Failure to Thrive

Nonorganic failure to thrive can be understood in terms of both physical and emotional deprivation of the child, and has both physical and behavioral signs. Caloric deprivation of an infant may be caused more or less innocently by lactation failure, extreme poverty, parental ignorance of proper infant feeding, or strange nutritional beliefs. Parents of children with nonorganic failure to thrive, however, typically give a history of adequate or often exaggerated amounts of nutritional intake belied by the child's obvious malnourished state.

By interviewing and observing the mother, it is noted that feedings are marked by a lack of the mutual pleasurable relationship of giving and receiving that is the hallmark of normal feedings. In contrast, the mother may admit that she props the bottle or even sometimes forgets regular feedings.

There may be other evidence of poor caregiving and physical neglect, such as unwashed skin, diaper rash, skin infections, and dirty clothing. The back of the baby's head may be flat with a bald patch over the flattened area, implying that the child is left unattended for long periods of time lying on his back in the crib. The baby may exhibit a lack of appropriate social responsiveness, with an expressionless face and classic avoidance of eye contact. Normal vocal responses, such as cooing and blowing raspberries, may be absent. In children older than five months, there may be no anticipatory reaching for interesting objects. Motor milestones may be delayed. When held, instead of cuddling normally, the baby characteristically arches his back and scissors his legs, or lies limp as a rag doll in the examiner's arms. By contrast, babies with organic failure to thrive typically do not show the characteristic withdrawal behaviors of non-organic failure to thrive infants, and respond best to their mothers.

Prominent features in the mother's history may include symptoms of acute or chronic depression, personality disorder, substance abuse, and a generally high level of psychosocial stress related to poverty, social isolation, or spousal abuse. Often the mother was abused or neglected as a child, producing an apparently transgenerational pattern of insecure attachment. Parents of infants with nonorganic failure to thrive are often initially evasive. They usually take the baby to an emergency room for another illness, whereupon the baby's malnutrition attracts attention. Upon the child's admission to the hospital, the parents may disappear for several days.