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Patrick H. Casey, MD
Department of Pediatrics
University of Arkansas for Medical Sciences
Little Rock, AR 72205
Diana Cutts, MD
Department of Pediatrics
Hennepin County Medical Center
Minneapolis, MN 55415
Robert F. Drewett, DPhil
Department of Psychology
University of Durham
Durham DH1 3HP, United Kingdom
Dennis Drotar, PhD
Department of Pediatrics
Case Western Reserve University School of Medicine
Cleveland, OH 44106
Deborah A. Frank, MD
Department of Pediatrics
Boston Medical Center
Boston, MA 02118
Robert Karp, MD
Department of Pediatrics
State University of New York Downstate Medical Center
Brooklyn, NY 11203
Daniel B. Kessler, MD
Department of Pediatrics
University of Arizona College of Medicine
Tucson, AZ 85724
Children’s Health Center
St Joseph’s Hospital,
Phoenix, AZ 85013
Alan F. Meyers, MD, MPH
Department of Pediatrics
Boston University School of Medicine
Boston, MA 02118
Charlotte M. Wright, MD
Department of Child Health
Glasgow University
Glasgow G12 8QQ, Scotland
To the Editor.—
As pediatricians and psychologists who have conducted research involving children with failure to thrive (FTT) and/or treated literally thousands of children with FTT, we wish to share our concerns regarding the report "Failure to Thrive as a Manifestation of Child Neglect"1 from the American Academy of Pediatrics (AAP) Committee on Child Abuse and Neglect and Committee on Nutrition.
Six aspects of the report are particularly troubling. First, the report does not make it sufficiently clear that FTT as a manifestation of child neglect represents a minority of children with FTT. We agree that, in some cases, FTT may be a marker of neglect and that the diagnosis of abuse and/or neglect should be considered if there is any history of "intentional withholding of food from the child; strong beliefs in health and/or nutrition regimens that jeopardize a child's well-being; and/or family that is resistant to recommended interventions despite multidisciplinary team approach." Indeed, children with both FTT and neglect have lower cognitive skills initially and years after treatment2,3 than children with either FTT or neglect alone.
A second concern is the conflation of poverty with child neglect. In any social class, family violence or alcohol/substance abuse should raise protective concerns as possible impediments to adequate care of any child, FTT or not. Many of the other risk factors for neglect as a cause of FTT listed in the report are highly nonspecific and could be applied to many conditions associated with childhood poverty (eg, iron deficiency, overweight, and developmental delay). FTT in combination with neglect is a relatively rare occurrence, as illustrated by a February 2004 report from the Massachusetts Department of Public Health covering 6 years of statewide experience with 
1700 children referred to 6 multidisciplinary clinics for FTT.4 Almost 60% were from families below 200% of the federal poverty level, and 31% lived with single mothers. Most of these children would fulfill at least 1 of the criteria for neglect, as presented in the AAP report, yet the multidisciplinary clinicians providing care to the children judged abuse/neglect to be a relatively rare concern and referred only 7% of them to protective services.
Our third concern is that a casual reading of this nuanced report might lead some readers to the conclusion that the family of a child identified with FTT should be considered abusive and/or neglectful until proven otherwise. Too often neglect is assumed to be responsible when organic causes are not found; neglect should not be a diagnosis by exclusion. Thus, the report might inadvertently serve to promote a punitive rather than a therapeutic approach to families, in effect "blaming the victim"5 for failing to meet the needs of the child.
A fourth concern is that the report reflects the early literature on FTT, which was based on hospitalized samples of children with almost no citation of important articles published in the last 10 years. Evidence supports the benefits of treating most children with FTT through sustained participation in multidisciplinary outpatient clinics and home visiting programs.6–9 Even when hospitalization is unavoidable in the short-term for the most seriously malnourished, acutely infected, or otherwise acutely ill children, successful follow-up care requires a multidisciplinary team to work with the family in their home, wherever possible, which is an approach endorsed by the Committee on Nutrition in the Pediatric Nutrition Handbook.10 Follow-up studies based on children recruited from primary care or population-based surveys have shown that the long-term cognitive and academic consequences of early FTT are much less severe than reported previously from samples of hospitalized children.11
The fifth concern is the vague approach to the medical evaluation of children with FTT. In the Massachusetts sample, for example, nearly 30% of children with FTT were anemic. Although we agree with the recommendation to avoid unfocussed laboratory testing, it is often beneficial to test children for iron deficiency and other common but occult conditions impeding growth, such as lead poisoning.
Our final concern is that an unintended consequence of this statement may be to increase the number of children at risk of nutritional deprivation. Food insecurity is highly prevalent in the United States and has been increasing throughout the decade, affecting 42% of low-income households with children <6 years of age in 2004.12 In the current climate, safety-net programs for the poor are often in jeopardy in response to budgetary pressures.13 Despite evidence of nutritional benefits for low-income young children whose families participate in the Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Food Stamp programs,14,15 a statement attributed to the AAP that nutritional growth failure is often a consequence of neglect could fuel arguments that child nutrition programs are unnecessary.16
The AAP policy statements and clinical guidelines are rightfully accorded great significance, not only among clinicians but also among policy makers and the general public. We recommend that the statement be clarified to emphasize that the AAP recommends adequate nutritional resources for all low-income families with children, long-term multidisciplinary services for children with FTT, and referral to protective services for any children suspected of experiencing abuse/neglect, whatever their growth.
REFERENCES
Related articles in Pediatrics:
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