Failure to grow: lack of food or lack of love?
AbstractOne of the most important criteria for good health in childhood is normal growth. Taking regular accurate measurements of length and plotting them on a centile chart is essential to spot early signs of growth disorders. Be alert for a "zig-zag" pattern on the chart: it could indicate psychosocial dwarfism (see opposite). Length is more important than weight for identifying growth disorders. Lack of love, or an adverse emotional or social environment, can cause growth failure even in a child who is eating enough. Such children have a condition called psychosocial dwarfism, which is due to hypopituitarism (too little growth hormone secretion from the pituitary gland). This condition does not respond to growth hormone treatment. Once the child is placed in an alternative environment, eg a good foster home, the hypopituitarism is reversed and rapid "catch-up" growth takes place. It often emerges that such children have been physically, emotionally or sexually abused.
The following 3 subtypes are described, based on the patient's age at presentation and the clinical findings:
- In type I PSS, the age of onset is infancy. Usually, failure to thrive (FTT) is present, but no bizarre behaviors are observed. Patients are often depressed. Normal growth hormone (GH) secretion is found, but responsiveness to GH is unknown. No history of parental rejection is present in type I PSS.
- In type II PSS, the age of onset is 3 years or older. Some of these patients have FTT. Bizarre behaviors are usually observed, and patients are often depressed. Decreased or absent GH secretion is found with minimal responsiveness to GH. A history of parental rejection or pathology is present.
- In type III PSS, the age of onset is in infancy or older. FTT is not usually present, and bizarre behavior is not usually observed. GH secretion is normal; responsiveness to GH is significant. No history of parental rejection is present.
Several authors have suggested that the following historic factors are important in making the diagnosis of classic PSS:
- Psychological disturbance is present.
- Bizarre behaviors centered on food and water acquisition, despite seemingly adequate caloric and fluid intake and its availability (polyphagia, polydipsia, hoarding food, gorging and vomiting, eating from garbage bin, drinking from toilet, stealing food)
- Sleep disturbances (insomnia, night wandering)
- Abnormal behaviors (withdrawal, apathy, anxiety, irritability, temper tantrums, shyness, accident proneness, self-injury)
- Developmental delays (speech retardation, cognitive retardation, psychomotor retardation)
- The caregiver appears to have some psychopathology, and the relationship with the child appears or is known to be abnormal. The following can apply to mothers or caregivers and/or the environment:
- Personality disorders
- Domestic violence or marital instability
- Substance abuse
- Absent spouse or father of child
- Myriad of other child abuse–associated issues involving poverty, poor education, generational abuse, and neglect
- Abnormal endocrine function is present but normalizes when the child is removed from the unsafe and nonnurturing environment.
- Malnutrition or inadequate caloric intake alone is not demonstrated to be the primary cause of the growth failure. However, steatorrhea is often observed in individuals with type II PSS.
- Diagnosis of PSS is confirmed by the removal of the child from the unsafe or nonnurturing environment and observation of the following with time:
- Demonstration of catch-up growth
- Improvements in behaviors
- Normalization of hormonal disturbances
This, sadly reminds me of the two adorable brothers who are failing to grow. I wish I could give you the love you are not getting. Hugs and kisses, I wish they would reach you from afar.