When Failure to Thrive Is About Our Failures: Reflecting on Food Insecurity in Pediatrics

She was a small, pink bundle resting quietly in her mother’s embrace. Yet, in looking closer, and even before unwrapping her gently tucked outer layer, I could see that her eyes were wizened and weather-beaten. The bony prominences of her cheeks jutted out inorganically; the overlying skin was pallid. She was 2 months today but could not have appeared larger than a 2-week-old. Her beanie engulfed her head, oversized like that of a doll in dress-up clothing. It was clear that she was not growing. That was why she was here.

Though recent literature has transitioned to the use of the term “growth faltering” to better underscore the anthropometric parameters associated with growth challenges in infancy and to eliminate undertones of parental blame and guilt, “failure to thrive” remains an imbedded aspect of our every-day jargon in pediatrics.¹  At its core, it encompasses a 3-pillared framework that helps delineate the myriad causes of growth issues; this includes the many reasons for inadequate caloric intake, insufficient nutrient absorption, and increased metabolic demand. In the absence of key risk factors or red flags, the approach to work up typically begins with a comprehensive nutritional and social evaluation.² 

As the resident physician on the pediatric ward meeting this patient and family for the very first time, I reviewed these concepts and provided insight into the anticipated next steps in the hospitalization: over the following few days, we would watch the infant cue and feed and assess the adequacy of her weight gain. The objectives were simple. The infant’s mother, rocking her daughter softly as we spoke, gazed up at me and nodded, though her eyes then darted past mine, and down toward the floor. “Doctor, what if I am the cause of her failure?” I looked at her blankly, not knowing how best to respond.

It was then that I learned of the dyad’s homelessness shortly after nursery discharge. That in the stress of the moment, and in the chill of the autumnal air, her breastmilk supply dwindled. Then, came the hurried transition to formula, but with the inability to afford the necessary cans without government assistance. The struggle to gather the required documentation and the lack of transportation back-and-forth to the hospital enrollment site barred submission of an application. The only way forward was to dilute the infant’s chalky yet life-sustaining white powder with more water than recommended.

“This is not your fault,” I said. We sat together as she wept. I wished I could have done more.

A large proportion of the US population faces food insecurity: it impacts 14.8% of US households and roughly 22% or 10 million US children. Single parent and non-Hispanic black and Latino households are disproportionately affected.³  Within this demographic, 13.5 million individuals live in regions of food desert in which there is no nearby supermarket or large grocery store.⁴  Because of a variety of factors, including job instability and school closures, the coronavirus disease 2019 pandemic contributed to a rapid doubling of the number of food-insecure households across the nation.⁵  The most substantial increase was within racial and ethnic minority comminuties.⁶ 

Whereas growth faltering does not necessarily suggest a state of frank malnutrition, the 2 diagnoses are inextricably linked, particularly when food insecurity contributes to a state of chronic undernutrition. Therefore, it is important to highlight that the health consequences of malnutrition are many, with risk for developmental delays and behavioral dysregulation representing some of the earliest manifestations.^7,8  These children are also much more likely to face repeated hospitalization during childhood.⁹  Downstream, those with prior histories of pediatric malnutrition suffer from higher rates of obesity and chronic disease.¹⁰  Prevalence of both asthma and depression, among other comorbid conditions, is also increased.¹¹ 

Several key federal programs are focused on the provision of effective nutrition to those at-risk. Relevant to our pediatric patients, these include the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and for older children, the National School Breakfast and Lunch Programs. Of those families eligible for these benefit programs, however, only 82% are enrolled in SNAP and 57% in WIC nationally.¹²  The reason for lower-than-expected participation in these programs is multifactorial, though beyond a lack of awareness regarding eligibility, likely reflects nonstreamlined, administratively burdened application and renewal processes, and pervasive culturally-driven stigmatization.^13–15 

Yet, the inherent ties between social determinants of health and growth are clear and especially so for our youngest patients at such a critical time of early development.¹⁶  In response, advocacy efforts have focused in recent years on the more ubiquitous implementation of food insecurity screening in the pediatric setting. This is particularly the case considering the high sensitivity rate of a 2-question screening tool published by the American Academy of Pediatrics in 2015 on identification of food-related concerns in the community.⁷  Nevertheless, there is much more work to be done.

As pediatricians, it is imperative that we do our part to close the nutrition gap. From a legislative standpoint, we can continue to study and evaluate the ways in which food insecurity impacts pediatric health and outcomes to strengthen the data that underlies policy reform. Relatedly, we can lobby for the implementation of better mechanisms to facilitate enrollment in food benefit programs (including through increasing the number of application sites and developing a virtual platform option for those with reliable internet access, for example). In our communities, we can advocate for the establishment of more readily accessible food pantries and grocers, ensure universal screening for food insecurity in our clinics, and train resource specialists in both inpatient and outpatient contexts to better partner with patients and families applying for SNAP and WIC and to help identify additional supports. On an individual level, we cannot only imbue ourselves with a more comprehensive knowledge-base on issues surrounding food insecurity to better inform and guide care, but can also strive to dismantle the associations between household food insecurity and feelings of caretaker shame and humiliation in personal interactions, and shift the conversation toward structural issues that contribute to cycles of poverty and inequity (Table 1).

Food is medicine. No child should ever go hungry. No parent should ever need to stretch a can of formula just a little bit further. When social factors contribute significantly to growth impairment, we must recognize that the burden of “failure” in “failure to thrive” should fall to us, not to our patients and families.