Skuse, David Henry; (1996) Failure to thrive in the first postnatal year: an inner city community survey. Doctoral thesis (M.D), UCL (University College London).

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Abstract

For many years it has been suspected that faltering somatic growth during early postnatal life can be associated with the subsequent impairment of mental and psychomotor abilities. Previous research has failed to find a clear connection, largely because of the difficulty of controlling for potentially confounding variables. This study aimed to address former methodological deficiencies by means of a novel strategy. Firstly, cases of failure to thrive were identified from a prospectively recruited whole population birth cohort (n=2610) in an inner city area of the United Kingdom, in order to increase the representativeness of the findings. Previous studies in the developed world have almost always selected cases from hospital referrals for failure to thrive. Case criteria were strictly anthropometric, and cases were identified by the independent monitoring of the growth of all Child Health Clinic attenders. Accordingly, reporting bias was avoided. Secondly, our aim was to examine growth faltering in children who were in good health in other respects. Children in the developing world who participate in studies on the outcome of growth failure for cognitive and behavioural development frequently suffer from intercurrent infections, which may independently impair their mental and psychomotor performance. Thirdly, the project aimed to measure a very wide range of other potentially confounding variables and to match cases more closely to a normally growing comparison sample than had previously been attempted. This was possible because of the social homogeneity of the area surveyed, and because of the potentially large number of comparison infants in the birth cohort. Forty-seven otherwise healthy infants with persistent failure to thrive (FTT) were selected on the basis of anthropometric criteria. Cases were identified from the independent plotting of routine clinic weighings, details of which were supplied on a regular basis to a member of the research team. Case status was confirmed by personal examination. A closely (pairwise) matched comparison group was selected from the survey population. All subjects were seen at approximately 15 months of age. Both groups received a comprehensive home-based assessment by the research team. Measures included interviews with the index child's mother, a medical and anthropometric examination of the infant and assessment by a speech therapist with a focus on oral-motor skills. Videorecordings were made of the infant during a standard mealtime and during a structured play session with the mother. A variety of measures were taken of the quality of the home environment for promoting infant development. Preliminary findings indicated that although they were more psychosocially advantaged the outcome for infants whose growth failure had commenced within six postnatal months was worse than those for whom the faltering commenced later, despite the fact that the children from the worse outcome group came from less psychosocially disadvantaged families. A statistical model was constructed that enabled the timing, the duration and the severity of growth faltering to be used as predictors of mental and psychomotor functioning. Up to 37[percent] of the variance in cognitive and psychomotor outcome at 15 months could be explained by the model on the basis of just three explanatory variables. These were the quality of maternal stimulation in her interaction with the infant, a measure of total minor congenital abnormalities and the growth trajectory of the infant since birth. Of these the degree of growth faltering was the most important, alone accounting for 25[percent] of the variance in outcome. Their impact on mental and psychomotor development was independent of one another. In 1990 a search was made of child protection records pertaining to the area in which the original research had taken place. Our aim was to identify the names of all members of the original birth cohort which had subsequently been placed on a Child Protection Register, or who had been subject to an investigation of suspected abuse or neglect without registration, in the intervening 4 years. Of the 2610 1986 births, 2.5[percent] names had been placed on a Child Protection Register by 1990. A further 1.2[percent] names had been recorded as a 'cause for concern', but they were not formally registered. Four of the failing to thrive cases' names (8.5[percent]) had been registered and a further 4.2[percent] case names were recorded as constituting 'a cause for concern', for reasons other than the growth problem. Two main conclusions may be drawn from our investigation. Firstly, the early postnatal months appear to constitute a 'sensitive period' for the relationship between growth and mental development in full-term infants. Growth faltering at this time is associated with a deficit in mental and psychomotor abilities in the second year. There is a moderate correlation between the degree of growth failure and the detriment to those abilities, which is independent of the quality of the home environment. Secondly, infants who fail to thrive without organic disease or disorder are at an increased risk of otherwise being abused or neglected during the preschool years, within a socioeconomically disadvantaged population. However, the degree of risk is lower than was previously reported. The results from this investigation may not be generalisable to other populations, either within the United Kingdom or elsewhere in the world. Others may however have longitudinal data sets upon which the hypotheses outlined here may be tested. Should our findings be confirmed in other disadvantaged populations, the implication for policy and practice are wide ranging. The potential magnitude of detriment to mental and psychomotor development, caused by preventable growth failure in chronically undernourished at-risk populations, is considerable.

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