PEDIATRICS Vol. 117 No. 4 April 2006, pp. 1458-1459 (doi:10.1542/peds.2006-0041)
Failure to Thrive as Distinct From Child Neglect: In Reply
Robert W. Block, MD, FAAPChairperson
American Academy of Pediatrics,
Committee on Child Abuse and Neglect
In Reply.—In reference to the letter from Black et al, we agree that failure to thrive (FTT) as a manifestation of child neglect represents a small but highly significant percentage of cases, that conflation of poverty with neglect is inappropriate, that all etiologies and conditions associated with FTT should be considered during evaluations, that current literature on FTT is important, and that medical evaluations should be thorough and specific. Although the members of the Committee on Child Abuse and Neglect respect the work of the authors of the letter, we respectfully urge them and other readers to read the report with the same care that was used in its crafting. We share their concern that "a casual reading" of any medical literature can lead to inappropriate conclusions. We would remind all readers that a clinical report issued by the American Academy of Pediatrics (AAP) represents "guidance for the clinician in rendering pediatric care," rather than representing definitive policy. In this case, the statement provides guidance to enable physicians to consider neglect as a cause of FTT and to guide their thinking when this is the case. As the statement clearly states, it "serves as a guide for the assessment, management, and support of children with FTT as a manifestation of neglect."
We feel the report clearly states that neglect is but one cause of FTT. It definitively states that "the fundamental cause of FTT is nutritional deficiency," followed by a long, but not all-inclusive, list of problems other than neglect associated with FTT. As the authors point out, "children with both FTT and neglect have lower cognitive skills...." For the general pediatrician who is not an expert in either FTT or child abuse and neglect, remembering to include neglect in the differential may save lives and improve brain development in some children.
The report does not conflate poverty with child neglect. It states that "[p]overty is the greatest single risk factor for FTT," not neglect, which is supported by 2 citations in the letter by Black et al. Although we agree that the listed risk factors in our report are nonspecific, we argue that being nonspecific does not equate with irrelevant. Risk factors are not "criteria," as misperceived by Black et al.
It is unfortunate that Black et al continue to subscribe to the attitude that a report to a child protective services agency is only punitive, when it should be a valuable part of a multidisciplinary approach to supporting a family and/or protecting a child.
Our report does not contain references to more recent literature, which is a valid concern of Black et al, but it clearly refers readers to the very current Pediatric Nutrition Handbook from the AAP for an expanded discussion of FTT and references. The report was carefully coordinated with the Committee on Nutrition to ensure that any general statements were in line with the information in the handbook. The fifth concern in the letter refers to a "vague approach to the medical evaluation of children with FTT." We chose to focus on the important components of history, physical examination, feeding observation, home visit, and thinking clearly about laboratory studies but did not include detail to preserve focus on the point of the report, clearly stated in the title, with reference again to the Pediatric Nutrition Handbook for additional information.
Response to the authors' last concern is difficult, because it misquotes the report and is highly conjectural. Nowhere in the statement do we contend that "nutritional growth failure is often a consequence of neglect." To speculate that policy makers might ignore child nutrition programs because a small proportion of FTT cases are caused by severe neglect is a spurious argument. In sum, Committee on Child Abuse and Neglect members recommend a careful reading of all AAP statements, because many, like ours, focus on a specific issue and should not be inappropriately generalized.
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
CiteULike 
Connotea 
Del.icio.us 
Digg 
Facebook 
Reddit 
Technorati 
Twitter What's this?
Related articles in Pediatrics:
- Failure to Thrive as Distinct From Child Neglect
- Maureen M. Black, Howard Dubowitz, Patrick H. Casey, Diana Cutts, Robert F. Drewett, Dennis Drotar, Deborah A. Frank, Robert Karp, Daniel B. Kessler, Alan F. Meyers, and Charlotte M. Wright
Pediatrics 2006 117: 1456-1458.[Extract] [Full Text]
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
