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Child Malnutrition/Failure to Thrive Project 2008

Literature Review

Project Officer – Susan Grant

Acknowledgements

The author is grateful to the many people who have assisted in the production of this report, including:

• Mick Arundell, Clinical Analyst, DHF

• Annette Flaherty, Topic Coordinator, Remote Child Protection Practice, CFRH

• Melissa Lindeman, Director, PHCRED Program, CFRH

• Clare MacVicar, Community Paediatrician, Remote Health

• Rob Roseby, Head of Paediatric Department, ASH

• Andrew White, Community Paediatrician, Remote Health

Alice Springs Hospital

( Department of Health and Families, Northern Territory 2008.

This publication is copyright. The information in this report may be freely copied and distributed for

• non-profit purposes such as study, research, health service management and public information subject to the inclusion of an acknowledgment of the source. Reproduction for other purposes requires the written permission of the Chief Executive of the Department of Health and Families, Northern Territory.

Printed by the Government Printer of the Northern Territory, 2008.

An electronic version is available at: .au/health/

General enquiries about this publication should be directed to:

CEO Alice Springs Hospital

Department of Health and Families

PO Box 2234, Alice Springs, NT, 0871

Phone: (08) 8951 7777

Table of Contents

Introduction 7

Method 7

Methodological complexity 7

Definitions of child malnutrition and failure to thrive 8

Terminology 8

Measuring growth 8

Malnutrition definition 9

FTT definition 10

Relationship between FTT and CM 11

Consequences of CM/FTT 11

The Australian context 13

Prevalence of CM/FTT in the NT 13

Features of CM/FTT in the NT 14

Skinny Kids 14

Causes of CM/FTT 15

History of Research into Causation of Failure to Thrive 15

Determinants of CM/FTT in the NT 16

Contributing Factors 17

Assessment 21

Medical assessment 21

Psychosocial assessment 21

Mothers views of poor growth 22

Multidisciplinary Approach 22

Treatment and Interventions 23

Primary Prevention 23

Care Practices 24

Secondary Interventions 25

Combined interventions 25

Community based interventions in the NT 25

Nutrition Interventions 26

Supplementary Feeding Programs 26

Growth Monitoring 26

Tertiary Interventions 27

Hospitalisation 27

The role of hospitalisation for CM/FTT 27

When should a child be hospitalised for CM/FTT 28

Rates of hospitalisation in the NT 29

When should a child be discharged from hospital? 30

The effectiveness of hospitalisation for CM/ FTT 30

Intervention Delay 31

Role of parents 31

CM/ FTT as a child protection issue 32

Tensions for practitioners 33

Implications of research into child development 34

Other treatment contexts for children with CM/FTT 35

Implications for Policy 36

Areas requiring further research 36

References 37

Acronyms 43

List of tables

Table 1 WHO Classification of malnutrition 10

Table 2 GAA data 13

Introduction

This literature review was undertaken as a component of the Child Malnutrition/ Failure to Thrive Project (CM/FTT) conducted by Alice Springs Hospital (ASH) in 2008.

The aim of this literature review is to guide improvement in the management of children with CM/FTT at Alice Springs Hospital. It will do this by exploring what has been written locally and elsewhere on the subject, assisting to clarify the role of Alice Springs Hospital (ASH), and informing the recommendations of the CM/FTT Final Report.

The main areas reviewed here are;

1. Definitional issues, given the inconsistencies in this area

2. Australian literature on CM/FTT in indigenous communities, particularly in the Northern Territory (NT)

3. Local and international literature on interventions for CM/FTT in hospital and community based settings

4. Although current thinking about consequences, causation and prevention of CM/FTT is beyond the scope of this project, these areas will be briefly addressed as they impact on approaches to intervention

This is a difficult field of work. The issues involved include some of the most complex and challenging in acute care paediatrics. As such, it is imperative that the published evidence-base informs recommendations for practice, hospital and departmental policy, and research.

Method

The literature on CM/FTT is vast and complex. The literature was identified via a search of databases for medical, social work and nursing journals, as well as bibliographies of relevant papers and consultation with practitioners.

A substantial amount of the literature on CM/FTT is from outside Australia, particularly the USA and UK and developing countries. In reviewing the literature, the relevance of research to the NT context and to the primary audience for this report was considered. Due to the huge volume of international literature on CM/FTT, summary and review articles were used where possible. In general, literature from the last 15 years was reviewed.

Methodological complexity

The research field is plagued by methodological complexities and diagnostic inconsistencies between studies. Ambiguities in the definition of FTT and its relationship to malnutrition make comparing samples and generalising findings a recurring problem in the literature.

Research limitations include poor quality data, inconclusive data, small sample sizes, non-standardised studies, cross sectional rather than longitudinal studies, the predominance of retrospective data from hospital based studies, and the practical and ethical issues involved in conducting research on children and family life [1-3].

Moreover, interestingly CM and FTT have tended to be described in separate literatures, with malnutrition research focusing on broad population based studies in developing countries, and FTT literature deriving from research on poor and middle class families in the developed world. It has been argued that neither of these contexts is readily transferable to the Australian indigenous context, making the applicability of much of the available research and evidence questionable [4, 5]. However, Cousoz warns against placing too much emphasis on the problems of generalisability and transferability of research findings to the indigenous context at the expense of a consideration of how findings might be applied [6]. Much of this uncertainty is reflected in this literature review.

Overall, there are serious gaps in evidence to inform interventions for CM/FTT in the particular context and conditions of Indigenous children in Central Australia [5, 7, 8]. This puts the onus on local practitioners and policy makers to extrapolate from the literature what might be useful to this particular context. It is hoped that this literature review might make a contribution to this end.

Definitions of child malnutrition and failure to thrive

Terminology

There is a considerable body of literature on definitional issues, particularly in relation to FTT. Some authors question the usefulness of the term FTT due to its lack of clarity and possible pejorative implications. However it continues to be used for its familiarity and historical connections [3, 9, 10].

Problems with growth are variously described in the literature as FTT, malnutrition, paediatric undernutrition, growth deficiency, growth failure, poor weight gain, growth faltering, poor growth, and growth delay. It is not unusual for a variety of terms to be used in the same study, often without clear definition. These terms have in common that they refer to children whose rate of growth has not kept pace with age and gender expectations. This literature review will use the terminology of the study being discussed, and so will reflect these variations. When discussing poor growth in general, the term growth faltering will be used as it is commonly used in the Australian literature.

For the purposes of this review, ‘growth faltering’ is defined as;

• a reduction in the expected rate of growth along an infant’s previously defined growth curve [11]

Measuring growth

Any attempt at reviewing definitions of CM/FTT requires some attention to methods of measuring growth. The use of growth indicators is founded on the concept that growth assessment best defines the health and nutritional status of children. However, there is little consistency in this area.

Interpretation of child growth is based on selections of anthropometric indicators and reference population with identified cut off points for classifying children according to variable degrees of undernutrition. There are no standardised criteria internationally but trends have been identified. The indicators most commonly used are weight-for-age, length/height-for-age, and weight-for-height.

There is consensus in the literature about the following definitions. [9, 12]:

• Underweight (weight-for-age z score ≤ -2)

• Wasting/thinness or acute weight loss or acute malnutrition (weight-for-height z score < -2)

• Severe wasting or severe malnutrition (weight-for-height z score < -3)

• Stunting or chronic malnutrition (length/height-for-age z score ................
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