Prediction of weight for height following intervention in three-year-old children with early histories of nonorganic failure to thrive

01452134/89 $3.00 + .OO Copyright 0 1989 Pergamon Press plc

CbiidAhuse& h’egkcf, Vol. 13, pp. 19-28, 1989 Pnnted in the U.S.A. All rights rewved.

PREDI~ION OF WEIGHT FOR HEIGHT FOLLOWING INTERVENTION IN THREE-YEAR-OLD CHILDREN WITH EARLY HISTORIES OF NONORGANIC FAILURE TO THRIVE LYNNE

STURM,

Departments

PH.D.

AND DENNIS

DROTAR,

PH.D.

of Psychiatry and Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH

Abstract-The present study assessed the weight for height outcomes of 59 3-year-old children who had been hospitalized for nonorganic failure to thrive (NOFT) as infants (average age of 5 months) and received time-limited outreach intervention. Although the majority of children attained normal weight for height, nearly one-third demonstrated at least mild wasting. Type of outreach intervention did not affect weight for height at outcome. The predictive efficacy of a variable set which included characteristics of NOFT (age of onset and duration), velocity of weight gain subsequent to diagnosis and environmental characteristics (income and home stimulation) was tested. Shorter duration of NOFT prior to diagnosis and greater initial rate of weight gain following hospitalization predicted weight for height at 36 months. The findings underscore the need for close monitoring of physical growth and nutritional status of NOFI children following hospitalization as well as comprehensive assessment and treatment for children who continue to demonstrate nutritional deficits, Additional studies of factors which affect the prognosis of NOFI children are needed.

INTRODUCTION NONORGANIC FAILURE TO THRIVE (NOFT) is a frequent pediatric condition which places children at risk for chronic physical growth and psychological deficits [ 1, 21. Positive changes in physical growth and nutritional status associated with initial pediatric hospitalization or outpatient management of NOFT are not necessarily maintained over time. Followup studies of NOFT’ children’s recovery from nutritional and growth deficits evident at diagnosis have documented variable outcomes [3-S]. Some investigators have reported significant improvement in physical growth (weight and length) one year or more following initial hospitalization [3-61. Other studies have described less adequate long-term physical growth outcomes [7, 81. For example, Haynes and coileagues noted that outreach intervention did not prevent significant growth retardation for a majority of NOFT children (78%) who were assessed 6 months after initial diagnosis [S]. Only one-fifth of this sample demonstrated catchup growth. Several investigators have also described deficient physical growth in children with early histories of NOFT compared to norms or comparison groups. Mitchell and colleagues’ Research supported by Grant #MCJ-390557, Division of Maternal and Child Health Research, Bureau of Health Care Delivery and Assistance, National Institute of Mental Health Prevention Research Center #30274 and a National Clinical Infant Center Fellowship to the senior author. Received for publication May 16, 1988; final revision received July 18, 1988; accepted July 3 1, 1988. Reprint requests may be sent to Dennis Drotar, Ph.D., Department of Psychology, Cleveland Metropolitan General Hospital, 3395 Scranton Road, Cleveland, OH 44 109. 19

20

Lyme Stum and Dennis

Drotar

one-year follow-up of a subsample ( 19 of 30) of 2-5 year olds indicated that NOFT children had less adequate weight outcomes than a comparison group of physically healthy children [9]. In a recent follow-up of 4-year-old NOFI children initially diagnosed at 4-18 months of age, Kristiansson and Fallstrom found that 38% had subnormal weight (less than two standard deviations below the mean) [ 1Of. In addition, NOFT children did not fare as well in physical growth as children with organic failure to thrive. It is not known why some children with early histories of NOFT achieve and maintain adequate physical growth at follow-up while others develop chronic growth and nutritional deficits. Studies of predictive factors might provide useful insights concerning prognosis. Some investigators have su&gested that such factors as early diagnosis and intervention, degree of psychosocial risk [ 10J, or duration of failure to thrive [ 1 I- 121may influence physical growth outcomes. However, predictive follow-up studies of physical growth or nutritional status among NOFT children are relatively infrequent. In one of the few predictive studies, Casey, Wortham and Nelson assessed 93 children one year after they were diagnosed with NOFT in a rural ambulatory cfinic I.i 31. Although half of these chifdren demonstrated improved physical growth, the remainder either did not achieve catch-up growth or worsened. Children with the best compensatory growth had a lower birth order, were black, and from lower socioeconomic status families in which parents were less likely to be married. However the significance of these findings was limited by the short follow-up period of onIy one year. The conclusions that can be drawn from most studies of the physical growth outcomes of NOFT children are limited by smalf sampIe sizes, lack of information concerning the course of physical growth or intervention effects, and the failure to study a comprehensive set of predictor variables. Without sequential assessments of progress, it is impossible to determine the point at which improvement in physical growth occurred or the degree to which children maintained recovery over time, Moreover, intervention effects have not been well described, Despite the fact that most NOFT children generally receive some form of nutritional and/or psychosocial intervention in current patterns of pediatric care, follow-up studies ofphysical growth have generally not described interventions given to NOFT children or evaIuated their effects. While prior studies have focused primarily on weight as an outcome measure, NOFT children’s nut~tional status is a clinically relevant outcome which should also be documented in follow-up studies. The percentage of weight for height provides an objective assessment of nutritional deficiency (wasting) [ 14, 151, which can be used to identify NOFT children who need additional nutritional intervention subsequent to diagnosis and initial treatment. The purpose of the present study was to describe and predict the nutritional status (weight for height) of 3-year-old children who were hospitalized for NOFT during their first year of life and received time-limited outreach intervention, To address the need for prognostic studies, this investigation assessed the predictive efhcacy of a comprebensivc variable set which included NOFT characteristics (age of onset and duration), growth velocity following point of diagnosis, and environmental characteristics (family income and stimulation). This set of predictor variables was chosen to assess biologic and environmental risk factors expected to influence nutritional outcomes on the basis of clinical observation and prior research [ 10, 16, 171. METHOD

In accord with standard practices for pediatric diagnosis of NOR [ 11, children were included in the sample if they demonstrated four criteria: (1) weight at or below the 5th percen-

Nonorganic failure to thrive

21

tile based on National Center for Health Statistics (NCHS) norms [ 181; (2) absence of significant organic conditions that could directly affect capacity to gain weight and/or cognitive development as indicated by physical and laboratory examination, including complete blood count and urinalysis: (3) demonstration of weight gain in hospital [IQ and (4) decrease in rate of weight gain from within normal limits at birth to below the 5th percentile based on NCHS norms [ 181. Children who demonstrated slow but constant patterns of growth consistent with constitutional growth deficits were not included. Children with below normal growth potential were also excluded by requiring growth parameters (height, weight, and head circumference) to be appropriate for gestational age at birth and a birth weight of at least 1,500 grams. Three criteria were used to increase sample homogeneity and simplify data collection: ( 1) age of admission between 1 and 9 months ofage; (2) absence of child abuse (three children were excluded for this reason); and (3) geographic proximity (within an hour’s distance of Cleveland). To increase sample representativeness, subjects were recruited from children hospitalized for NOFT at one of seven Cleveland hospitals. Eight families with children who fit study criteria did not choose to participate. This group did not differ in income, family size, maternal age, and education or physical growth status from the study group as assessed by analyses of variance. Of the initial sample of 80 children from 77 families who chose to participate, 16 were Iost to follow-up because they moved out of the area, could no longer be located, or refused further pa~icipation. Another 5 children were still enrolled in the study but could not be located in time for the 36-month assessment_ The attrition sample did not differ sign& cantly from the study group in family demographic characteristics (income, family size, maternal education) or child characteristics including age, physical growth status, and cognitive development assessed at study intake as tested by analyses of variance. Sample CharacteriJ*tics A total of 59 children with completed 36month outcome data comprised the study sample. The mean age of the sample at study intake was 5.1 months (Sf, = 2.9). The sample included 39 males and 20 females, and had varied races represented, including 24 white, 32 black and 3 Hispanic children. Children were from economically disadvantaged families. The majority (48 or 8 1%) of families received Aid to Dependent Children (ADC). Mothers of NOFT children were relatively young (M = 2 1.9 years, SD = 4.2) and had on the average more than one child (M = 2.5; SD = 1.4). Mean maternal educational level was 11th grade (SD = 1.7).

During pediatric hospitalization in which the diagnosis of NOFT was established, families were randomly assigned to one of three time-limited intervention plans, each of which was conducted in home visits, for an average duration of 12 months but differed in frequency of contact and/or focus. Ethical considerations guided the decision to test the efficacy of alternative models of intervention while providing some form of help to each family. Family-centered intervention (n = 19) involved members of the family group (mother, grandmother, or father) in weekly (on the average) sessions directed toward enhancement of family coping skills and support of the mother in order to enhance the chifd’s nurturing [20]. Parent-centered intervention (n = 20) involved weekly visits with a supportive educational focus on enhancing the quality of the mother’s nutritional management and reIationship with her child. In the third intervention plan, advocacy (n = 20), the child’s mother was seen for an average of 6 home visits which focused on providing emotional support and helping the mother secure resources from community agencies. Most of the home visits in the advocacy

Lyme Sturm and Dennis Drotar

22

group were conducted within two months after the child’s hospital discharge. Thereafter, contact was maintained by phone Family-centered intervention was expected to result in greater long-term progress because this approach involved more family members and presumably had greater potential generalizabihty than the alternative intervention approaches. Assessmennt

Plan

Physical growth and psychoiogical outcomes were assessed at study intake and at &month intervals at 12 months to 3 years of age. Predictive analyses of cognitive developmental outcomes have been reported elsewhere [ 16, 171. This analysis focused on prediction of weight for height outcome.

Age of‘ctnse#.Age of onset was defined as the estimated age at which the child’s deceleration in rate of weight gain first reached or crossed the fifth percentiIe on NCHS norms f 173, based on information from birth and pediatric growth charts. Duration. Duration or chronicity of NOFT was defined as the time that elapsed between the age at which the rate of child% weight gain first reached or crossed the fifth percentile based on information from pediatric growth charts and the child’s age at study intake. Growth retociry ~~b~eq~~~~t to ~l~s~~t~~ adrn~~~~~~. Velocity of physical growth (weight) from study intake to the first follow-up assessment at 12 months of age was assessed by a procedure recommended by Heimindinger and Laird (2 1J to determine changes in physical growth which resulted from interventian. Value added scores were used to estimate expected growth in percentiles. Children’s weight was converted to a standardized 2 score and then subtracted from the standardized expected score based on NCHS norms [ 181. The resulting score represented change in physical growth that was not attributable to statistical artifacts such as regression to the mean, age, or gender. Income. Family income at hospital admission was determined from standard payments from Aid to Dependent Children (ADC) or SSI payments. Reported family income was assessed for those families who did not receive ADC. Home Environment. The quality of home stimulation was assessed by the Home Inventory for Measurement of the Environment (HOME} Scale, a widely used measure with adequate internal consistency and interrater reliability 1221. Prior studies using the HOME Scale have indicated that the home environments of NOFT children were fess optimal than those of comparison groups f23]. The HOME ScaIe yields scores on several subscales including Maternal Responsivity, Involvement with Child, Provision of Play Materials, Opportunities for Variety in Stimulation, and Organization of Environment as well as a total score. The total score was used in this analysis. Assessment of the home environment was conducted at 6month intervals starting at 12 months of age. In accord with Yeates and colleagues [24], a composite measure based on the sum of the Z score transformations of rated total scores at 12, t 8, 24, and 30 months was used to assess cumulative environmental stimulation prior to the 36-month outcome assessment [24]. Assessmcv~tyf‘phy.siculgrowth and nutritional status. Infants were weighted on equivalent scales (Health-O-Meter Pediatric Scale, Continental Model No. 322). All measurements were

23

Nonorganic failure to thrive Table 1. Description of Weight fur Height from Study Intake to 36 Months

N

M

SD

Number with No Wasting

40

Number with Mild Wasting

%

Number with Moderate or Severe Wasting

t:

AdIk!.iOXl months

I2

94.5 80.58 f

9.5I 8.96

45 9

66 f3

24 I9

28 35

35 4

65 :: 59

18 months 24 30 months 36 months

95.35 96.21 95.10 93.58

8.72 10.17 10.92 8.72

50

77

40 37 40

63 73 68

13 20 12 15

20 22 34 25

2 23 4

% 52 6 :3 5:5 7

taken at study intake and at 6-month intervals canning at 12 months of age. Eased on Waterlow [ 14, IS], weight for height was defined as the percentage ofthe chiid’s weight typical for a given height as specified by growth charts. Four classifications of degree of wasting were derived: 0 = 90% or greater weight for height ratio; mild wasting = 80-890/o;moderate wasting = 70-79%; severe wasting = less than 70%.

RESULTS Description ofPredictor Variables Mean family (A4 = 59) income was 6,102 (SD = 6,700). The mean onset of NOFT was 3.3 months (SD = 2.5), and the mean duration was 1.7 months (&XI= 1.8). The mean total scores on the Caldwell Scale ranged from 3 1,39 at 12 months to 3 1.36 at 30 months (SD = 5.47 and 5.9 1, respectively). These scores were generally consistent with those obtained from other low SES famifies [23]. The mean of the total 2 score was -003 (SD = 3.17, range = - 6.86 to -i- 6.52). Description of Weight for Height Outcome The means and standard deviations of weight for height and frequencies of children who demonstrated normal weight for height (greater than 90%) versus mild to severe wasting (less than 89%) from the time of study intake to 36 months are shown in Table 1. The sample demonstrated s~gn~~~a~t deficits in weight for height at study intake as indicated by a mean of 80.58 (down from 96.4 at birth). The majority (88%~ of children demonstrated at least mild wasting at hospita1 admission as indicated by a weight for height of less than 90. Four (6%) children had severe wasting; 3 1 (45%), moderate wasting; and 25 (37%), mild wasting. Although weight for height generally improved from study intake to 36 months, a significant number of children (19 or 32%) had at least mild wasting at age 36 months. Of this group, 15 children were mildly wasted, 2 moderately, and 2 severely wasted. The majority of children who showed significant wasting at 36 months f 15f 19) had demonstrated these deficits for 6 months or more. At 36 months, weight percentiles of 9 children f 15%) were below the 5th percentile while 3 children (5%) had length percentiles below the 5th. All children whose weight was below the 5th percentile at 36 months also had at least mild wasting. Student Newman-Keuls multiple range tests indicated that weight for height improved from point of hospital admission, M = 8 1.95, SD = 8.99, to 12 months, M = 93.79, SD = 28.72, F(2,58) = 24.82, p c .Ol; but did not change from 12 to 36 months, M = 93.43, SD = 8.14.

Lynne Sturm and Dennis Drotar

24 Table 2. Hierarchical

Regression

Analyses:

Prediction of Weight for Height at 36 Months

Multiple R

Cumulative R’

R2 Increment

1. Income

.I2

.Ol

.Oi

2. Characteristics of NOFI (onset, duration) 3. Velocity from admission to 12 months 4. Home Scale

.42

.I8

.I7

.58

.34

.16

.hl

.31

.03

Set with Component Variables

FValue with increment with degrees due to set of freedom .76 (1.55) 5.46 (2,52) 12.24 (I, 51) 1.85 (1%37)

Significance level ns .Oi .Ol ns

Twelve children had been referred to the Department of Human Services for neglect at time to diagnosis. This group did not differ from the rest of the sample in weight for height at time of diagnosis (M = 78.6 versus 8 1.OO,t = 84 n.s.) or at 36 months (M = 95.03 versus 94.57, t (57) = .2 1, n.s.). However, a subgroup of children (n = 8) who were eventually placed in foster care had lower weight for height at time of diagnosis (hl = 75.54) than the rest of the sample, M = 8 1.25, t (57) = - 2.72,~ < .05. However, by 36 months there were no differences between the foster care group (M = 92.9) and the rest ofthe sample (,W = 93.65, t (57) = - .19, n.s.). Treatment Effects The means and standard deviations of weight for height at 36 months of the 3 treatment groups were as follows: Family-Centered, A4 = 93.90, SD = 9.94; Parent-Centered, M = 93.67, SD = 8.24; and Advocacy, M = 93.10, SD = 7.98. A multivariate analysis of variance indicated no effect of Type of Treatment, F (2, 56) = 02, n.s.; or for the Treatment by Time interaction, F(2,56) = .27, n.s. Prediction of Weight for Height at 36 Months Table 2 summarizes the results of the hierarchical multiple regression analysis including the R* values resulting from the addition of each set, the increment in percent variance in weight for height accounted for by each variable, and the significance of the increment [26]. The order of entry of the predictor variables was as follows: income, onset and duration of NOFT, velocity of weight gain from diagnosis to 12 months, and HOME scores. The findings indicated that characteristics of NOFT, especially duration and velocity of weight gain from study intake to 12 months, accounted for more of the variance in weight for height at 36 months than the environmental characteristics. Neither income nor the HOME Scale summary score accounted for significant variance. Characteristics of NOFT age of onset and duration (chronicity) resulted in a significant increment in variance, F (2, 53) = 5.45, p < .05. Additional analyses indicated that neither onset and duration alone, when included with income in a regression equation, predicted weight for height as follows: for income and onset, R* = .07, F = 1.87, 2; 54 ns; for income and duration, R* = . 10, F = 3.1 I, 2, 54, p = n.s. However, when both variables were entered in a simultaneous equation, the proportion of variance explained was significant, R2 = .18, F (3, 53) = 3.82, p -c .02. Comparison of the standardized beta values indicated a significant role for duration (/3 = - .49, , p < .OOOS)but not for onset (P = - .25, y < .07). This analysis

Nonorganic failure to thrive

25

indicated that when age of onset was controlled, longer duration of NOm was associated with less optimal weight for height at 36 months. Growth velocity following study intake also accounted for a significant increment in variance, F (1,52) = 12.27, p = .O108, from 18% to 34%. Children who demonstrated greater velocity of weight gain from study intake to 12 months of age attained more optimal weight for height at 36 months, An additional regression analysis indicated similar results, R* = .35, F (5, 52) = 5.41, p = < .0008, when weight for height at study intake was included in the equation, suggesting that the predictive power of growth velocity did not depend upon initial weight for height status. Based on recommendations for transformation of proportions [25], the regression analyses were repeated using an arcsine transformation of the weight for height measure. The proportion of variance accounted for by each set of variables was unchanged in this analysis.

DISCUSSION Hospitalization and time-limited outreach intervention were associated with significant improvement in weight for height from time of diagnosis to 12 months and maintenance of progress through 36 months in this sample of NOR infants. The significant improvement in the level of nutritional deficits apparent at time of diagnosis is consistent with several prior reports of physical growth outcomes in NOFT children [ 3-61. On the other hand, salient individual differences were also evident in nutritional status at age 3 years. While the majority of children attained normal weight for height, one-third of the sample demonstrated significant deficits. Contrary to prediction, type of outreach intervention did not affect weight for height outcome at 36 months of age. Several issues may explain the failure to demonstrate specific intervention effects. All children were hospitalized and received psychosocial intervention which included continuity ofcare and supportive outreach. It is quite possible that the nonspecific effects of hospitalization and outreach intervention may have overridden the unique effects of individual treatment plans and improved the nutritional status of the sample as a whole. Moreover, intra-sample variation in environmental and NOFT risk factors may have obscured treatment effects. In support of this notion, regression analyses indicated clear differences in the efficacy of individual predictor variables. Duration of NOFT and velocity of weight gain following diagnosis were more powerful predictors of weight for height at 36 months than environmental characteristics (income and HOME Scale). Children with less chronic NOFT (shorter duration) prior to diagnosis and who also demonstrated better growth velocity following study intake had more adequate weight for height outcomes at 36 months. These findings suggest that the combination of less chronic NOFT prior to diagnosis and a greater initial growth velocity following diagnosis (hospitalization) may protect the NOFlchild from eventually developing clinically significant nutritional deficits as measured by weight for height. On the other hand, children who present with chronic NOFT and who also show less recovery in rate of weight gain during and immediately following hospitalization may be at special risk for developing nutritional deficits on longer term follow-up. Several limitations of this study should be considered in interpreting our findings. Based on a sample of hospitalized NOFT infants who were selected by research criteria, identified during their first year of life, and who received psychosocial intervention, the present findings may not be generalizable to other NOR populations. One might expect less optimal physical growth outcomes and perhaps different predictions of outcome in older NOFI’ children, those with chronic NOFT, or NOR children who have also been abused. While our predictions of weight for height were statistically significant, they accounted for less than 50% of the variance

26

Lynne Sturm and Dennis Drotar

in this measure. The restricted range of socioeconomic status of the sample may have limited the power of predictions based on environmental factors. Alternative measures of the quality of the family environment might yield more powerful predictions. For example, assessment of parent-child interactions concerning feeding might identify factors which influence caloric intake, weight gain, or nut~tional outcomes more directly. In addition, measures of family stress and dysfunction or parental psychological adjustment or parental perceptions of the child might yield more effective predictions of nutritional status than the HOME Scale or family income. The present findings have several implications for clinical intervention with NOFT children and their families. Our findings are consistent with a growing number of studies which indicate substantial individual differences in NOFT children’s psychological and health status at time of diagnosis and prognosis ( 19,20,26-283. The finding that some NOFT children developed significant nut~tional deficits as preschoolers underscores the need for close monito~ng of their physica growth and nutritional status following hospitalization. Individual difference characteristics should be considered in clinical assessment and monitoring the progress of NOFT children. Children who do not demonstrate adequate recoveries in weight gain during and immediately following hospitalization may be at special risk. These children benefit from more comprehensive differential diagnosis, including detached observations of feeding and play, additional nutritional intervention as well as more focused interventions such as parent training 1291or parent-child psychotherapy 1301. Our findings also suggest several directions for future research. Studies of the influence of individual difference characteristics on the physical growth, nutritional, and psychosocial outcomes of NOFT children have special significance in light of the heterogeneity of this population. The outcomes of subtypes of NOFT children who differ in factors, such as chronicity or severity of NOFT, behavioral and feeding problems, family or maternal characteristics, should be assessed [27, 28, 3 11. Detailed studies of parent-child interaction and NOFT children’s feeding behavior might provide valuable insights concerning the specific interactional processes that are associated with adequate progress versus continuing risk for nutritional deficits as well as relevant psychological outcomes (e.g., self-esteem, social competence) in this population.

REFERENCES 1. BITHONEY, W. G. and RATHBUN, J. M. Failure to thrive. In: Developmental and Behavioral Pediatrics, M. Levine, W. G. Carey, A. C. Cracker and R. J. Gross (Eds.), pp. 557-582. W. B. Saunders, New York (1983). 2. DROTAR, D., MALONE, C. A. and NEGRAY, J. Psychosocial intervention with the familiesoffailure to thrive infants. ChjldAb~e & Neglect 31927-935 (1979). 3. HUTTON, I. and OATES, K. Nonorganic failure to thrive: A long-term follow-up. Pediatrics 59:73-77 ( 1977). 4. SHAHEEN, E., ALEXANDER, E., TRUSKOWSKY, M. and BARBERO, G. J. Failure to thrive: A retrospective profile. Clinical Pediatrics 71255-26 1(1968). 5. WHITE, J., MALCOLM, R., ROPER, K., WESTPHAL, M. and SMITH, C. Psychological and developmental factors in failure to thrive: One- to three-year follow-up. Developmental and Behavioral Pediatrics 2: 112- 114 (1981). 6. ELMER, E., GREGG, G. and ELLISON, P. Late results of the failure to thrive syndrome. Clinical Pediatrics 8: 584-589 (1969). 7. GLASER II, W., HEAGARTY,

M. C., BULLARD, D. M. and PIVCHIK, E. C. Physical and psychological development of children with early failure to thrive. Journal ofPediatrics X%690-695 ( 1967). 8. HAYNES. C.. CUTLER, C., GRAY, J. and KEMPE, R. Hospitalized cases of nonorganic failure to thrive: The scope of the problem and short-term lay health visitor intervention. Child Abuse & NLgiect 8:229-242 (1984). 9. MITCHELL. W. G.. GORELL. R. W. and GREENBERG. R. A. Failure to thrive: A study_ in a _ nrimarv_ care setting, epidemiology and follow-up. Pediatrics 65:97 I-977 (1980). 10. KRISTIANSSON. B. and FALLSTROM, S. P. Growth at the age of 4 years subsequent to early failure to thrive. ChildAbuse&

Neglect 11:35-46 (1987).

Nonorganic failure to thrive

27

11. EID, E. E. Follow-up study of physical growth following failure to thrive with special reference to a critical period in the first year of life. Acta Puediutricu Scundinuvicu 60:39-48 (197 1). 12. CHASE, H. P. and MARTIN. H. P. Undernutrition and child development. New England Journal of Medicine 282:933-939 (1970). 13. CASEY, P. H., WORTHAM, R. N. and NELSON, J. Y. Management of children with failure to thrive in a rural ambulatory setting: EpidemioIogy and growth outcomes. Chnicul Pedi~rics 23:325-330 ( 1984). 14. WATERLOW, J. C. Classification and definition of protein-calorie malnu~tio~. 3r~tish ~edicul Journai~564569 (1972). 15. WATERLOW, J. C. and RUTHISHAUSER, 1. H. E. Early malnutrition and mental development. In: Symposia ofthe Swedish Nutrition Foundation. Vol. 12, J. Cravioto, L. Hambreaeus and B. Vahlquist (Eds.), pp. 13-26.

Almquist 8~Wiksell, Stockholm (I 974). 16. DROTAR, D., NOWAK, M., MALONE, C. A., ECKERLE, D. and NEGRAY, J. Early psychological outcome in failure to thrive: Predictions from an interactional model. Journal of Clinical Child Psychology 9:236-240 (1985).

17. DROTAR, D. and STURM, L. A. Prediction of intellectual outcome in children with early histories of failure to thrive. Journal ofpediatric Psychology. 13:28 l-295 (1988). 18. HAMMILL, P. V. V., DRIZD, T. A., JOHNSON, C. L., REED, R. B., RQCHE, A. F. and MOORE, W. M. Physical growth: National Center for Health Statistics percentages. American Journal ofCiinica~ nutrition 32: 607-629 ( 1979).

19. SCHMITT, B. (Ed.). The Child Protection Team Handbook. STM, New York (1978). 20. DROTAR, D. and MALONE, C. A. Family-oriented intervention in failure to thrive. In: Birth Interaction and Attachment Vol. 6. M. Klaus and M. 0. Robertson (Ed%). pp. 104- 112. Johnson and Johnson Pediatric Round ,__ Table, Skillman, NJ (1982). 21. HEIMENDINGER, J. and LAIRD, N. Growth changes: Measuring the effect of an intervention. Evaluation Review 780-95

(1983).

22. CALDWELL, B. M. and BRADLEY, R. N. Hame Observation for the Measurement ofthe Environment. Center for Child ~velopment and Edu~tion, University of Arkansas, Little Rock (1980). 23. CASEY, P. H., BRADLEY, R. and WORTHAM, B. Social and nonsocial en~ronments of infants with nonorganic failure to thrive. Pediatrics 73:348-353 (1984). 24. YEATES, K. O., MACPHEE, D., CAMPBELL, F. A. and RAMEY, C. T. Maternal IQ and home environment as determinants of early childhood intellectual competence: A developmental analysis. Developmental Psycho/ogy 19:73 l-739 (1983). 25. COHEN, J. and COHEN, P. Applied Multiple Regression/Correlation Analysis for the Behavioral Sciences. Erlbaum, Hillsdale NJ (1983). 26. CHATOOR, I. and EGAN, J. Nonorganic failure to thrive and dwarfism due to food refusal: A separation disorder. Journal ofthe American Acudemy of Child Psychiutrty 22:294-30 1 ( 1983). 27. AYOUB, C. C. and MILNER, S. G. Failure to thrive: Parental indicators, types, and outcome. Child Abuse d Neetect 9:49 l-499 ( 1985).

28. WGOLSTON, J. W. Diagnostic classification: The current challenge in failure to thrive syndrome research. In: New Directions in Failure to Thrive: Implicationsfir Research and Practice, D. Drotar (Ed.), pp. 225-234. Plenum, New York (1985). 29. DROTAR, D., WILSON, F. and STURM, L. Parent intervention in the management of failure to thrive. In: Handbook ofParent Training. L. E. Schaefer and J. M. Briesmeister (Eds.). John Wiley, New York (In press). 30. FRAIBERG, S. (Ed.). Clinical Studies in Infant Mental Health. Basic Books, New York (1980). 31. WOOLSTON, J. L. Eating disorders in infancy and early childhood. Journal ofthe American Academy ofchild Psychiutry22:114-121(1983).

R&urn&-Une etude a eti faite sur un groupe de 59 enfants ages de 3 ans qui avaient et& hospital& autrefois pour une hypotrophie nonorganique lorsqu’ils etaient nourrissons i l’age, en moyenne, de 5 mois. On s’est occup(: surtout du poids et de la taille atteints i 3 ans. Ces nourrissons avaient et&I’objet d’interventions limit&es dam le temps pour cot-tiger leur hypotrophie. La majorite des enfants ii 3 ans avait atteint un poids normal pour leur taille, mnis presque l/3 presentait encore une certaine hypotrophie pond&ale. Le devenir du poids de ces enfants n’etait pas en rapport avec le type d’intervention pratique lorsqu’ils etaient nourrissons. Les auteurs ont test&d’une part la valeur predictive des caracterisitiques de t’hypotrophie non organique, telles que la p&ode i laquelie a debut& I’hypotrophie et sa dur&e, la rapidite de la recuperation du poids apr& que le diagnostic ait et& fait; et d’autre part, certaines caracteristiques de l’environnement, telles que revenus et stimulations a la maison. Si ~hypotrophie etait de courte de dun& avant d’etre diagnostiquie et si la prise de poids initiale apr&s I’hospitahsation &gaitrapide, on pouvait p&dire le poids par rapport a la taiile i 36 mois. Ces trouvailles souiignent le besoin dune surveillance attentive de la croissance physique, de l’etat nutritionnel des enfants souffrant d’hypotrophie non organique apres leur retour de l’hopital et egalement le besoin dune evaluation globale et dun traitement plus suivi pour les enfants qui continuent i dimontrer des deficiences nutrionnelles ap& I’hospitalisation. Les auteurs pensent que des etudes supplementaires sont nicessaires pour voir quels sont les facteurs qui affectent le pronostic de ces enfants.

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Lynne Sturm and Dennis Drotar

Resumen-Esta investigation evaluo 10s resultados de1 tratamiento de 59 nitios de 3 aiios de edad que habiin sido hospitalizados cuando beaks (con edad promedio de 5 meses) con la diagnosis de NOFT (desarrollo insuficiente de origen noorginico). El tratamiento consistio en visitas al hogar por un tiempo limitado, y 10s resultados fueron evaluados en termino de1 peso con relation a la estatura. Aunque la mayoria de 10s niiios alcanzaron un peso normal en relation con su estatura, casi un tercio mostraron por lo menos una consuncion ligera. El tipo de visita al hogar no afecto 10s resultados. Se examine el poder predictive de un grupo de variables que incluyi, las caractetkticas de1 NOFf (edad en que comenzo y duration), la rapidez de1 aumento de peso subsecuente a la diagnosis asi coma las caracterkticas de1 medio ambiente (ingresos y estimulacion en el hogar). Una duration mh cotta de1 NOFT con anterioridad a la diagnosis y un aumento de peso m&r rapid0 subsecuente a la hospitalization predijeron el peso con relation a la estatura a 10s 36 meses. Los resultados subrayan la necesidad de vigilar el desarollo fisico y el estado nutritional de 10s cases de NOFf subsecuentemente a la hospitalization, asi coma la necesidad de una evaluation y tratamiento comprensivos de 10scases que continuan mostrando deficiencias nutricionales. Es necesario que se lleven a cabo rnas investigaciones de 10s factores que afectan la prognosis de1 NOFf.