Non-Organic Failure to Thrive

Infants depend entirely on caregivers to meet their needs, so a disturbed caregiver-infant relationship can show up as a physical problem in the child. Non-organic failure to thrive (NOFTT) is inadequate growth and development with no underlying medical or organic cause; it comes from environmental, psychosocial, and nutritional factors that block normal growth. These children show poor weight gain, poor linear growth, and developmental delay, usually falling below expected percentiles for age. Your job is to find the cause, optimize nutrition, and build a supportive environment, and the response to that environment is itself diagnostic.

What is Non-Organic Failure to Thrive?

Four things drive human growth: food, rest and activity, adequate hormone secretion, and a satisfactory relationship with a consistent, nurturing caregiver who provides loving contact and stimulation. Infants who fail to gain weight and show delayed development are classified as failure-to-thrive. Most definitions hinge on a weight less than the 5th percentile on the growth chart or a decreasing rate of weight gain.

Classification

Failure to thrive splits into two types. Organic failure to thrive results from a disease condition. Non-organic failure to thrive has no apparent physical cause.

Pathophysiology

Non-organic failure to thrive usually comes from interacting medical, behavioral, developmental, and psychosocial factors. It is not a disease or disorder; it describes a child who is undernourished and either does not receive or cannot process enough calories. The clinician sets an ideal weight by comparing the child's weight, age, and sex to national averages, and children who fail to thrive fall well below it. A child can also be diagnosed when linear growth stalls at a point where height should still be climbing.

Statistics and Incidences

Up to 80% of children with growth failure have no apparent growth-inhibiting disorder; the failure traces to environmental neglect, stimulus deprivation, or both. In the United States it shows up in 5 to 10 percent of children in primary care settings and 3 to 5 percent in hospital settings. Prevalence depends heavily on the definition used and the population studied, running higher in economically disadvantaged rural and urban areas. About 80% of children with failure to thrive present before 18 months of age.

Causes

• Not enough food offered. Incorrect formula measurement, breastfeeding problems, trouble transitioning to solids, restricted fat intake, and financial constraints.
• The child eats too little. Prematurity, developmental delays, or conditions like autism.
• Digestive system problems that block weight gain.
• Food intolerance, where the body reacts to certain foods.
• Ongoing illness or disorder that makes eating hard, so calorie intake falls short.
• Infections. Parasites, urinary tract infections, tuberculosis, and others burn nutrients fast and cut appetite.
• Metabolic disorders that impair breaking down, processing, or extracting energy from food.

Clinical Manifestations

• No weight gain, the hallmark finding.
• Developmental delays in milestones like rolling over, crawling, and talking.
• Poor muscle tone and loss of subcutaneous fat.
• Immobility for long stretches from lack of energy.
• Unresponsiveness, sometimes actively avoiding cuddling and vocalization.
• Irritability. Many fall into the "difficult" category, while others are listless and passive and seem not to care about feedings.

Assessment and Diagnostic Findings

• Growth charts. Plot weight, length, and head circumference at each well-child exam.
• Health history, including a detailed feeding history.
• Physical exam. Signs of deprivation matter; when the child improves in a nurturing environment, the diagnosis is confirmed.
• Laboratory tests. When history and exam do not point to a cause, most experts limit screening to CBC with differential, ESR, BUN, serum creatinine, electrolyte levels, urinalysis and culture, and stool for pH, reducing substances, odor, color, consistency, and fat content.

Medical Management

Treatment provides the health and environmental resources needed for satisfactory growth.

• Nutritional treatment. Cut empty calories, schedule regular meals and snacks (usually 3 meals and 2 snacks), offer solids before liquids, fortify with extra oils and carbohydrates, increase protein, and consider vitamin and mineral supplements, especially zinc and iron.
• Psychosocial evaluation. Detailed look at how the family and the child function within the family.

Nursing Management

Treatment initially depends almost entirely on good nursing care.

Nursing Assessment

• Physical exam. Observe skin turgor, anterior fontanel, signs of emaciation, weight, temperature, apical pulse, respirations, responsiveness, listlessness, and irritability.
• Interaction. During the caregiver interview, watch the caregiver-child interaction, the caregiver's responsiveness to the child's needs, and the child's response to the caregiver.
• History. Take a careful history of feeding and sleeping patterns or problems.

Nursing Diagnosis

• Disturbed sensory perception related to insufficient nurturing.
• Imbalanced nutrition: less than body requirements related to inadequate calorie intake.
• Deficient fluid volume related to inadequate oral intake.
• Impaired urinary elimination related to decreased fluid intake.
• Constipation related to dehydration.
• Risk for impaired skin integrity related to malnourishment.
• Impaired parenting related to lack of knowledge and confidence in parenting skills.

Nursing Care Planning and Goals

• Improve alertness and responsiveness.
• Increase caloric and oral fluid intake.
• Maintain normal urinary and bowel elimination.
• Maintain skin integrity.
• Improve parenting skills and build parental confidence.

Nursing Interventions

• Provide sensory stimulation. Cuddle the child, talk in a warm, soothing tone, and allow age-appropriate play.
• Maintain nutrition and fluid intake. Feed slowly in a quiet environment, snuggle and gently rock during feeds, and feed every 2 to 3 hours initially.
• Postfeeding. Burp frequently during and after each feeding, then position the child on the side with the head slightly elevated or held chest-to-chest.
• Involve the caregiver in the child's feedings when present.
• Document intake with caloric counts and strict intake and output records.
• Monitor elimination. As food and fluids increase and the child rehydrates, bowel and urine output normalize.
• Promote skin integrity. Lubricate dry skin with lanolin or A and D ointment at least once each shift, and turn the child at least every 2 hours.
• Family teaching. Point out the child's development and responsiveness to the caregiver, and praise positive parenting behaviors.

Evaluation

Goals are met when the child shows improved alertness and responsiveness, increased caloric and oral fluid intake, normal urinary and bowel elimination, and intact skin, and when the caregiver demonstrates improved parenting skills and confidence.

Documentation Guidelines

• Individual findings, specific deficits and associated symptoms, and perceptions of the client and significant others.
• Caloric intake.
• Cultural or religious restrictions and personal preferences.
• Degree of fluid deficit and current sources of fluid intake.
• Intake and output, fluid balance, weight changes, presence of edema, urine specific gravity, and vital signs.
• Results of diagnostic studies.
• Parenting skill level, deviations from normal parenting expectations, family makeup, and developmental stages.
• Availability and use of support systems and community resources.
• Plan of care and teaching plan.
• Responsiveness to interventions, teaching, and actions performed.
• Attainment of or progress toward desired outcomes.
• Modifications to the plan of care.