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Full Title: Criteria for Determining Disability in Infants and Children: Failure to Thrive
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Objectives: The evidence report provides a systematic review of the scientific evidence to answer the question of whether children, defined by investigators as failing to thrive (FTT) or grow adequately, have a concurrent "disability," or will have one within 6 months. The population of interest includes children age 18 years or younger, both male and female, of all racial, ethnic and socioeconomic groupings.
Search Strategy: Systematic searches were performed for relevant articles in MEDLINE® from 1966 through December 2000, with updates through September 2001. Additional studies were identified from other databases, reference lists of review and primary articles, and from domain experts. Since disability is not a specific medical condition that can readily be searched for, many studies with related concepts (i.e., medically definable impairments that are related to disability) were reviewed to identify potentially relevant studies. Search terms were textwords: failure to thrive, failure to grow, growth retardation, childhood malnutrition, protein-calorie malnutrition, starvation and psychosocial dwarfism.
Selection Criteria: Eligibility criteria for study inclusion included:
- Published articles including at least one disability related outcome.
- Cross-sectional or longitudinal studies.
- Studies with at least two arms, one of which had a non-failure to thrive or healthy control group [added to control for potential confounders for any particular statistically significant outcome or covariate].
- Studies conducted in either developed or developing countries.
Studies of sample size of less than 10 subjects per arm, or those concerned primarily with particular diagnoses and conditions were excluded, as were studies published only as abstracts. Investigators' own definitions of failure to thrive were retained despite their resulting variability in inclusion criteria across studies.
Main Results: Including studies found from other sources, a total of 10,966 English language citations were identified. A total of 275 original studies were retrieved for careful evaluation. Detailed examination of these articles identified 52 publications comprising 43 studies that met inclusion criteria. Detailed data extraction was performed on these 43 studies.
- Persistent disorders of growth. Overall these studies comparing children who were thriving with those who were undernourished in both developed and developing countries show that children with FTT have poorer growth in weight, height, and head growth, and that this poorer growth is often long-standing despite appropriate interventions. Earlier intervention leads to potentially better long-term outcome.
- Associations of FTT with immunologic/infectious outcomes. The evidence that children with FTT have significantly greater susceptibility to infection is strong, with significant immunologic dysfunction and clinical infectious complications seen consistently across a variety of conditions. The laboratory markers of immunologic dysfunction were apparent in children with moderate severity. Only one study demonstrated improvement following immunologic intervention. Severe complications were most prevalent among the most severely malnourished children.
- Disabilities related to child behavior associated with Failure to Thrive. The evidence identified by the search showed that children with failure to thrive concurrently exhibited a variety of behavioral disorders as well as at followup. The behavioral problems ranged from eating disorders, increased negative and decreased positive affective expression, to lower scores in communication and mood.
- Developmental disorders associated with Failure to Thrive. FTT is associated consistently with depressed developmental test scores. In both clinical and epidemiological samples, FTT is associated on average with roughly 2/3 of a standard deviation decrease in developmental test scores. As a result, a greater proportion of children who are failing to thrive than children in a reference population will score in the supplemental security income (SSI) qualifying range for developmental delay.
- Evidence that Failure to Thrive (FTT) is associated with other psychosocial and family factors. Compared to well-nourished peers, children with FTT were more likely to have had neonatal problems (jaundice, possible sepsis, and poor feeding, and family problems). There were no differences however in the incidence of prematurity, LBW, or maternal pregnancy complications.
Conclusions: The findings emphasize the importance of early and intensive intervention for children with poor growth velocity (FTT) so as to prevent permanent growth retardation. The evidence also supports the value of identification of children with growth failure as a marker for chronic and multiple acute infections. Children with a history of FTT were found to have clinically and statistically significant behavioral deficits and consistently depressed scores in cognitive, neurological, and psychomotor development. The increased risks for secondary disability generally persist in spite of intervention.
In summary, there is persuasive evidence that failure to thrive is associated with a range of organic and psychosocial difficulties and significant disability. Primary categories of associations include the child's age, socioeconomic factors (lower income, lower maternal education, less enriched family environment/interactions); neonatal morbidity; acute illnesses and hospitalizations; and neurological/anatomical abnormalities.
Criteria for Determining Disability in Infants and Children: Failure to Thrive
Evidence-based Practice Center: Tufts-New England Medical Center
Topic Nominator: Social Security Administration
Current as of March 2003