to one-half of cases of FTT may go unrecognized (Batchelor, 1996; C. M. Wright, GENERAL CONSIDERATIONS Failure to thrive (FTT) refers to faltering weight, typically in early childhood. It is a common problem seen by pediatricians today and has been a concern for physicians for more than a hundred years. FTT occurs when there is a deceleration in growth velocity, and it is an important physical sign (Zenel, 1997) or manifestation of childhood disease (Shaheen et al., 1968) that may be caused by almost any type of chronic disease (English, 1978). The approach to diagnosis of FTT is known to most physicians and can become expensive and frustrating. One of the first cases in the literature was in the first edition of The Diseases of Infancy and Childhood by L. Emmett Holt, published in 1897. Holt described a child who “ceased to thrive” and recognized that FTT could occur in a variety of clinical scenarios (Schwartz, 2000; Stanga et al., 2008). Chaplan later described how FTT in orphans could be caused by the “institution” in which they lived. These children had poor diets, atrophy, and a “downward trend” to death if they returned from the hospital to the same environment (orphanage) from which they came. Widdowson (1951) described the deleterious effects of psychosocial deprivation on the growth of orphans in occupied Germany in the late 1940s. Others believed that children with FTT were emotionally deprived by their caregivers, leading to growth retardation. The term maternal deprivation syndrome was used, because mothers were usually the primary caretaker (Patton, 1963; Skuse, 1985). Such early observations led to the understanding that FTT was closely associated with neglect or maltreatment. This perspective, however, was challenged by research demonstrating that maternally deprived infants were underweight because of “undereating ” resulting from being offered too little food or not accepting it, not because of the psychological effects of materFailure to Thrive and Maltreatment HANS B. KERSTEN, M.D. DAVID S. BENNETT, PH.D. 21 Failure to Thrive and Maltreatment 221 from 1963–1994, from various U.S. cities. In an effort to improve the accuracy of the charts for children less than 2 months of age, the charts were updated in 2000 with data from large samples of children. As a result, these charts provide a reference of how children grew at a specific point in time. However, based on the premise that children’s weight should be compared with that of children with ideal growth standards, the World Health Organization (WHO) developed growth charts to provide international standards of growth for children 0–59 months of age (GrummerStrawn , Reinold, & Krebs, 2010). The CDC convened an expert panel from the American Academy of Pediatrics and the National Institutes of Health to review the evidence and provide guidance for health care providers on which growth charts to use (GrummerStrawn , Reinold, & Krebs, 2010). The panel recommended that clinicians...

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