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Literature Review

FTT definition
The research on FTT appears to be as inconsistent as practice in regard to the variability in
definitions and diagnostic criteria. This section attempts to find common threads from the
Most authors agree that FTT is considered a descriptive term of a diagnostic problem rather than
a diagnosis, however confusion arises as it is sometimes also equated with paediatric
undernutrition [1, 3]. A review of recent trends in the international medical literature found there
was a consensus towards a purely nutritional/ growth based definition. There was agreement on
using anthropometric criteria to define FTT, however there was no agreement on which growth
parameters to use and whether to use attained values or velocities.
The overall trend in definitions of FTT was towards [4];

the lack of attainment or maintenance of the growth potential expected for a child
when the childs growth crosses 2 or more or centile lines on a standard growth chart or
when growth falters to below the 5th or 3rd centile for age

In Australia, FTT definitions have followed the above trend. However, Brewster argues that the
tendency to use FTT to refer to children below the 3 rd centile for weight at a given age risks
missing significant weight loss in a bigger child and mis-identifying genetically small children
with infection related transient growth deceleration. He argues that FTT should be defined as[3];

growth deceleration or crossing growth centiles, particularly falling through 2 centile

spaces on the standard child growth chart

In a paediatric review of FTT Schwartz adds that an age component (younger children and
infants) and psychosocial and developmental components are integral to a diagnosis of FTT [20].
It is argued that FTT usually occurs in children under 3 because they normally grow rapidly and
depend on their parents for food [3].
Relationship between FTT and CM
There are different opinions in the literature about the relationship between FTT and CM.
Undernutrition underlies FTT, and this links FTT with definitions of malnutrition. Some authors
argue that CM and FTT are essentially the same condition described in different literatures [1].
Brewster claims that FTT tends to be used when describing children in developed countries like
Australia or in middle class families, whereas in developing countries or underprivileged (for
example indigenous) families malnutrition is more likely to be used. Other authors see FTT as a
syndrome of growth faltering which may or may not result in malnutrition [5]. There is general

agreement that all children with FTT have some degree of inadequate nutrition to sustain a
normal rate of growth, whatever the cause.
The weight deficits used in diagnosing FTT are equivalent to those used to diagnose malnutrition
[24]. The severity of CM/ FTT informs its management. Anthropometric indicators alone are
generally used to diagnose malnutrition in populations, whereas an analysis of the growth pattern
over time is mainly used to diagnose FTT in individuals [4].
It is interesting that growth assessment tends to continue to dominate definitions and diagnosis of
CM/ FTT despite the variability in measures and the capacity for error. Much of the CM/ FTT
literature is medical in orientation, and Wright and Talbot argue that weight loss or gain offers an
objective and pragmatic measure of change in a complex and confusing area. However the term
failure to thrive also implies other aspects of a childs wellbeing and recent research on child
development is increasingly highlighting the importance of thriving across the physical, socioemotional and cognitive domains. McCain and Mustards influential work on the Early Years
stresses that children need not only nutrition, but also stimulation, care, security, attachment and
love to thrive [6].
Consequences of CM/FTT
Early child development can affect health, well-being and competence across the balance of the
life course. Even though understanding of the specific contribution of childrens growth as a
determinant of health and development is still emerging, The Lancets recent series on maternal
and child undernutrition warned that the evidence that growth failure has a huge cost is now
This section presents a brief overview of the evidence for short and long term consequences of
undernutrition from review articles. The seriousness of the findings is sobering both in terms of
the possible impacts on individuals and on human capital.
The short term effects of undernutrition have been found to include;
Ongoing growth deficits, severe infection, diminished immunological response, greater
risk of death, delayed cognitive and psychomotor development, learning disabilities and
behaviour problems, and diminished physical activity. [1,3]
A recent systematic review of the evidence on maternal and child undernutrition in developing
countries found overwhelming evidence for long term effects;
Poor foetal growth or subsequent stunting (height-for-age z score <-2) in the first 2 years
of life leads to irreversible damage including increased susceptibility to infections and
greater mortality, cognitive and educational deficits, shorter adult height, lower attained
schooling, reduced adult income, and decreased offspring birthweight.
Undernutrition can affect cognitive development by causing direct structural damage to
the brain and by impairing infant motor development and exploratory behaviour. Longterm effects arise through the persistence of early deficits, particularly in the absence of
opportunities for remediation in deprived environments, and by altering the way in which
individuals deal with learning.

Children who are undernourished in the first 2 years of life and who put on weight
rapidly later in childhood and in adolescence are at high risk of chronic diseases related
to nutrition. However there appears to be no evidence that rapid weight or length gain in
the first 2 years of life increases the risk of chronic disease, even in children with poor
foetal growth. In fact rapid weight gain in infancy is associated with lower morbidity and
mortality, and bodysize at 2 years of age is associated with enhanced human capital.
There is growing evidence that a high birthweight and weight gain in infancy results in
the accumulation of lean body mass, whereas weight gain in later childhood produces fat
mass. There is a need for more research to define the age at which rapid growth should be
avoided [7].

Other studies have found that;

Underweight and stunting are also associated with apathy, less positive affect, lower
levels of play and more insecure attachment, problems with conduct, poorer attention,
and poorer social relationships at school age than non growth retarded children
Nutrition in foetal life and poor infant growth patterns are associated with the
development of adult chronic diseases, particularly cardiovascular disease, type-2
diabetes, and chronic renal disease
A Lancet series on child development highlighted that many children in developing
countries are exposed to multiple risks, including poverty, malnutrition, poor health and
unstimulating home environments, which detrimentally affect their cognitive, motor and
social-emotional development. It found that poor cognitive stimulation, stunting, iron
deficiency and iodine deficiency represent urgent risks to child development. More
research was recommended into the mechanisms, importance of timing, duration, severity
of exposure and reversibility of effects.
A UK systematic review of cohort studies that attempted to assess the long-term
outcomes for children who have non-organic FTT found little good evidence for longterm effects. However there was a relative lack of usable data due to the paucity of high
quality longitudinal studies [8].
There is very little research into the long term consequences of undernutrition in Australia.
Skull et al found that wasting was significantly associated with microcephaly in Top End
children at RDH. The study raised the possibility of long term reduced IQ in these
children but a causal relationship between nutrition and head growth was not proved.
An Australian review of FTT indicates that stunting, microcephaly, iron deficiency and
vitamin A status during the vulnerable brain growth spurt (0-2 years) have serious
detrimental consequences for immune, intestinal, and cognitive performance.[8]
Causes of CM/FTT
This section addresses broad themes in the literature relating to causation.
Causal factors for malnutrition are identified as deficiency in quality and quantity of food in the
context of inadequate health care, poor-quality education, unemployment, large family size, poor

environmental health and poverty. Whilst population based studies investigating malnutrition
tend to identify environmental and socio political causes, many smaller studies looking at FTT
identify a plethora of risk factors located in the maternal/child dyad.
In general the final or proximal cause of CM/FTT is seen as caloric inadequacy as a result of
inadequate intake of food, increased energy required, or decreased absorption of ingested food.
History of Research into Causation of Failure to Thrive
Studies of the causes of FTT are heterogeneous and methodologically diverse (cohort studies,
case-control studies, surveys and trials) and focus on a diverse range of variables (attachment,
feeding, social environment, maternal psychopathology) which makes it difficult to draw
consistent and reliable conclusions. There are virtually no qualitative studies or intervention
Understandings of the causes of FTT have changed over time along with scientific and
theoretical developments. The term FTT was first used in the US medical literature in 1897 to
describe weaning malnutrition.
Between the 1940s 60s the hypothesis of a psychological cause for poor growth emerged
from a plethora of mostly small, hospital based studies on the effects of institutionalisation,
hospitalisation and maternal deprivation on infants in the US. Iwaniec traces understandings of
FTT at this time through a range of classifications such as disorder of hospitalism, deprivation
dwarfism, psychosocial dwarfism, environmental FTT, and maternal deprivation syndrome
In the 1960s the concept of child abuse emerged following the publication of The Battered
Child Syndrome by Kempe, and a medical-psychiatric model of causation for FTT was
postulated based on studies exploring various aspects of maternal psychopathology and
attachment theory. The parent-child dyad was seen as the locus of FTT and children were
classified under various psychiatric disorders according to the developmental age of onset
(disorders of homeostasis, disorders of attachment, or disorders of separation and individuation).
Problems in the feeding relationship were seen as central to the parent-child dyad. Maternal
problems included breastfeeding difficulties, errors in formula preparation, poor diet selection,
improper feeding techniques, and anxiety over poor weight gain. Individual child problems
included poor feeding skills, undemanding behaviour, delayed weaning, food aversion, appetite
control, narrow range of food preferences, and oral-motor dysfunction such as poor suck and
difficulty chewing and swallowing [5].
In the 70s and 80s FTT was classified as organic (biomedical) or non-organic (NOFTT)
(psychosocial). Organic FTT was caused by major disease processes or organ dysfunction.
NOFTT was caused by insufficient emotional or physical nurturing in the absence of obvious
physical abnormality [20]. NOFTT was seen as a combination of maternal factors, child
characteristics, and maternal-child interactions [3, 1].

The distinction between organic and NOFTT went out of fashion in the late 90s as it was
increasingly recognised that FTT was the result of an often complex interaction of both
nutritional and socio-emotional factors.
In the 21st century there has been an explosion of evidence from different fields about the impact
of early life settings on childrens longer term developmental and health outcomes. Advances in
understandings of child development have highlighted the important and complex relationships
between nutrition, attachment, emotional nurturing, stimulation and genetics, modulated by brain
cell connection development, in the first years of life . It is now recognised that childrens
development is multiply determined by characteristics of the child, the family and care
environment, and factors in the childs larger social environment [9].
Understanding of FTT continues to evolve and now incorporates medical, psychological,
interpersonal, familial, ecological and cultural factors. Future research into FTT will be
influenced by the strong evidence base for the critical importance of the early years for both
individuals and communities.
Determinants of CM/FTT in the NT
Brewster [3] identifies the immediate determinants of FTT in indigenous children as
dietary intake, including breastfeeding and complementary foods and factors influencing
health status, including birth weight, prematurity, the infection-nutrition cycle, and
environmental enteropathy in Top End children.
and underlying determinants;
household food security (household income and food access)
mothers and caregivers (caregiver education, knowledge and child care practices
health environment and services (safe water supply, sanitation, access to health care)
McDonald et al attribute patterns of growth faltering in the NT to a complex mix of factors
including poor nutrition, acute and chronic infections and parasitic diseases in a context of poor
living conditions, overcrowding, low socioeconomic status, family and community dysfunction
and poor access to early intervention and social support services [11].
Other researchers in Australia are exploring the effects of racism on health and wellbeing.
Although there is little Australian research in this area, there is a discourse around the continuing
impacts of colonisation and dispossession on indigenous childrens emotional and physical
health [10]
Contributing Factors
Various contributing factors are identified in the literature. Many require further research for
relevance to the NT context.

Sub optimum introduction of solid feeds

Sub optimum introduction of solid feeds is seen as a key cause of undernutrition in indigenous
children [7, 3]. The WHO recommends exclusive breastfeeding until 6 months of age.
Breastfeeding rates in the NT are highest for indigenous infants in rural areas and below national
targets for Indigenous infants in urban areas.
Even with optimum breastfeeding children will be undernourished if they do not receive an
adequate quantity and quality of solid foods after 6 months of age when they have a high demand
for nutrients. The developmental window to wean on to solids is short and if a child is still
predominantly breastfeeding at 9 months, it can lead to smaller appetites and difficulty taking
solids. The Lancet review argues that improvements in solid food introduction need to focus on
feeding frequency, energy density, quality of diet and micronutrients [1].
Nutrition/infection cycle
The vicious cycle of infection and malnutrition is well-documented. The malnourished child is
more prone to infectious diseases that further impair the nutritional state by depressing the
appetite and increasing the demand on the childs reserves of protein and energy [1]. Studies of
hospitalised children in the NT show that some children have repeated hospital admissions and
limited opportunities to overcome the malnutrition-diarrhoea-hospitalisation cycle.
Iron Deficiency Anaemia (IDA)
Anaemia is often associated with malnutrition. Rates of anaemia in children under 5 years of age
measured by the GAA Program are high in NT remote communities. In 2007 in the Alice Springs
Remote district 28% children aged 0-5 years had anaemia compared with 25% children in the
whole of the NT. The highest rates are in 12-36 month olds [40]. IDA has been found to correlate
with poor cognitive and motor development, behavioural problems and impaired immune
function, especially when it occurs in children less than 2 years. Major risk factors are low birth
weight and an inadequate weaning diet [11].
Recent surveys of indigenous agencies and parents have highlighted concerns about nutrition and
child development. Respondents were concerned about childrens poor diet, especially in remote
areas, and the use of convenience rather than fresh foods and food money being spent on
gambling and alcohol. A need for parental education about early childhood development was
highlighted [11].
A study conducted by NPY Womens Council found that poor diet in remote areas is due to loss
of traditional food supplies, lack of access to good quality food, and inadequate dietetic services
and nutritional education. In 2005 costs of food in the NT on average were 32% more expensive
in remote community stores than in a Darwin supermarket. A survey of housing in the NT found
that only 50% houses in remote communities met at least 4 of 5 recommended requirements for
healthy living practices. A major deficit in housing was the capacity to adequately prepare and
store food [11].

Nutrition transition
According to The Lancet, A baby of low birthweight, who is stunted and underweight in
infancy and gains weight rapidly in childhood and adult life, can represent a worst case scenario
for cardiovascular and metabolic disease [12].
The recent upsurge in chronic disease in the Aboriginal population is being attributed to a rapid
shift towards a westernised diet and lifestyle and a decline in physical activity characteristic of
demographic, epidemiological, and nutritional transitions. This pattern is also seen
internationally where low and middle income countries undergoing rapid transitions are facing
an epidemic of overweight and obesity. The implications for policy and public health messages
are complex. There is a need to prevent undernutrition but also excessive weight gain after
infancy [7, 11].
In a recent article on nutrition related disorders, Gracey argued the increase in chronic disease in
the Indigenous population was related to basic issues of social justice. He attributes the increase
to social factors such as poverty, inferior housing, severe overcrowding, poor standards of
domestic and community hygiene, racial discrimination, educational disadvantage, high
unemployment rates, heavy dependence on social welfare, limited access to affordable and
nutritious foods, poor understanding of health and nutrition.and limited access to quality
health care and disease prevention and health promotion programs.[13]
Deficiencies of zinc, vitamin A, iron, iodine, calcium, B vitamins (especially folic acid and B12)
and vitamin D have all been implicated in poor child and maternal health [1]. A recent review of
the evidence for the effects of micronutrients on child development found that there is evidence
for the effect of low iodine on child development but the effect of zinc deficiency remains
unclear and there is not enough evidence for the effects of vitamin A and B12. There is a need for
more research into the effects of micronutrients on undernutrition in Indigenous children.
Maternal factors
The situation of women as primary caregivers is internationally recognised as critical to
childrens growth and development. Mothers have a critical role in protecting children from the
environment and mediating harmful influences. The nutritional status of women before and
during pregnancy and the level of maternal education have been shown to relate to improved
outcomes for children in developing countries [1]. In Australia, the links between indigenous
maternal education and child health have not been shown to be as clear [14], suggesting there
may be other mediating factors.
Post natal depression (PND)
Studies in developing and developed countries have found associations between FTT and
maternal depression. A UK study on the influence of maternal socioeconomic and emotional
factors on infant weight gain found evidence for a strong, but transient effect of PND. A review
of the research from South Asia found evidence of the impact of PND on physical development,

with FTT found to be more common in infants whose mothers have postnatal depression. There
is little Australian data on the prevalence of PND for Aboriginal women. Anecdotal reports
suggest PND often goes unrecognised by both service providers and Aboriginal women
A Queensland study linked PND with overcrowding, substance misuse,
unemployment, money problems and lack of support. More research is required into the links
between maternal depression in indigenous women and CM/FTT.[14]
Domestic Violence
A recent report on child abuse in indigenous communities found there were high rates of
violence, including domestic violence, in indigenous communities in the NT. A 2007 study at
ASH found that hospitalisation rates for injuries due to assault are significantly higher for
Aboriginal women. There is evidence that violence towards women is more common during and
after pregnancy. Abuse during pregnancy has been associated with preterm birth and LBW.
Internationally, exposure to violence in young children has been shown to result in posttraumatic stress disorder, aggression, attention problems, and depression. The effect of trauma on
the developing brain is now well recognised.[12]
Foetal Alcohol Syndrome (FAS) and Foetal Alcohol Spectrum Disorder (FASD)
Children with FAS / FASD have poor somatic growth both in utero and in the early years.
FAS/FASD is considered difficult to diagnose before 2 years of age. In the NT prevalence of FAS
has been assessed at 4.7 cases/1000 live births compared to 0.7/1000 for non-Aboriginal women
[64]. A higher estimated prevalence of 15/1000 was identified in the Aboriginal paediatric
population in Far North Queensland. The highest reported rates outside of Australia are in South
Africa with a prevalence of 5/1000 [13].
Parenting Styles
Research from developed countries has identified 3 aspects of parenting that are consistently
related to young childrens cognitive and social-emotional competence; cognitive stimulation,
caregiver sensitivity and responsiveness to the child, and caregiver affect. However the effect of
these factors has been shown to be sensitive to contextual factors such as poverty, and cultural
values and practices [12].
Indigenous parenting styles can vary from acculturated to more traditional approaches.
Australian surveys have identified enormous diversity in Aboriginal family life and living
circumstances, with striking variations in care arrangements of children in families across levels
of relative isolation and age groups as well as culturally different meanings attached to concepts
of family unit, family relationships and responsibilities. Even so, it is argued that broad themes
associated with indigenous parenting styles persist. These include that shared parenting occurs in
an extended family context, the parents role is not to shape and create behaviour but to provide a
context for its expression, and children are allowed to make many decisions because they are
considered a person in their own right and are free to explore their own environment. This has
obvious implications for feeding of children.

Research on indigenous parenting in Australia has found that Indigenous Australians

understandings of poor child development can significantly differ from those of health
professionals, and that indigenous parenting practices could be interpreted as passive, permissive
and lacking control of childrens behaviour compared with mainstream parenting practices. An
ethnographic study exploring child rearing styles among the Ngaanyatjarra people found that
differences in child rearing styles could lead to tensions with health staff, especially where
mothers had less control over their children than non- Aboriginal people expected. In some
circumstances families may follow culturally congruent approaches to parenting, even though
there may be adverse consequences for their children perceived by others [15].
Population mobility has a negative impact on child growth, especially younger children needing
weaning foods. Children often experience slow growth or a decline in weight when they are
away from the community. A community based nutrition study estimated population mobility in
a CA community to be 35% of the community population. Highly mobile children are difficult
for clinicians to monitor. The study found that mothers acknowledge the impact of mobility on
child growth [7].
The literature on malnutrition is unanimous in calling for a focus on the alleviation of poverty.
Poor children are more likely than their wealthier peers to have less diversified and nutritious
diets, to report episodes of infectious disease, including fever and diarrhoea, to live in foodinsecure households, and to be exposed to unhealthy household environments with reduced
access to health services. Poverty is also associated with poor maternal education, increased
maternal stress and depression, and inadequate stimulation in the home. Risk factors for poverty
tend to occur together, and the development deficit increases with the number of risk factors.
Developmental deficits are seen in infancy and increase with age [3].
However, a number of recent studies from the UK have challenged the traditional assumption
that FTT is strongly linked to family poverty, arguing that in the UK and similar populations FTT
is more likely to be related to child characteristics, or the maternal and child feeding interaction.
In Australia there are debates about the relevance of international measures of poverty to the
unique economic position of indigenous Australians as a minority in a wealthy first world nation
Medical assessment
Guidelines for the clinical assessment of CM and FTT are well covered in the medical literature.
Common elements of clinical assessment across the literature from the developed countries
include; a comprehensive medical history and physical examination, dietary history and
assessment, developmental assessment, observation of parent-child interaction, feeding

observation, comprehensive family history including assessment of family stress/ dysfunction/

neglect and the childs broader social environment.
The timing and use of laboratory tests for clinical assessment is contested. Overall laboratory
tests are seen as not being cost effective and having limited value since major organic disease is
found in only 3- 5 % of cases of FTT and the yield of positive laboratory data is generally very
small. However this may be different in the CA context. A CA study found that 43% children
hospitalised with malnutrition had an acute illness and clinical investigations yielded a high rate
of abnormalities, often occurring with multiple co-morbidities [3].
Psychosocial assessment
There are concerns about the over medicalisation of CM/FTT. The social work and nursing
literature warn against a purely medical evaluation to the exclusion of an assessment of
psychosocial factors and recommends a multi factorial and holistic assessment framework.
Iwaniec argues that FTT is like a jigsaw puzzle requiring an integrated response incorporating
nutritional and psychosocial factors together with a multidisciplinary team. She argues that the
wait and see approach should be avoided. The earlier FTT is identified, the easier it is to
respond with universal or targeted services. More complex cases require a tailored response to
the specific requirements of each family. A social work assessment can be used to develop a
shared understanding of the problem with the family. All contributing factors need to be
addressed, but it is recommended to begin with the least intrusive elements and tailor the
approach to familys strengths and needs. A thorough assessment itself can be effective in
provoking change[5].
Iwaniec discusses the application of ecological models, cognitive-behavioural approaches and
attachment theory in working with FTT, although some authors have critiqued the use of
attachment theory with indigenous families, given the cultural differences in child rearing. An
ecological theoretical framework is popular in the literature. Iwaniec describes an assessment
framework for children introduced by the UK Department of Health in 2000. The framework is
based on ecological theory and explores parental capacity, childrens developmental needs,
family factors, and wider societal, cultural and environmental factors [5].
Mothers views of poor growth
Very little is known about mothers views of childrens growth. It is argued that encounters
between service providers and parents regarding childrens growth can involve transactions
between two explanatory models that can result in communication and relationship problems
[67, 83]. An ethnographic study of the explanatory models (EM) of mothers of growth deficient
children in the US found that mothers had different EMs for size and growth. The cause of size
was seen as hereditary and beyond the mothers control, whereas the cause of growth was seen as
increased food. The study highlighted the importance of understanding mothers views of growth
in any intervention.
Ethnographic and participatory research projects in the NT have identified differences in
indigenous and non-indigenous understandings of growth that have implications for how

nutritional and health messages are delivered. Among the Ngaanyatjarra people, an ethnographic
study found that cultural differences in feeding practices and the cultural meanings of food could
lead to misunderstandings with clinic staff. Gill highlighted the need for clinicians to understand
culturally constructed meanings of growth in addition to biomedical meanings.
A community development project in Arnhem Land found significant differences between
indigenous and health service providers understandings of child growth. It highlighted a failure
to develop shared understandings of key constructs around the problem and its solutions.
Indigenous participants were more concerned about poor child development as a result of
inadequate care than they were about poor physical growth and growth monitoring. .
A community based nutrition project at a remote CA community found that Aboriginal people
attributed poor growth mainly to social and economic reasons. Again it stressed that nutrition
programs need to address participants understandings in order to be effective.
These studies indicate that a critical element in the success of interventions for child growth is to
develop a shared understanding of the problem with caregivers. A systematic review of lay
views about infant size and growth found that lay views as well as scientific views need to be
considered to maximise the effectiveness of public health advice.
In a paper on child protection, Scott argues that The definitions of the problem, the approach
taken and the suggested solutions are usually defined by the professionals involved. She says it
is important that clients or recipients of services are at least equal participants in defining and
responding to the needs of their children. This poses particular challenges to health professionals
and families in the NT due to language and cultural differences.
Multidisciplinary Approach
The literature is unanimous in recommending a multidisciplinary approach to the assessment and
treatment of CM/FTT, given its complexity [1,3].
Kessler advises that assessing FTT requires that practitioners embrace complexity by
simultaneous assessment of risk factors in multiple domains [1]. Outpatient team approaches
have been shown to decrease the frequency of hospitalisation.
A UK study identified that differing professional responses to FTT in the health and social care
sectors led to deficiencies in assessment, consistency, and interdisciplinarity which resulted in
some children dangerously falling through a gap in care. Taylor advised that there is a need for
models of assessment that enhance joint working and sharing of information [82].
A Multidisciplinary Feeding Clinic at Westmead Childrens Hospital has adopted an approach to
working with children with clinical feeding difficulties where medical, nursing and allied health
professionals work with community based agencies and families as part of a multidisciplinary
The operation of multidisciplinary teams has not been extensively evaluated. There are differing
views about which professions should be involved and which team structure is most effective.

Various models are identified in the literature. In multidisciplinary and interdisciplinary teams,
professionals make individual assessments and feed them into the team plan in different ways. In
a trans-disciplinary team there tends to be more of a deliberate crossing of traditional disciplinary
boundaries. Team membership may include combinations of a doctor, nurse, social worker,
physiotherapist, health visitor, psychologist, clinical consultant, dietician, speech pathologist and
OT. It has been suggested that there is a need for coordinated interdisciplinary protocols in order
to define professional roles and the way in which they relate and work with each other. It is
recognised in the literature that a full multidisciplinary team may not always be available,
especially in rural areas, and not all disciplines required for assessment may be present at the
same facility [80, 88]. Protocols are recommended for interagency collaboration to avoid gaps in
service delivery or duplication of roles [8].
It is acknowledged that a multidisciplinary approach can require a high level of working
partnership both with colleagues and family [5].

Treatment and Interventions

Interventions for families and children are methodically problematic. There is very little good
evidence for the effectiveness of interventions for CM/FTT from systematic reviews of random
controlled trials as few studies fit the strict scientific criteria. There are many influences on
childrens growth that are difficult to monitor and measure. Evaluation of social interventions
presents problems not generally encountered in more clinical settings.
Primary Prevention
There is consensus in the literature that prevention is the best intervention for undernutrition and
that solutions to undernutrition should be community and population based. Although
intervention strategies in one primary health care setting do not necessarily work in another,
broad elements of prevention are seen as incorporating universal programs, structural change,
capacity building and long term commitment from government and non-government sectors.
Researchers argue that primary prevention requires a broad scale political commitment to
addressing the social, economic and environmental inequities experienced by Aboriginal
Australia [3].
Themes in the child protection and early childhood literature relating to interventions include an
emphasis on the merits of community based approaches which foster social networks and
strengthen partnerships. The need to reduce risk factors and strengthen protective factors has also
been a consistent theme, although there is little evidence on specific risk and protective factors
for Aboriginal families. Overall there is an emphasis on holistic prevention and strategies and
coordinated, integrated whole of community approaches.
It is argued that Australia is only just beginning to recognise the importance of embedding
services for young children into holistic community capacity-building programs. Integrated
services are recommended, such that early childhood services are linked in with community
development initiatives and services that are already connected to families (child and maternal

health, early childhood education, schools, adult mental health, drug treatment services). A
model of integrated hub based services has been shown to be successful overseas and was a
recommendation of the Little Children Are Sacred Report. Strengths-based and ecological
approaches are recommended that focus on childrens wellbeing, and pay attention to broader
family, community and societal conditions.
However in Australia researchers have warned that ameliorative programs alone will not solve
structural disadvantage [5].
The literature also identifies that effective community based programs should not lead to the
replacement of individually-targeted programs. Not all prevention efforts will reach those who
need them, or will be successful with those they reach [8].
Care Practices
In the 1990s international agencies took the lead in placing care at the centre of child survival,
growth and development. Care was identified as the critical link between food and health
resources, and the childs physical growth and psychological development. It was argued that
enhanced caregiving could optimise the use of existing resources even in conditions of poverty,
food insecurity and limited health care. A UNICEF model identified care as the provision in the
household and the community of time, attention and support to meet the physical, mental, and
social needs of the growing child and other household members. Care practices were identified
as care for women (prenatal, safe birthing, equal access to education), breastfeeding, food
preparation, hygiene practices and home health practices, and good psychosocial care (warmth,
verbal interaction, encouragement of learning). UNICEF describes a continuum of care that
includes the dimension of time ensuring essential services during pregnancy, childbirth,
postpartum, infancy and early childhood, and place linking delivery of services in a primary
health care system that integrates home, community, outreach and clinical services at primary
health facilities and district hospitals. UNICEF claims that gaps in care in developing countries
are often most severe in households and the community, locations where care is most required
(UNICEF 2008).
In Australia, a WA survey on indigenous children found that strains on the potential care
practices of households and communities can lead to fewer opportunities for Aboriginal children
to be buffered by protective influences. It is very difficult to hold the infant in mind when the
whole community is suffering. The compounding of family and community risks frequently
underlies the vicious cycle of deteriorating conditions affecting children, families and
communities [1].

Secondary Interventions
Combined interventions
A WHO evaluation [29] of the effectiveness of interventions for improving physical growth
and/or psychological development where children were suffering from malnutrition and
developmental delay due to poverty found that appropriate feeding (food and practices) and

responsive parenting (attentive listening, proactive stimulation, appropriate response) were more
effective as a combined intervention than when delivered alone.
Combined interventions were likely to have the most impact prenatally and during infancy and
early childhood. Children at highest risk showed the greatest response to growth and
development interventions. A number of delivery channels (eg home visits, group counselling,
preschool centre-based programs, mass media) were more effective than a single channel and
programs were more effective when parents were involved. WHO recommends community
based interventions with community ownership and decision-making.
Community based interventions
Although there is little good quality data on the effectiveness of prevention or early intervention
programs for growth faltering in remote indigenous communities, evidence for a range of
interventions was assessed by a recent review [5]. The interventions included:
food supplements
growth monitoring
education and counselling
de worming
vitamin and mineral supplements
multiple micronutrient supplements
The review found that growth faltering may be prevented by community-based nutrition
education/counselling interventions using a range of strategies and involving carers, community
health workers and representatives, as well as addressing the underlying causes of growth
faltering. It recommended that other interventions should only be considered in the context of a
broad primary health care approach and/or based on identified local needs [11].
A research project into early childhood in Alice Springs identified a number of gaps in child
health services, including gaps in access and equity for indigenous children, gaps in child care
services, post-natal follow up of children, post-natal follow up of women living in town camps,
follow up of women from remote communities, and problems with discharge summaries and
referral procedures for newborns. The report identified gaps in service provision between
problems being identified in a family and the child being removed by FACS and placed into
foster care. Possible services suggested were family support, parenting, and family counselling
services. The report recommended an expansion of home visiting and community outreach
services as well as consideration of funding a centre-based child health education and support
Nutrition Interventions
There is evidence from developing countries that nutrition interventions during pregnancy and
early life reduce stunting. Although Australian research identified the need for improved
nutrition in pregnancy and early childhood over a decade ago, there is little good evidence of the

success of nutrition programs in Aboriginal communities. This may be due to a lack of good
quality data, as well as lack of political commitment to sustained programs in communities.
Remote nutrition services in the NT are based on a primary health care model and are aimed at
resourcing community initiatives. They offer limited case management which may be
problematic. A nutrition awareness project initiated in 1996 by NPY Womens Council initially
aimed to support mothers of children with FTT at ASH. However the need for a more intensive
and comprehensive case management approach was identified due to the serious and complex
nature of the cases [4].
Supplementary Feeding Programs
In Australia, food supplementation programs such as breakfast programs and school lunches
were provided for Aboriginal children in the past but became politically unpopular as a result of
concerns about paternalism and the perpetuation of welfare dependence. A number of researchers
have grappled with the place of food supplementation as a response to the poor nutritional status
of Aboriginal children. Gracey states that it is difficult for paediatricians not to advocate for food
supplementation when poor nutrition is clearly a key issue for Aboriginal children and infants
[49]. Brewster has been a vocal advocate for food supplementation programs. He recommends
integrated nutrition programs targeting at risk families by communities committed to
addressing childhood malnutrition and taking ownership of the programme [51]. In recent years
many remote communities have again developed school feeding programs and a number of
communities have child care facilities providing meals to younger children as well as education
and support to mothers [3].
Food supplementation has consistently been shown to benefit childrens current nutritional status
and cognitive development, but there is little information on the long term benefits of food
supplementation. It also worth noting that most preschool and school feeding programs do not
target young children who are most at risk from undernutrition. If there is a choice between the
two, prevention is recommended rather than food supplementation for long term benefits [3].
Growth Monitoring
In most primary care services in the NT regular growth monitoring is performed via the Growth
Action and Assessment (GAA) program. GAA was developed and implemented in Central
Australia in 1998 in response to concerns about poor growth. The aim of GAA is to improve the
growth and nutritional status of children less than 5 years, and involves promotion of growth and
good nutrition, regular monitoring of growth and implementation of early action if growth
falters. In recent years with the centralisation of program management in the NT, GAA has
become more focused on monitoring and data collection, although some of the other elements
remain [4].
Growth monitoring has come under scrutiny in recent times. A much quoted systematic review
found little evidence for the benefits of routine growth monitoring. This may be related to an
emphasis on weighing and charting, rather than follow up action. A worldwide review of growth
monitoring in developing countries identified both conceptual (eg interpreting growth charts) and
practical (eg lack of equipment) problems. There were consistent difficulties for health workers

associated with plotting and interpretation of charts, understanding concepts of child growth and
of child at risk, and practical difficulties [14]. Some argue that growth charts are conceptually
abstract and difficult to interpret.
Several Australian studies have reported problems with growth monitoring. A project in Arnhem
Land found that deficiencies with the GAA program included insufficient involvement of
families and communities, poor understanding by health service providers of social and cultural
issues impacting on indigenous childrens growth, poor understanding of growth monitoring by
families and health service providers, and the need for community action to improve growth. A
nutrition program at Kintore identified that the high staff turnover at the health clinic may cause
relapses in growth monitoring and education of new mothers.
There is a consensus in the literature that growth measurements, growth standards and the
effectiveness of routine growth monitoring are best decided at a regional level. Given the high
rates of growth failure in the first few years of life in Aboriginal children, growth monitoring
continues to be recommended for the NT provided that children with growth failure are followed
up by an appropriate action plan including history, examination, tests, advice, and follow-up
including home visits[5].

Tertiary Interventions
Alice Springs Hospital is not alone in its conundrums around hospitalisation for children with
FTT [99]. Clinical decision-making is complicated by the lack of consensus around definitions
and diagnosis, as well as the lack of a clear evidence base for the effectiveness of interventions.
The role of hospitalisation for CM/FTT
There are advantages and disadvantages of hospitalisation for CM/FTT identified in the
literature. Hospital is seen as providing a more controlled environment to assess caloric intake,
feeding techniques, and parent-child interactions, as well as providing access to multidisciplinary
interventions. Nutritional rehabilitation can occur in a medically safe environment and careful
discharge planning can enable referrals and follow up.
However these advantages are often offset by the disadvantages of separating the child from their
family and home environment, inconsistencies in staffing, pressures on the childs carer in the
hospital environment, the impact of hospital distractions on feeding, the risks of hospital
acquired illnesses and the high cost of hospital admissions.
In Australia Russell et al claim that the role of hospitalisation in the management of malnutrition
should be the identification and treatment of organic factors, nutritional rehabilitation,
assessment of feeding and parent-child interaction, addressing social issues and enacting a
nutritional plan on discharge [53]. Brewster stresses that although hospital has a role in
assessment, follow up should occur in the community where possible [3].

Rural hospitals in Australia are used to rehabilitate malnourished Aboriginal children when
community-based interventions have failed, or when the child has an intercurrent illness [7].
Brewster agrees that hospitalisation may be necessary where community-based therapy is failing,
however he argues that hospitalisation should be reserved for children with severe wasting,
dehydration and/or infection. He stresses the importance of accurate growth assessment in
sorting out the difference between wasting and stunting if a child is underweight in order to
facilitate decision making about hospitalisation. Severely wasted children should be treated in
hospital, but stunted children are best treated in the community [3, ].
In Australia there are inconsistencies between hospital and community based treatment
recommendations for CM/FTT [106]. Improved integration and consistency of hospital and
community based treatments for severe malnutrition is recommended [5].
When should a child be hospitalised for CM/FTT
There is debate in the literature as to when a child should be hospitalised for malnutrition and
FTT. Historically, hospital based care has been the standard treatment for children with severe
acute malnutrition based on WHO guidelines [8]. Royal Darwin Hospital (RDH) has developed
diagnosis and treatment guidelines for paediatric malnutrition based on the WHO
recommendations. Hospital care has also historically been a routine part of the initial
management of patients with FTT.
In the US and UK hospitalisation for FTT now tends to be recommended only for children with
multiple nutritional, medical and psychosocial complications (eg severe FTT and/or if abuse or
neglect is suspected), where intensive outpatient management has failed or where there are other
threats to the childs safety. These changes can lead to tensions in hospitals between
administrators and clinicians, as well as between clinicians themselves. In the US Schwartz has
argued that even though hospital administrators are increasingly reluctant to authorise
hospitalisation for the evaluation and treatment of FTT, clinicians need to advocate for
hospitalisation when necessary. However he also advises clinicians to treat on an outpatient basis
where possible [9].
In a paper called When should a child be in the hospital?[102] Dougherty asserts that the
necessity for hospitalisation will depend on the specific services which are needed, and the
degree to which these services might be available in the home or in other alternative settings
This has relevance to the CA context, given the socio economic disadvantage and multiple risks
experienced by many Aboriginal children, as well as the lack of a basic community based family
support infrastructure to support children and families at home [5].
A WA study found that children were likely to be admitted to hospital more readily and
discharged later where there were barriers to access to local health facilities and availability of
skilled staff, a perceived likelihood of poor compliance with medications, limited opportunities
for follow up care after discharge, and where patients lived a long distance from hospital [103].
In 2006, 81.2% indigenous population in the NT lived in remote or very remote locations [39].

These issues highlight some of the dilemmas in CA clearly decisions around hospitalisation are
influenced by a range of factors including diagnostic complexities, the availability of community
based services and treatments, levels of disadvantage, economic considerations and policy
When should a child be discharged from hospital?
Discharge from hospital is assessed on anthropometric, behavioural and psychosocial criteria.
The WHO recommended anthropometric criteria for discharge from hospital are weight-forheight -1 SD (90%) of the median NCHS/WHO reference values. WHO advises that in some
instances a child may be discharged before he or she has reached the target weight-for-height for
discharge, however the child would need ongoing care on an outpatient basis. Psychosocial and
safety factors are considered important to resolve before discharge, as the childs social
environment is the context in which malnutrition developed [8].
An early Sydney study highlighted the importance of long term treatment for NOFTT. It
recommended close involvement with community agencies in any treatment plan, given their
role in following up the child on discharge. The study criticised the practice of keeping children
in hospital for weight gain and then discharging them to the same situation. It argued that this is
only of short term benefit unless the home environment can also be improved [10]. Sampson
agrees that the treatment plan needs to rehabilitate the care giving environment as well as the
child [8].
In the NT, RDHs CM/ FTT clinical guideline [5] recommends that children should meet one of
the following discharge criteria;
Weight for height Z score < - 2.0 OR > 80% SWFH and appetite returned
75-80% SWFH and gaining > 5g/kg/day on oral diet, mother educated on appropriate diet for
home, hygiene, social issues addressed if required and food supply secure at home
If poor social situation/food security issues not in process of being resolved consider remaining
an inpatient until weight for height Z score -1.0 of (90% SWFH)
Additionally a nutrition discharge plan should include;
Identify need for ongoing provision of paediatric food supplement
Education about weaning diets, adequate diet for growth, consequences of ongoing poor growth
Recipe for concentrated formula if required and ensure mother able to make up
Discharge summaries faxed to the clinic
The effectiveness of hospitalisation for CM/ FTT
There is limited evidence for the effectiveness of hospitalisation for FTT. Schwartz claims that
meta-analysis has highlighted the efficacy of hospitalisation for physical growth, more than
psychosocial improvement [2]. The only Australian study on the effectiveness of hospitalisation
for children with malnutrition found mixed outcomes. Hospital admission was effective in reestablishing weight gain but at the cost of high rates of readmission (53% within 6 months) and
hospital acquired infections (38%). Children continued to grow 2 months after hospitalisation,

but they did not sustain catch-up growth. Hospital was also effective in identifying the organic
contributors to malnutrition [3].
Brewster has argued that the emphasis for treatment of malnourished Aboriginal children in the
NT needs to change from hospital case management with enteral tube feeding to improved
community management in a primary health care setting. He argues that hospitalisation has high
relapse rates, is less effective in identifying the underlying causes of malnutrition, and is a costly
intervention that is disruptive for the child and carer. He attributes this approach to childhood
malnutrition to the affluence of the Australian health care system [1].
Intervention Delay
Russell et al found that there was an intervention delay in CA of approximately 6 months
between recognition of a child not gaining weight and admission to hospital. The median age at
recognition of malnutrition by community clinics was 8.6 months, yet the median age at index
admission was 15.1 months. 76% of children in the study had not gained weight for 3 months
prior to admission and 24% had crossed down 2 major percentile lines. The study did not review
what interventions had occurred in the community or the timeliness of hospitalisation, but did
recommend the importance of early intervention. The study only included children who were
admitted to ASH and did not identify children for whom community interventions were
successful and so were never admitted [3].
A UK community based FTT service found a similar delay between growth faltering and referral
to a specialist service. It argued that practitioners need to strike a balance between waiting for
positive change to occur and prompt intervention if the child is at risk. Early identification is
critical, since the longer and more severe the poor weight gain, the more serious the
Role of parents
Little is known about families experience of FTT. A Canadian qualitative study of families of
children in hospital with FTT found that parents often felt blamed, isolated and helpless, and
were affected by negative attitudes of health care professionals. Families appreciated being
included in care team and having their expertise on the child valued [4].
The literature emphasises the importance of the role of the parent or caregiver in hospital. Carers
are seen as essential to the diagnostic and therapeutic process. Parental involvement in the
multidisciplinary team is considered to promote better follow up post discharge and better
parenting. The importance of a non judgemental attitude is emphasised in the literature from
developing and developed countries [1].
A Scottish social work study on NOFTT quotes Marcovitch in suggesting that although the
community is considered the most appropriate intervention setting for undernutrition, parents
may favour hospital intervention as non-medical approaches can imply a failure to care for their
children and parents may feel stigmatised [6].

An ARACY review of the research into parent-provider relationships found that developing
positive partnerships with parents requires empathy, respect, genuineness and a willingness to
work collaboratively with families. There may be organisational constraints to this in ASH where
a stigma and history of child removal and legal obligations to report suspected child abuse or
neglect can act as a barrier to trust of health professionals. Organisations can enhance positive
worker-parent relationships by creating a culture of inquiry and refection that encourages a
questioning of assumptions about families needs, problems and resources, and by providing staff
supervision and training in cultural competence [5].


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