Child Malnutrition/Failure to Thrive Project 2008
Literature Review
Project Officer – Susan Grant
Page 35 of 44
Acknowledgements
The author is grateful to the many people who have assisted in the production of this report, including:
· Mick Arundell, Clinical Analyst, DHF
· Annette Flaherty, Topic Coordinator, Remote Child Protection Practice, CFRH
· Melissa Lindeman, Director, PHCRED Program, CFRH
· Clare MacVicar, Community Paediatrician, Remote Health
· Rob Roseby, Head of Paediatric Department, ASH
· Andrew White, Community Paediatrician, Remote Health
Alice Springs Hospital
Ó Department of Health and Families, Northern Territory 2008.
This publication is copyright. The information in this report may be freely copied and distributed for
· non-profit purposes such as study, research, health service management and public information subject to the inclusion of an acknowledgment of the source. Reproduction for other purposes requires the written permission of the Chief Executive of the Department of Health and Families, Northern Territory.
Printed by the Government Printer of the Northern Territory, 2008.
An electronic version is available at: www.nt.gov.au/health/
General enquiries about this publication should be directed to:
CEO Alice Springs Hospital
Department of Health and Families
PO Box 2234, Alice Springs, NT, 0871
Phone: (08) 8951 7777
Table of Contents
Introduction 7
Method 7
Methodological complexity 7
Definitions of child malnutrition and failure to thrive 8
Terminology 8
Measuring growth 8
Malnutrition definition 9
FTT definition 10
Relationship between FTT and CM 11
Consequences of CM/FTT 11
The Australian context 13
Prevalence of CM/FTT in the NT 13
Features of CM/FTT in the NT 14
Skinny Kids 14
Causes of CM/FTT 15
History of Research into Causation of Failure to Thrive 15
Determinants of CM/FTT in the NT 16
Contributing Factors 17
Assessment 21
Medical assessment 21
Psychosocial assessment 21
Mothers views of poor growth 22
Multidisciplinary Approach 22
Treatment and Interventions 23
Primary Prevention 23
Care Practices 24
Secondary Interventions 25
Combined interventions 25
Community based interventions in the NT 25
Nutrition Interventions 26
Supplementary Feeding Programs 26
Growth Monitoring 26
Tertiary Interventions 27
Hospitalisation 27
The role of hospitalisation for CM/FTT 27
When should a child be hospitalised for CM/FTT 28
Rates of hospitalisation in the NT 29
When should a child be discharged from hospital? 30
The effectiveness of hospitalisation for CM/ FTT 30
Intervention Delay 31
Role of parents 31
CM/ FTT as a child protection issue 32
Tensions for practitioners 33
Implications of research into child development 34
Other treatment contexts for children with CM/FTT 35
Implications for Policy 36
Areas requiring further research 36
References 37
Acronyms 43
List of tables
Table 1 WHO Classification of malnutrition 10
Table 2 GAA data 13
Introduction
This literature review was undertaken as a component of the Child Malnutrition/ Failure to Thrive Project (CM/FTT) conducted by Alice Springs Hospital (ASH) in 2008.
The aim of this literature review is to guide improvement in the management of children with CM/FTT at Alice Springs Hospital. It will do this by exploring what has been written locally and elsewhere on the subject, assisting to clarify the role of Alice Springs Hospital (ASH), and informing the recommendations of the CM/FTT Final Report.
The main areas reviewed here are;
1. Definitional issues, given the inconsistencies in this area
2. Australian literature on CM/FTT in indigenous communities, particularly in the Northern Territory (NT)
3. Local and international literature on interventions for CM/FTT in hospital and community based settings
4. Although current thinking about consequences, causation and prevention of CM/FTT is beyond the scope of this project, these areas will be briefly addressed as they impact on approaches to intervention
This is a difficult field of work. The issues involved include some of the most complex and challenging in acute care paediatrics. As such, it is imperative that the published evidence-base informs recommendations for practice, hospital and departmental policy, and research.
Method
The literature on CM/FTT is vast and complex. The literature was identified via a search of databases for medical, social work and nursing journals, as well as bibliographies of relevant papers and consultation with practitioners.
A substantial amount of the literature on CM/FTT is from outside Australia, particularly the USA and UK and developing countries. In reviewing the literature, the relevance of research to the NT context and to the primary audience for this report was considered. Due to the huge volume of international literature on CM/FTT, summary and review articles were used where possible. In general, literature from the last 15 years was reviewed.
Methodological complexity
The research field is plagued by methodological complexities and diagnostic inconsistencies between studies. Ambiguities in the definition of FTT and its relationship to malnutrition make comparing samples and generalising findings a recurring problem in the literature.
Research limitations include poor quality data, inconclusive data, small sample sizes, non-standardised studies, cross sectional rather than longitudinal studies, the predominance of retrospective data from hospital based studies, and the practical and ethical issues involved in conducting research on children and family life [1-3].
Moreover, interestingly CM and FTT have tended to be described in separate literatures, with malnutrition research focusing on broad population based studies in developing countries, and FTT literature deriving from research on poor and middle class families in the developed world. It has been argued that neither of these contexts is readily transferable to the Australian indigenous context, making the applicability of much of the available research and evidence questionable [4, 5]. However, Cousoz warns against placing too much emphasis on the problems of generalisability and transferability of research findings to the indigenous context at the expense of a consideration of how findings might be applied [6]. Much of this uncertainty is reflected in this literature review.
Overall, there are serious gaps in evidence to inform interventions for CM/FTT in the particular context and conditions of Indigenous children in Central Australia [5, 7, 8]. This puts the onus on local practitioners and policy makers to extrapolate from the literature what might be useful to this particular context. It is hoped that this literature review might make a contribution to this end.
Definitions of child malnutrition and failure to thrive
Terminology
There is a considerable body of literature on definitional issues, particularly in relation to FTT. Some authors question the usefulness of the term FTT due to its lack of clarity and possible pejorative implications. However it continues to be used for its familiarity and historical connections [3, 9, 10].
Problems with growth are variously described in the literature as FTT, malnutrition, paediatric undernutrition, growth deficiency, growth failure, poor weight gain, growth faltering, poor growth, and growth delay. It is not unusual for a variety of terms to be used in the same study, often without clear definition. These terms have in common that they refer to children whose rate of growth has not kept pace with age and gender expectations. This literature review will use the terminology of the study being discussed, and so will reflect these variations. When discussing poor growth in general, the term growth faltering will be used as it is commonly used in the Australian literature.
For the purposes of this review, ‘growth faltering’ is defined as;
· a reduction in the expected rate of growth along an infant’s previously defined growth curve [11]
Measuring growth
Any attempt at reviewing definitions of CM/FTT requires some attention to methods of measuring growth. The use of growth indicators is founded on the concept that growth assessment best defines the health and nutritional status of children. However, there is little consistency in this area.
Interpretation of child growth is based on selections of anthropometric indicators and reference population with identified cut off points for classifying children according to variable degrees of undernutrition. There are no standardised criteria internationally but trends have been identified. The indicators most commonly used are weight-for-age, length/height-for-age, and weight-for-height.
There is consensus in the literature about the following definitions. [9, 12]:
· Underweight (weight-for-age z score ≤ -2)
· Wasting/thinness or acute weight loss or acute malnutrition (weight-for-height z score < -2)
· Severe wasting or severe malnutrition (weight-for-height z score < -3)
· Stunting or chronic malnutrition (length/height-for-age z score <-2)
Whilst weight-for-age is a universal and often sole anthropometric measure used, combining it with length/height-for-age and weight-for-height permits the distinction of stunted and wasted from underweight and allows a more appropriate targeting of interventions [12, 13].
Percentiles are commonly used in clinical settings given their straightforward interpretation. Whilst the z score system is recommended due to its population-based applications, there has been resistance to its use for individuals. It is harder to understand and health professionals need training in the concept of z scores and standard deviation if it is to be used routinely in clinical settings. The use of charts combining the two systems is discouraged as it further complicates the interpretation of growth charts [14].
There is also no universal usage of growth references and standards [14]. In the NT a number of different growth charts are used across health, community and hospital services. A discussion paper is recommending a change to the new WHO (2006) growth charts as the best growth assessment tool for indigenous populations [15]. Consistency between service providers will be a great step forward.
The paediatric literature stresses the importance when assessing growth to consider normal growth variants, such as catch up and catch down growth, and familial short stature, and to differentiate CM/FTT from early problems with breastfeeding [16, 17].
Malnutrition definition
The WHO defines malnutrition as;
· suboptimal nutritional health, incorporating undernutrition (poor growth), overnutrition (obesity) and specific micronutrient deficiencies (eg iron, iodine, zinc, vitamin A). Malnutrition generally refers to undernutrition rather than overnutrition in the literature.
Undernutrition is defined as;
· an inadequate intake of protein, energy, and micronutrients, with resulting frequent infections
Malnutrition is classified as mild, moderate or severe. Very severe forms of malnutrition are kwashiorkor (sufficient calorie intake, but inadequate protein intake) or marasmus (inadequate intake of protein and calories) [1, 18].
WHO 1999 Classification of malnutrition in children
Weight for height / Z score (SD)
between –2.0 and –3.0
OR
70-79% SWFH
(moderate wasting) / Z score (SD) < -3.0
OR
<70% SWFH
(severe wasting/marasmic) /
Height for age / Z score (SD)
between –2.0 and –3.0
OR
85-89% SHFA
(moderate stunting) / Z score (SD) < -3.0
OR
<85% SHFA
(severe stunting) /
Symmetrical oedema / No / Yes
(oedematous malnutrition
/kwashiorkor) /
Table 1 WHO Classification of malnutrition
FTT definition
The research on FTT appears to be as inconsistent as practice in regard to the variability in definitions and diagnostic criteria. This section attempts to find common threads from the literature.
Most authors agree that FTT is considered a descriptive term of a diagnostic problem rather than a diagnosis, however confusion arises as it is sometimes also equated with paediatric undernutrition [10, 13, 19]. A review of recent trends in the international medical literature found there was a consensus towards a purely nutritional/ growth based definition. There was agreement on using anthropometric criteria to define FTT, however there was no agreement on which growth parameters to use and whether to use attained values or velocities.
The overall trend in definitions of FTT was towards [9, 14];
· the lack of attainment or maintenance of the growth potential expected for a child
· when the child’s growth crosses 2 or more or centile lines on a standard growth chart or
· when growth falters to below the 5th or 3rd centile for age
In Australia, FTT definitions have followed the above trend. However, Brewster argues that the tendency to use FTT to refer to children below the 3rd centile for weight at a given age risks missing significant weight loss in a bigger child and mis-identifying genetically small children with infection related transient growth deceleration. He argues that FTT should be defined as[13];
· growth deceleration or crossing growth centiles, particularly falling through 2 centile spaces on the standard child growth chart
In a paediatric review of FTT Schwartz adds that an age component (younger children and infants) and psychosocial and developmental components are integral to a diagnosis of FTT [20]. It is argued that FTT usually occurs in children under 3 because they normally grow rapidly and depend on their parents for food [13, 21].
Relationship between FTT and CM
There are different opinions in the literature about the relationship between FTT and CM. Undernutrition underlies FTT, and this links FTT with definitions of malnutrition. Some authors argue that CM and FTT are essentially the same condition described in different literatures [10]. Brewster claims that FTT tends to be used when describing children in developed countries like Australia or in middle class families, whereas in developing countries or underprivileged (for example indigenous) families malnutrition is more likely to be used [17]. Other authors see FTT as a syndrome of growth faltering which may or may not result in malnutrition [22, 23]. There is general agreement that all children with FTT have some degree of inadequate nutrition to sustain a normal rate of growth, whatever the cause.
The weight deficits used in diagnosing FTT are equivalent to those used to diagnose malnutrition [24]. The severity of CM/ FTT informs its management. Anthropometric indicators alone are generally used to diagnose malnutrition in populations, whereas an analysis of the growth pattern over time is mainly used to diagnose FTT in individuals [9].
It is interesting that growth assessment tends to continue to dominate definitions and diagnosis of CM/ FTT despite the variability in measures and the capacity for error. Much of the CM/ FTT literature is medical in orientation, and Wright and Talbot argue that weight loss or gain offers an objective and pragmatic measure of change in a complex and confusing area [25]. However the term failure to thrive also implies other aspects of a child’s wellbeing and recent research on child development is increasingly highlighting the importance of thriving across the physical, socio-emotional and cognitive domains [26]. McCain and Mustard’s influential work on the Early Years stresses that children need not only nutrition, but also stimulation, care, security, attachment and love to thrive [27].