Incidence of Failure to Thrive and its Risk Factors in Children 0 to 24 Months Referred to Health Centers in Bojnurd City during 2008-2013
Failure to thrive (FTT) is a global problem and one of the most common and important health problems in childhood that is involved in many other factors such as social, economic and cultural factors. Considering the adverse effects of FTT in the future of children, we studied to investigate FTT and its related factor in children under the age of 2 years in Bojnurd.
Materials & methods
This study was a retrospective cohort study on 1000 health records, born in 2007-2009. Sampling method is based on simple random method. The data was collected using a checklist in existing health centers. Finally, the data were analyzed using Chi-square, logistic regression and independent t-test in SPSS19 software, with less than 5% error.
Of the 1,000 children examined, 257 children, 25.7% of the total, had experienced FTT in their first two years of life. There was a significant relationship between head disorders at birth, maternal age at delivery, mother's education level, type of delivery, unspecified gestational age with FTT in children.
Considering the high incidence of FTT in children, increasing awareness about timely feeding and promoting the health of the households, prevention and control of infectious diseases are recommended to improve the development of children.
FTT, Risk factors, Children
Failure to thrive (FTT1) is a global problem and one of the most common and important health problems in childhood that is involved in many other factors, such as social, economic and cultural factors . In fact, FTT is associated with an inadequate physical growth or inability to maintain the desired growth rate over time, in children . In developing countries, FTT causes disrupt in children's weight, mental development, mental health and defenses against infection. According to WHO, more than 30% of children under the age of 5 year suffer from FTT, of which 80% have stunting and 20% are underweight . According to studies, the prevalence of FTT in third world countries is higher than in other part of the world, and in most of these countries, the physical growth of children is lower than the international standard. In our country 16.3% of girls, 15% of boys and totally 15.7% of children are underweight and 18.4% of girls, 19.5% of boys and totally 18.9% of children are stunting . On the other hand, in our country, the most prevalent age of FTT is 6-12 months, which is at the same time as the onset of supplementary feeding and stunting is from 12 to 24 months of age . Low birth weight increases with age, so that at 2 years of age it reaches a peak of 13.8% . One of the most important causes of FTT is the deprivation of the baby from breast feeding, the early or late start of a supplementary feeding, not giving enough food to the child, child illness, emotional and psychological problems, non-compliance with health issues and the use of unhealthy water . The studies show that 46% of the FTT are due to non-specific causes (poverty and lack of access to inadequate food, low parenting education) and 26% of the cases are due to organ causes . Obviously, identifying risk factors is possible by monitoring the growth of children. Growth monitoring is one of the most important sources of information to diagnose FTT and malnutrition in children. Also, FTT is usually a very slow process, not recognizable by the families. Considering the above-mentioned issues and the adverse effects of future growth disorder in children, including possible mortality, increased other related diseases, reduced learning ability and reduced mental and physical capacity; Since in our country there are few studies on the risk factors of FTT, we examined FTT in children under the age of 2 years and factors that affecting it, in the city of Bojnurd.
Materials & Methods
The present study was a cohort-retrospective study on 1000 health records. The target population was children who were born in Bojnurd city and had health records in the years of 2008-2013. By using a stratified sampling (based on the year of birth and urban sanitary facility in Bojnurd), the quota of each center was determined and then equally distributed in each cohort of birth. Based on simple random sampling, household records were selected. The data needed in this study was collected using a checklist that was derived from maternal and child care records and available in health centers. Information collected in this checklist includes the physical growth of children (weight, height, head circumference) over two years, as well as variables such as demographic characteristics and underlying diseases of the mother, as well as the previous pregnancy status of mothers. The criteria for selecting cases in this research are the use of random selection as well as the completeness of the file in terms of the variables under consideration. In the case of incomplete data (due to being illegible, incomplete, confusing, etc.), the following file was used for review. Finally, the data were analyzed by Chi-square, logistic regression and independent t-test using SPSS19 software with less than 5% error.
In this study, 1000 health records of children were studied. There were, 522 boys (52.2%) and 478 girls (47.8%). The mean and standard deviation of maternal age at delivery is 26.8 ± 5.3 years. 87.5% of mothers were housewives and 44.3% had undergraduate education. Of the 1,000 children examined, 257 children (25.7%) had FTT, and 743 children had no FTT (74.3%). The frequency of FTT shows in Figure 1.
The highest FTT was shown in 18 months of age that was 13.2%, the least FTT at 3-5 days of birth that was 0.1% and no abnormality was observed at birth. The frequency of FTT based on the months shows in Figure 2. The quantitative characteristics of the factors affecting FTT are presented in Table 1.
As it is seen, head circumference in children with FTT is significantly lower than those without FTT. Also, there is a significant difference between maternal age at delivery in two groups. The qualitative characteristics of the factors affecting FTT, maternal high risk pregnancy status, previous pregnancy are presented in Table 2. FTT is higher in children whose mother's age is under 18 years. Also FTT is lower in children whose mothers have higher education levels. There is a significant relationship between type of delivery, unspecified gestational age with FTT in children. However, there is no significant relationship between the history of previous pregnancy of mother with FTT in children.
In the present study, the incidence of FTT was 25.7 with a confidence interval (23-28.5). 37.4% of children were underweight. 15% were stunting. Similar studies have reported low birth weight among children of 26.6% . Also in this study, children's FTT started from one year old and the highest was at 18 months about 13.2%. Also, there was a significant relationship between head circumference at birth and FTT in children. So that children with FTT had less mean head circumference. Such studies confirm our results. They had shown that children aged 0-11 months were less likely to develop FTT, which may be due to the protective role of the breast feeding . At 12 months of age, a further FTT appears, which can be attributed to inappropriate complementary nutrition . In the present study, there was no significant relationship between the history of high risk pregnancy in mothers and FTT.
Such studies have reported different results. So history of abortion, stillbirth, cesarean section had a significant relationship with children's FTT [9,10]. Also, there was a significant relationship between maternal age during labor and FTT in children. Mothers who were younger than 18 year at the time of delivery were more likely to develop FTT in their children. However, no significant relationship was found between age of mother over than 35-years-old. Such studies have also shown that the age of mother under 24 year and over than 35 year increases the risk of developing child's FTT؛ Which can be attributed to the lack of readiness of the mothers for taking care of their children and the lack of livelihood of mothers . In the present study, there was no significant relationship between birth ranking, number of children, first pregnancy, fifth pregnancy, and FTT, but studies have shown that children born in families with more than 3 to 5 children are more likely to have FTT; Which can be attributed to less paid attention of parents to their children [5,10,11]. Also, in this study, there was no significant relationship between the gestational interval less than 3 years and FTT in children, but such studies have shown that the interval between pregnancies less than 3 years increases the risk of developing FTT in children, which contradicts with our study [12,13]. In this study, maternal BMI, height less than 150 cm, mother's desirable weight gain during pregnancy had no significant relationship with FTT in children. Such studies have been reported contrary results. They have shown that maternal weight, maternal height plays an important role in the development of FTT . In the present study, there was no significant relationship between the type of infant feeding, the onset of supplemental nutrition with FTT in children; however, Such studies have shown that long-term breastfeeding, early or later onset of supplemental nutrition, help to increase the incidence of FTT in children . In this study, there was no significant relationship between the sex of the child and mother's occupation with FTT; However, such studies have shown that boys , some girls  were more susceptible to FTT, and the incidence of FTT is greater in working mothers. There is also a contradiction with the results of our study . In the present study, there was a significant relationship between mother's education level and FTT in children, so that higher education has a preventive role in the development of children's FTT. Such studies confirm our results; that can be attributed to better management, greater use of health services and promotion of health care in these people [12,16]. But such studies did not show a significant relationship between the level of mothers education and childhood FTT, unlike our results . Also, in this study, there was a significant relationship between type of delivery and FTT. Natural delivery is a preventative factor in the development of childhood FTT. Such studies confirm our results . In this study, there was a significant relationship between uncertain pregnancy age and the incidence of childhood FTT, which increased FTT 3.6 times. Such studies confirm our results . Also, in this study, there was no significant relationship between mother's disease history with FTT, but such studies have shown that maternal diseases had been associated with FTT in children, which contradicts with our results .
In this study, there was no significant relationship between high risk behaviour in mothers with childhood FTT, which can be attributed to low maternal reporting due to social shame. But unlike this study, such studies have also reported significant results . Regarding the high incidence of FTT in children, increasing parents' awareness, Start timely nutritional supplements, promotion of household health and prevention and control of infectious diseases are recommended to improve the growth of children.
Conflict of Interest
The authors declare that they have no conflict of interest.
The authors would like to appreciate Health Center staff, who help us in the present study.
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Andishe Hamedi, M.Sc in Epidemiology, Shirvan Center of Higher Health Education, North Khorasan University of Medical Sciences, Shirvan, Iran.
© 2019 Lashkardoost H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.