What is excessive force? excessive removal of a child from its parents? Starvation if even well intentioned “to reduce risk of high cholesterol and needing a bypass surgery” is neglecting to meet the hunger signals and body language shown by crying and fussing in a typical infant. If an infant is too malnourished however they will be listless and not fuss much at all. A loving parent might think things are okay because the baby is quiet. This blog discusses types of failure to thrive – reasons for no weight gain – my main question unanswered from the newspaper article is what happened with the infant’s head circumference and height/age and length/weight curves.
“Couple Accused of Starving Baby,” the Assoc. Press, New York Daily News (11-17-11) [articles.nydailynews.com]
I recently wrote about occasionally having written nutrition assessment letters in support of a few “dinky” WIC children and their parents who were regularly offering a healthy variety of food. In the article I suggested that the common problem with that segment of my caseload was undiagnosed congenital hypothyroidism. Now I knew the children and parents that I wrote about and I had worked with them monthly or quarterly and measured their dinky, adorable, thriving in their own tiny way, children.
The other common thing amongst the little tykes was their growth chart patterns. There are three types of growth charts to be aware of regarding young children:
1. The head circumference isn’t discussed much but it will be the last curve “to fall off the chart” due to failure to thrive. An infant’s head is bigger than the passage already, so nature designed it to catch up and grow a little more rapidly outside of mom the first two years of life and then hatsize changes very little into adulthood. The neborn head circumference average is roughly 12-14 inches, by 3-6 months it may be 16-18 inches around, by one to two years old 20-22 inches. adult’s may be 24 inches around. I didn’t use a tape measure but mine is roughly 23 inches (level ribbon or tape measure held about one inch above the ears at the wide spot of the forehead/back of head – biggest loop that you can slide up and down with stiff tape measure but heald a little taut, really loose adds a quarter to half inch.)
To get back to malnourishment – the body always sacrifices itself for the brain, and the heart and lungs are second most important (or just as maybe that’s a type of trinity of life). A child that is “failing to thrive” or not growing normally may be doing so for physical malfunction reasons – plenty of food is being offered and/or even going in but the child is still not growing (and may be throwing up all over the laundry). Organic failure to thrive is due to physical problems with the stomach and reflux, or underlying genetic malfunction effecting metabolic pathways, or unidentified disease, or nutrient deficiency, or other reasons – known and unknown. Recording daily food being offered , amounts consumed and symptoms that occur and then tallying up all the intake nutrient values to see if it “should” be meeting average needs is a tool that I used when investigating non-growing / non-thriving children.
One of the children that probably would have died without my intervention needed communication assistance for organic failure to thrive due to malformed stomach and constant regurgitation. The parents were somewhat learning disabled, not necessarily by a definition but it can make it easy to make the wrong assumptions. I bought a dry erase board for them to make it easier to immediately record how big a bottle was made and how much was eaten – what was offered and what was consumed and then the info was copied later onto paper for me – the infant ended up needing surgery. Turned out that lots was going in and there was tons of dirty laundry but the couple wasn’t able to communicate that to the doctor.
That little boy did weigh his birth weight at two months but he looked starving. His head circumference was practically following a normal curve and his height was only beginning to drop off the chart – really long and skinny with a big head and sunken eyes. He looked very starving and the parents were working very, very hard to care for him for those two months of tons of laundry (the poor may smell bad because food stamps doesn’t pay for laundry soap or laundromats or gasoline to get there – did you want to give that baby a few bottles, burp the spitting up, screaming in stomach pain little tyke, Michele dear, the couple probably did occasionally hire a babysitter or swap labor (you watch my kid today and I’ll watch yours tomorrow.)
2. Back to growth charts- the height growth chart was mentioned above. It will be affected second, head circumference is most protected and weight can slip fairly quickly off the typical pattern.
The growth rate can be slowed down by malnourishment due to lack of food being provided, or lack of absorption of nutrients, or physical regurgitation/spitting up or projectile vomiting or the food, or too much fuel being burned up (common with a minor undiagnosed heart defect – saw one of those also , it took his parents a long time to get appropriate dx as well. Worms and early cancer also might increase calorie needs),
3. Weight gain rate growth is really only valuable if it is compared to the child’s height and to the own child’s previous growth rate. The dinky children that were relatively healthy and growing at an tiny barely plottable growth curve, were still growing and did have their own plottable growth curve (similar to each other BTW). They followed the normal curve but just weren’t on it. they chugged along in a few cases a half inch off the chart which would practically be 25% below “fifth” percentile.
To briefly review Bell curve and normal distribution (fromTarot blog recently) we expect f percent of children to look healthy and normal “oof the chart:” in either direction. Children of Asian descent are not common in Marquette but they always saw the dietitian because they never plotted on the growth chart for weight/height – narrow shoulders, narrow hips, narrow mom and dad. They all matched each other and were offering healthy food every two to three hours – no problems there except with the growth chart assumptions (that fifty percentile is a goal – no it is only a goal for fifty percent of children the other fifty percent would look too fat or too skinny at that weight for height).
4. I think I just started the weight for height growth chart so I thought I better put the number up.
Inorganic failure to thrive is due to parental/caregiver or stress/depression relationship type issues. Occasionally the baby really has no appetite and the parents are offering and offering and the infant isn’t accepting anything – starving itself – that is pretty rare and would take the careful recording of just exactly what is being offered versus what is being consumed (and the estimated amount that was kept down / not spit up). A family that is paranoid about cholesterol and excess weight gain may be offering too little and if stressful feeding interactions are also used the baby may give up rather than continue to fuss for food (too starved of an infant will get listless, apathetic, look a little depressed).
A dinky healthy child will have a bit of cush/moistness to the skin with a little bit of rounding over the muscles and bones, and a healthy glow of youth (moistness factor). A skinny child will be gangly with boniness and ribs showing but not up at the nipple / chest-bone area and dry skin and thin, wispy hair, possibly even falling out easily. A starving model will have chest-bone rib exposure while a thin model will have a bit of flesh rounding out the ribs at least a little. (Offer a skinny model a snack and if she says “No thanks, I’m not hungry” then zinc may be needed – too deficient and the appetite disappears – it can get uncomfortable to eat with too shrunken of a stomach; if she says “No thanks, I’m not hungry right now but maybe later,” then I’m a little less worried about her.)
A too skinny child will have that body builder appearance where you can see the outline of their muscles very clearly through paper-thin skin (lack of subcutaneous fat was referred to in the Associated Press article). The patella or kneebone will be very knobby and sticking out – it is just floating over the front of the leg suspended by ligaments – stringy cords. Moistness within the joints helps prevent arthritis/joint pain problems and reduce accidents over time. Hydration helps many things and Dr. Batmanghelidj helped asthma patients with more water and sea salt – chemical structure of bleached table salt may be less helpful to the body possibly and it doesn’t taste as good to me at least definitely.
A “dinky” hypothyroid child that followed their own special growth curve two standard deviations off the chart on weight and height for age, might actually plot normally weight is compared to height and head circumference was usually on the grid or just a bit below the fifth percentile. Weight and height compared to their age group were the most “abnormal” and if only weight was looked at the rest of the pattern might be missed. The physical appearance included – if you pick up a dinky child you can still support their bottom in the palm of your hand – narrow bone structure with narrow hips. A straving child will be bony and gangly and achingly sore where all that delicate skin isn’t sqooshy enough to prevent bruising with little pressure. (Stuffed teddy bear with too little stuffing left.)
To sum up – I would need to see the child and ideally see the history of measurements for weight, height and head circumference. If it is a dinky child with parents who are concerned about cholesterol then they may feel comfortable with small size. The tests that were all normal would not have caught congenital hypothyroidism that was due to a thyroid gland that used bromide, fluoride or chloride instead of the iodine (malfunction undetected by a TSH – Thyroid Stimulating Hormone test). Goiter is not evident any longer as a sign of iodine deficiency because the thyroid gland has adapted.
Clues that congenital hypothyroidism might be a problem besides having a two and half year old so small that their bottom fits in the palm of your hand (hard to disguise that oddity and there isn’t a growth chart for it):
1. Mom has hypothyroidism or the symptoms of it but no diagnosis (I do not care what her lab tests say unless she has done a 24 urine collection and had it assessed for iodine content.)
2. Mom has had several children and the baby is one of the youngest. (Mom may have started out with iodine stores but is running lower now because there really isn’t that much fortification or use of iodized table salt and really do we sprinkle on that vitamin D with a slat shaker or vitamin C?)
3. Baby was a twin or triplet . . . or was premature or small for gestational age – although a few of the dinkiest kind of started 7 pounds and just never took off with the more typical, rapid growth rate seen from birth to two and a little slower through preschool.
4. A congenital hypothyroid baby may look like an adorable little midget, pixie, elf child. Big eyes and biggish head compared to the dinky body but perfectly proportioned arms and legs to the body. A little person with other types of dwarfism may have the individual’s head and torso similar in size to that of a typical adult but their arms and legs may be proportionally much shorter than average. Hair on a congenital hypothyroid child may be fine, very soft and baby fine and possibly short with spikiness – nature’s little punk rockers.
5. The dinky child will have an appetite and eat quite normally without any odd quirks, but in vvery small bird like portions – matching their tiny body’s need when calculated based on body weight instead of looking at “recommended intakes” – recommended for the fifty children eating on the fiftieth percentile line perhaps.(autistic kids invariably had quirks in diet preferences or strong opinions.)
6. The iodine content of a urine collection for the child is also a useful indicator as to whether there is much iodine in the diet – lots going in will have more coming out – and a challenge loading dose of iodine can be given and the the urine again measured. The iodine deficient body will retain more of the excess loading dose and the urine will have more than in the first batch but no where near the total that was consumed for the day (I took the loading dose of 50 mg broken into AM and PM – with meals the stuff is a little icky on the stomach – patient forums seem to suggest that sea weed is more comfortable – don’t know – I use Iodoral.) Fluoride, bromide and chloride levels being excreted can also be monitored – high levels of those reflect the exchange having been made by the malfunctioning thyroid hormone of the non iodine (any port in a storm) for the iodine from the massive influx of the loading dose. The metallic taste in the mouth that can occur during iodine supplementation is theorized to be the bromide / fluoride taste. Yellowish stuff has been reported to stain white clothing (ooze from the skin) – that could be the iodine too it is yellowish, I never checked what color bromide or fluoride are typically.
– there are probably a few more clues and reference links but – brief sum up – Need to see and measure the child – iodine content of the child’s urine would be more concrete in a court than “dinky” although the healthy dinky growth chart pattern would be evidence if all four growth charts were used – Ht/Age, Wt/Age, Ht as Length/Wt, and Head Circumference/Age.
“Couple Accused of Starving Baby,” the Assoc. Press, New York Daily News (11-17-11) [articles.nydailynews.com]
growth chart info from the CDC website, [link]
Growth Reference Versus Growth Standard
The CDC and WHO growth charts differ in their overall conceptual approach to describing growth. The WHO charts are growth standards that describe how healthy children should grow under optimal environmental and health conditions. The curves were created based on data from selected communities worldwide, which were chosen according to specific inclusion and exclusion criteria. Deviation from the WHO growth standard should prompt clinicians to determine whether suboptimal environmental conditions exist, and if so, whether they can be corrected.
Whereas the WHO charts describe growth of healthy children in optimal conditions, the 2000 CDC growth charts are a growth reference, not a standard, and describe how certain children grew in a particular place and time. The CDC charts describe the growth of children in the United States during a span of approximately 30 years (1963–1994).
CDC (***the charts that I used)
The CDC growth curves for children aged Table 1). The curves were anchored at birth using national birth weight data obtained from U.S. birth certificates from 1968–1980 and 1985–1994 and birth length data from Wisconsin and Missouri birth certificates (the only states with these data available on birth certificates) from 1989–1994 (5). Birth data were based on 82 million birth weight measurements and 445,000 birth length measurements.
Breastfeeding and Growth Patterns (***The whole section because it is so important)
When the WHO growth curves were created, the difference in growth between primarily formula-fed infants and primarily breastfed infants was an important consideration (12). The WHO charts were based on the premise that the healthy breastfed infant is the standard against which all other infants should be compared. This is consistent with U.S. dietary reference intakes, in which norms for infant intakes of most nutrients are determined on the basis of the composition of human milk and the average volume of human milk intake (21).
In the WHO charts, 100% of the reference population of infants were breastfed for 12 months and were predominantly breastfed for at least 4 months. In contrast, approximately 50% of the infants in the CDC data set had ever been breastfed, and 33% were still breastfeeding when they reached age 3 months, rates that are lower than those for infant cohorts born today. Data from the CDC National Immunization Survey indicate that in 2007 in the United States, 75% of infants had ever been breastfed, and 58% had been breastfed for at least 3 months (22). In addition, the composition of infant formula has changed considerably during the preceding 35 years (23). Therefore, the current growth of U.S. infants might not be the same as the growth of infants used in the creation of the CDC growth curves.
The expert panel universally agreed that breastfeeding is the optimal form of infant feeding and recognized that the growth of breastfed infants differs from that of formula-fed infants. The panel also recognized that AAP has stated the breastfed infant “is the reference or normative model against which all alternative feeding methods must be measured with regard to growth, health, development, and all other short- and long-term outcomes” (24).
Some U.S. clinicians who are currently using the CDC charts might be unaware of or not understand the growth pattern of exclusively breastfed infants, which differs from that of formula-fed infants. These clinicians might inappropriately recommend that mothers supplement breastfeeding with formula or advise them to wean their infants from breastfeeding completely.
The WHO and CDC charts show different growth patterns that might lead clinicians to different conclusions about variations in growth. Healthy breastfed infants typically gain weight faster than formula-fed infants in the first few months of life but then gain weight more slowly for the remainder of infancy (25,26). Therefore, in the first few months of life, WHO curves show a faster rate of weight gain than the CDC charts for boys and girls (Figures 2 and 3). Use of the WHO charts in the United States might lead to an increase in the misperception of poor growth at this age.
Beginning at approximately age 3 months, WHO curves show a slower rate of weight gain than the CDC charts, both in weight for age and weight for length. Because WHO curves are derived from infants who breastfeed through 12 months, infants who are still breastfeeding at approximately age 3 months are more likely to maintain their percentages on the WHO growth charts but to decrease in percentages on the CDC charts. In contrast, if WHO charts are used to assess the growth of formula-fed infants, these infants might be identified as growing too slowly during the first few months of life but then be identified as gaining weight too quickly after approximately 3 months.
Use of WHO Growth Charts for Children Aged 0-24 Months
Use of the 2006 WHO international growth standard for the assessment of growth among all children aged 0 to24 months, regardless of type of feeding, is recommended. (The charts are available at [cdc.gov/growthcharts].) When using the WHO growth charts, values of 2 standard deviations above and below the median, or the 2.3rd and 97.7th percentiles (labeled as the 2nd and 98th percentiles on the growth charts), are recommended for identification of children whose growth might be indicative of adverse health conditions. The rationale for use of the WHO growth charts for this age group includes the following: 1) the recognition that breastfeeding is the recommended standard for infant feeding and, unlike the CDC charts, the WHO charts reflect growth patterns among children who were predominantly breastfed for at least 4 months and still breastfeeding at age 12 months; 2) clinicians already use growth charts as a standard for normal growth; and 3) the WHO charts are based on a high-quality study, the MGRS.
Continued Use of CDC Growth Charts for Children Aged 24–59 Months
Use of the CDC growth charts for children aged 24–59 months is recommended. The CDC charts also should be used for older children because the charts extend up to age 20 years, whereas the WHO standards described in this report apply only to children aged 0–59 months. The rationale for continuing to use CDC growth charts includes the following: 1) the methods used to create the WHO and CDC charts are similar after age 24 months, 2) the CDC charts can be used continuously through age 19 years, and 3) transitioning at age 24 months is most feasible because measurements switch from recumbent length to standing height at the this age, necessitating use of new printed charts.
The estimated prevalence of low weight for age and high weight for length among U.S. children differ depending on whether the CDC charts (using the 5th and 95th percentiles) or the WHO charts (using the 2.3rd and 97.7th percentiles) are used (Figure 6). A substantial difference exists in the prevalence of low weight for age, with the WHO standard showing a lower prevalence beginning at age 6 months. The CDC reference identifies 7%–11% of children aged 6–23 months as having low weight for age, whereas the WHO standard identifies <3%. The WHO standard also identifies fewer infants (aged
the end of the article is several more long paragraphs – to sum up – The U.S. clinics have not all started using the newer growth charts and recommendations, improved education in their use is recommended as well as a call for more research into what cut-offs / criteria are indicative of poor growth outcomes (just being on or under the 5 or 95th percentile was never assessed for health in either set of grids. Both sets were simply plotting a bunch of children’s measurements using different types of children.
Disclaimer: Opinions are my own and the information is provided for educational purposes within the guidelines of fair use. While I am a Registered Dietitian this information is not intended to provide individual health guidance. Please see a health professional for individual health care purposes.