of a normal, healthy child. Statistical norms have
been published for the growth patterns of normal
children. Plotting a child’s height, weight, and head
circumference on such charts yields valuable diagnos-
tic information. In children younger than age two, in-
adequate growth may be defined as falling below the
third or fifth percentile for the age, where weight is
less than 80 percent of the ideal weight for the age,
or where weight crosses two major percentiles sequen-
tially downward on a standardized growth chart.
The concept of failure to thrive, however, encom-
passes not just disturbances of the more obvious as-
pects of physical development but the more subtle
aspects of psychosocial development in infancy and
early childhood. ‘‘Thriving’’ is a concept that implies
that a child not only grows physically in accordance
with published norms for age and sex, but also exhib-
its the characteristics of normal progress of develop-
mental milestones in all spheres—neurological,
psychosocial, and emotional.
Early observations that an organic illness could
not be found in many cases of failure to thrive led to
the categorization of failure to thrive into the sub-
classes of organic and nonorganic causal factors. This
classification ultimately proved too simplistic, both
organic and environmental factors acting together
may cause poor growth, but it served to sharpen
thinking about the nonorganic causes.
Organic versus Nonorganic Failure to
Thrive
Organic failure to thrive is that caused by the
harmful effects on growth of organic disease. Growth
failure can be an extremely sensitive marker for un-
suspected systemic disease, revealing illness long be-
fore it would normally be detected. Likewise, the
progress of therapy is often dramatically mirrored by
improvement in growth. Any significant illness in an
infant or young child can cause growth failure. Thus
growth failure alone alerts the physician to search for
possible medical causes. Nevertheless, the search for
organic disease in young children with an initial diag-
nosis of failure to thrive most often finds no physical
(organic) condition to explain the growth failure; the
failure is therefore termed nonorganic.
The modern understanding of this disorder views
it as a fundamental failure of maternal-infant attach-
ment. In fact, it is referred to in psychiatric literature
as feeding disorder of attachment, as well as maternal
deprivation, deprivation dwarfism, and psychosocial
deprivation. Nonorganic failure to thrive reflects a
failed relationship between a mother and her infant
during the first year of life. Its chief characteristic is
a lack of engagement or bonding between mother
and infant in the daily routine of care, most dramati-
cally with respect to feeding.Diagnosis
Nonorganic failure to thrive can be understood
in terms of both physical and emotional deprivation
of the child, and has both physical and behavioral
signs. Caloric deprivation of an infant may be caused
more or less innocently by lactation failure, extreme
poverty, parental ignorance of proper infant feeding,
or strange nutritional beliefs. Parents of children with
nonorganic failure to thrive, however, typically give
a history of adequate or often exaggerated amounts
of nutritional intake belied by the child’s obvious mal-
nourished state.
By interviewing and observing the mother, it is
noted that feedings are marked by a lack of the mutu-
al pleasurable relationship of giving and receiving
that is the hallmark of normal feedings. In contrast,
the mother may admit that she props the bottle or
even sometimes forgets regular feedings.
There may be other evidence of poor caregiving
and physical neglect, such as unwashed skin, diaper
rash, skin infections, and dirty clothing. The back of
the baby’s head may be flat with a bald patch over the
flattened area, implying that the child is left unat-
tended for long periods of time lying on his back in
the crib. The baby may exhibit a lack of appropriate
social responsiveness, with an expressionless face and
classic avoidance of eye contact. Normal vocal re-
sponses, such as cooing and blowing raspberries, may
be absent. In children older than five months, there
may be no anticipatory reaching for interesting ob-
jects. Motor milestones may be delayed. When held,
instead of cuddling normally, the baby characteristi-
cally arches his back and scissors his legs, or lies limp
as a rag doll in the examiner’s arms. By contrast, ba-
bies with organic failure to thrive typically do not
show the characteristic withdrawal behaviors of non-
organic failure to thrive infants, and respond best to
their mothers.
Prominent features in the mother’s history may
include symptoms of acute or chronic depression,
personality disorder, substance abuse, and a generally
high level of psychosocial stress related to poverty, so-
cial isolation, or spousal abuse. Often the mother was
abused or neglected as a child, producing an appar-
ently transgenerational pattern of insecure attach-
ment. Parents of infants with nonorganic failure to
thrive are often initially evasive. They usually take the
baby to an emergency room for another illness,
whereupon the baby’s malnutrition attracts attention.
Upon the child’s admission to the hospital, the par-
ents may disappear for several days.146 FAILURE TO THRIVE