Kaylie Groenhout thought the scale was wrong. So did the doctor. But after resetting it and reweighing Groenhout's then 4-month-old daughter, Hadley, both realized what was really wrong: The baby's growth -- or lack thereof.
"I said, 'No way. That's only like a pound in change over her birth weight," remembers Groenhout, a 28-year-old in Loudoun County, Virginia, who was living with her husband on a military base in Okinawa, Japan at the time.
Hadley was swiftly admitted to a hospital, where the medical team ran bloodwork and other tests to determine why she wasn't growing at a normal rate for her age. It may have been a nutrient absorption problem from a food allergy, for example, or more unlikely, a sign of a chronic disease like cystic fibrosis. Almost three days later, the health care providers gave Groenhout a name: "failure to thrive."
"When they said that, I had this horrible mommy guilt that I had malnourished my child," Groenhout says. "When in actuality, I spent what felt like all day and all night nursing her."
Failure to thrive is a medical term that describes children who don't gain enough weight or don't gain it fast enough. It can happen in older children, but it's most common in the first three years of life, when development is rapid and critical, according to the American Academy of Pediatrics.
Failure to thrive is often applied when a child falls below the fifth percentile of weight for age more than once, or when his or her weight crosses two major percentile lines on a growth chart, according to a 2011 article in the American Family Physician. Still, there's no consensus on how it's defined.
"One of the problems with the general diagnosis of failure to thrive is it's a description rather than a diagnosis," says Kristi Watterberg, a professor of pediatrics in neonatology at the University of New Mexico and chair of the American Academy of Pediatrics Committee on the Fetus and Newborn. "Then there is a very wide variety of things which can lead to that end point."
Organic or Inorganic?
Up to 10 percent of children who visit primary care settings have failure to thrive, usually due to behavioral or psychosocial issues, according to the American Family Physician. For example, babies and moms may struggle with breast-feeding, or parents may unnecessarily avoid giving their children high-calorie foods when weaning off formula or breast milk. In these cases, failure to thrive is called "inorganic," and is identified through an evaluation of the children's eating habits and interactions with their parents.
Rather than related to a medical condition, inorganic failure to thrive is "caused by environmental factors, psychosocial problems, neglect -- either accidental or, on the rare occasion, not accidental neglect," says Jenifer Thompson, a pediatric dietitian at Johns Hopkins Children's Center. "So it's when you actually don't have enough food or you don't have the proper amounts of food or breast milk or formula."
Less often, failure to thrive is "organic," meaning it is a symptom of a condition or disease that causes malnutrition. For instance, some children with gastroesophageal reflux don't keep enough food down, while children with celiac disease don't absorb enough nutrients. Conditions such as thyroid disease and congenital heart disease can also be culprits, since they may cause children to burn too many calories.
Sometimes, failure to thrive is applied to children who end up being healthy, just small. Other times, babies who were overnourished in utero are born bigger but gain weight more slowly. In that case, they deviate downward from the growth curve but can wind up healthy, too.
"The main thing is to determine what the problem is -- and sometimes, it's not a problem at all," Watterberg says.
It Takes a Village
After ruling out organic causes of Hadley's minimal weight gain, the health care team in Okinawa concluded she wasn't getting enough nutrients from breast milk and put her on formula. For Groenhout, a first-time mom committed to breast-feeding, the news was "really, really upsetting," she says. "Emotionally, I was a little bit devastated."
But formula was a solution that worked: Hadley, who will turn 3 this summer, gained weight quickly and has since maintained average growth, Groenhout says.
In addition to addressing any underlying medical condition, health care providers commonly treat failure to thrive in babies by switching them to formula or teaching parents how to make formula more nutrient-dense, Thompson says. For older children, the advice might be to bulk up their kids' caloric intake by, for example, adding avocado or olive oil to foods, or by switching from skim milk to whole milk.
In severe cases, children may need more intense support like a feeding tube, but more often, the solution is parental education, Thompson says. "With proper nutrition advice ... [the kids] usually do outgrow it, and they'll catch up to their peers," she says.
With more education since becoming a doula -- someone trained in supporting women before, during and after birth -- Groenhout believes the root of the problem was her nipple shield, which she used to alleviate the pain of breastfeeding. While such shields can help a mom's sore, cracked nipples heal, among other uses, Groenhout says hers decreased her milk supply because she didn't receive proper guidance on how to use it. Being a first-time mom in an unfamiliar country didn't help either.
"It takes a village to raise kids and ... I really could have used someone to say, 'Hey, she doesn't look like she's gaining much weight' or 'How's nursing going?'" Groenhout says. "That would have changed things."
Being in close communication with a pediatrician or another child health care provider is key, Thompson says. "The earlier you catch it, the better it is to treat and turn around. So if your child is less than 2 [years old], and they're not gaining weight in a three-month time period, it may be a red flag," she says. "Talk to your pediatrician."