1. Background
Growth has always been considered as an indicator of health from early infancy to late adolescence (1). Growth monitoring is a basic component of health care, with growth charts considered as the most powerful tools to monitor growth development (2). Generally, height, weight, and head circumference are among parameters used to evaluate the growth of children (3). However, in many studies, weight gain disorder in children is used as a measure of Failure to Thrive (FTT), (4).
Failure to Thrive is a description of a clinical situation for identifying children with inappropriate growth and is widely considered as growth under standard growth curves. Failure to pay attention to this problem, which is generally seen among children under 5 years old, could lead to more serious complications, such as increased mortality and high incidence of related diseases (5). Children afflicted with FTT in their early life in addition to physical growth problems, have an increased risk of behavioral, cognitive, and emotional disorders over the later years of life (6).
Failure to Thrive is a global problem and according to the World Health Organization (WHO), more than 30% of children under 5 years old show FTT, of which 80% have stunted growth and 20% are underweight (5). Also, according to the report of the WHO in 2016, the average prevalence of stunting in children under 5 years around the world was 23.2% (7).
Results of studies across the world on the prevalence of FTT in developing countries indicate that in most of these countries physical growth of children and adolescents are below international standards (5). In Iran, a nation-wide cross-sectional study conducted on children aged 0 to 27 months in 2004, showed that 4.7% of Iranian children had stunting growth and 5.2% were underweight (8).
Various Studies have indicated that several factors are associated with malnutrition and FTT in children. These include maternal diseases, early onset of complementary feeding, family socioeconomic status, children's morbidities and diarrheal diseases in particular, maternal age under 20 years, birth rank above 3, number of children, low birth weight, experience of hospital admission in the first year of life, birth interval of less than 24 months, level of parental education, and mother’s addiction (3, 6, 9).
Nowadays human resource is considered as a main pillar of sustainable development across the world and paying attention to children’s growth is one of the cornerstones of achieving this aim for future generation (10).
Therefore, this study aimed at determining factors associated with FTT among children aged 3 to 72 months in Jahrom city, southern Iran. The results of such studies help implement health planning and policy making as an effective step towards appropriate growth and development of children.
2. Methods
This case-control study was carried out in Jahrom city in southern Iran, during year 2016, including 250 children aged 3 to 72 months from 10 urban and 14 rural health centers. In this study, the cluster sampling method was used, in which each health center was considered as a cluster. At first, at each center a sequential number was assigned to all children with FTT. Then, regarding the proportion of participants, cases were selected randomly using the random number table. Next, controls were selected from healthy children referred to centers and matched with cases in terms of age and gender.
Case and control groups were in equal in numbers, considering the inclusion criteria. The case group comprised of children with growth curves below the third percentile in more than one measurement and youngsters above the third percentile with failure to gain weight or with weight loss during at least 1 month. Controls were selected from children with a normal growth trend (4, 9). Children, who had diabetes, genetic disorders, cardiovascular, renal diseases, congenital abnormalities, and hormonal disorders were excluded from the study. Therefore, the investigation was only carried out on children, who were completely healthy at birth.
The data were gathered based on the interest variables, whereby a checklist was prepared and completed using the information of children’s document files at health centers. Data were analyzed using the Statistical Package for Social Sciences Version 17.0 (SPSS Inc., Chicago, IL, USA). Chi-square test, Odds Ratio (OR) and corresponding 95% confidence interval (%95 C.I) were used to evaluate the univariate relationship between independent variables and FTT as the dependent variable. In order to control the effect of possible confounders, the adjusted ORs were estimated using the backward multiple logistic regression method.
This project was approved by the Ethical Committee of Jahrom University of Medical Sciences (under code no. IR.JUMS.REC.1395.0001).
3. Results
This study comprised of 250 children, including 126 (50.4%) males and 124 (49.6%) females, with 68 (72.8%) being inhabitants of urban areas. The results obtained did not reveal any significant association between FTT and father’s education, father’s job, housing status, and the interval between birth deliveries (P > 0.05).
Table 1 indicates the univariate and adjusted association of demographic variables with the FFT. The unadjusted results showed a significant association between FTT in children and the level of mother’s primary school education (OR: 4.19, 95% CI: 1.89 to 9.29), Body Mass Index (BMI) of the mother being less than 18.5 (OR: 20.38, 95% CI: 4.60 to 90.19) before pregnancy, bottle feeding (OR: 2.18, 95% CI: 1.37 to 4.19), and parental consanguinity (OR: 2.17, 95% CI: 1.15 to 3.51). However, after adjustment, a significant association did not remain in regards to the feeding regimen.
Finally, the results of multiple backward logistic regression showed that children, whose mothers had lower level of education (P < 0.001), those with mothers’ BMI lower than 18.5 before pregnancy (P < 0.001), bottle-fed children (P = 0.005), and children with parental consanguinity (P = 0.028) were at increased risk of FTT (Table 2).
Table 1.
Univariate and Adjusted Associations of Demographic Variables With the Growth Status
| Variables | Normal Growth | With FTTa | Pb | ORc (%95 C.I) | ORd (%95 C.I) | |
|---|---|---|---|---|---|---|
| Mother education | University | 46 (36.8) | 32 (25.6) | < 0.001 | 1 | 1 |
| High school | 65 (52) | 54 (43.2) | 1.19 (0.67-2.12) | 1.07 (0.49 - 2.36) | ||
| Primary school | 14 (11.2) | 39 (31.2) | 4.19 (1.89-9.29) | 4.46 (1.65 - 12.07) | ||
| Mother job | Housekeeping | 108 (86.4) | 110 (88) | 0.705 | 1 | 1 |
| Employed | 17 (13.6) | 15 (12) | 1.15 (0.55-2.42) | 1.35 (0.42 - 3.05) | ||
| Mother BMI before pregnancy | 18.5 - 25 | 69 (55.2) | 44 (35.2) | < 0.001 | 1 | 1 |
| < 18.5 | 2 (1.6) | 26 (20.8) | 20.38 (4.60 - 90.19) | 23.9 (4.94 - 107.84) | ||
| > 25 | 54 (43.2) | 55 (44) | 1.59 (0.93 - 2.72) | 1.66 (0.92 - 3.07) | ||
| Mother disease | No | 120 (96) | 117 (93.6) | 0.393 | 1 | 1 |
| Yes | 59 (4) | 8 (6.4) | 1.64 (0.52 - 5.16) | 1.03 (0.23 - 4.49) | ||
| Type of delivery | Normal | 58 (46.4) | 54 (43.2) | 0.611 | 1 | 1 |
| Cesarean | 67 (53.6) | 71 (56.8) | 1.13 (0.69 - 1.87) | 1.15 (0.61 - 2.17) | ||
| Mother age in pregnancy | 18 - 35 | 107 (85.6) | 102 (81.6) | 0.694 | 1 | 1 |
| < 18 | 18 (14.4) | 23 (18.4) | 1.85 (0.45 - 0.75) | 1.14 (0.50 - 2.64) | ||
| Gestational age | > 37 | 117 (93.6) | 110 (78) | 0.024 | 1 | 1 |
| < 37 | 8 (6.4) | 15 (12) | 1.99 (0.82 - 4.88) | 2.67 (0.70 - 10.38) | ||
| Birth weight | ≥ 2500g | 112 (89.6) | 110 (88) | 0.688 | 1 | 1 |
| < 2500g | 139 (10.4) | 15 (12) | 1.75 (0.53 - 2.58) | 1.30 (0.38 - 4.45) | ||
| Birth height | ≥ 50cm | 28 (22.4) | 27 (21.6) | 0.879 | 1 | 1 |
| < 50cm | 97 (77.6) | 98 (78.4) | 1.04 (0.57 - 1.90) | 1.02 (0.46 - 2.20) | ||
| Head circumference at birth | ≥ 35cm | 23 (18.4) | 22 (17.6) | 0.869 | 1 | 1 |
| < 35cm | 102 (81.6) | 103 (82.4) | 1.05 (0.55 - 2.01) | 1.05 (0.47 - 2.35) | ||
| Birth interval with previous delivery | ≥ 3years | 51 (40.8) | 48 (38.4) | 0.852 | 1 | 1 |
| < 3years | 8 (6.4) | 9 (7.2) | 1.32 (0.48 - 3.64) | 0.98 (0.24 - 3.98) | ||
| Feeding schedule | Breast feeding | 88 (70.4) | 83 (66.4) | 0.002 | 1 | 1 |
| Bottle feeding | 17 (13.6) | 35 (28) | 2.18 (1.37 - 4.19) | 2.08 (0.95 - 4.60) | ||
| Both | 20 (16) | 7 (5.6) | 0.37 (0.15 - 0.92) | 0.32 (0.10 - 1.00) | ||
| Parental consanguinity | No | 97 (77.6) | 79 (63.2) | 0.013 | 1 | 1 |
| Yes | 28 (22.4) | 46 (36.8) | 2.17 (1.15 - 3.51) | 1.99 (1.02 - 3.88) | ||
| Living location | Rural | 30 (24) | 27 (21.6) | 0.65 | 1 | 1 |
| Urban | 95 (76) | 98 (79.6) | 1.14 (0.63 - 2.07) | 1.32 (0.62 - 2.80) |
a Children with failure to thrive.
b Using chi-square test.
c Univariate Odds Ratio (OR) and corresponding %95 confidence interval (C.I).
d Adjusted Odds Ratio (OR) and corresponding %95 confidence interval (C.I) computed using a multiple logistic regression model.
Table 2.
Adjusted Associations of Demographic Variables With the Growth Status Using Multiple Backward Logistic Regression Method
| Variables | ORa (%95 C.I) | P | |
|---|---|---|---|
| Mother education | University | 1 | - |
| High school | 1.07 (0.56 - 2.07) | 0.820 | |
| Primary school | 4.29 (1.80 - 10.25) | < 0.001 | |
| Mother BMI before pregnancy | 18.5 - 25 | 1 | - |
| < 18.5 | 22.06 (4.83 - 100.73) | < 0.001 | |
| > 25 | 1.55 (0.86 - 2.79) | 0.138 | |
| Feeding schedule | Breast feeding | 1 | - |
| Bottle feeding | 2.72 (1.34 - 5.34) | 0.005 | |
| Both | 0.35 (0.18 - 1.04) | 0.059 | |
| Parental consanguinity | No | 1 | - |
| Yes | 2.02 (1.081 - 3.79) | 0.028 |
a Adjusted Odds Ratio (OR) and corresponding %95 confidence interval (C.I) using backward method
4. Discussion
Malnutrition is currently a major problem around the world, especially in children aged less than 5 years. Lack of food and nutrients is not always the cause of malnutrition. Other important factors associated with malnutrition include insufficient knowledge of the mother, quality of childhood care, cultural and economic factors, childhood diseases, poverty, pollution, and an unhealthy environment (11). Children’s poor growth is one of the most important global health problems, especially in developing countries. Paying attention to this problem could result in colossal economic and social benefits and help promote the community’s health to a large extent (12).
Findings of this study showed that education level of the mother, mother’s BMI before pregnancy, parental consanguinity, and feeding schedule were factors associated with FTT among children aged 3 to 72 months in Jahrom.
Results of this study showed that children, whose mothers had elementary education were 4.29 times more likely to experience FTT than those whose mothers had university education. This finding is consistent with the results of studies from Iran (4, 13, 14) and other countries (15), despite studies, which did not reveal any significant relationship between education level of mother and child growth (6, 16). Lower educational status limits learning and restricts the process of internalizing educational contents (3). An Iranian study suggested that lower level of education in the mother is directly associated with economic and cultural impoverishment of the family. This in turn has a direct impact on their awareness, learning, and interests toward children’s nutrition, proper care, and protection against different diseases (17).
Findings of this study, similar to other Iranian studies (18), indicated that mothers with pre-pregnancy Body Mass Index (BMI) of less than 18.5 were at 22.06 times greater risk of having children with FTT than those with normal BMI (P < 0.001). Contrary to some previous reports, this study did not show any significant relationship between pre-pregnancy overweightness and FTT among children (4, 19, 20). According to a number of studies, appropriate weight before pregnancy and suitable weight gain during this period are 2 important determinants for prevention of low birth weight. Also, BMI of less than 18.5 or more than 25 during pregnancy are among risk factors affecting children’s growth so that mothers are highly recommended to postpone pregnancy until optimal weight achievement (4, 9).
This study showed that the risk of FTT was 2.02 times higher among children with parental consanguinity. This finding is not compatible with the results of other Iranian Studies (4). It could be assumed that in consanguineous marriage, some genetic factors may impact the growth and development of children, although this assumption remains as an area for more investigations.
The result of this study indicated that bottle-fed children were 2.72 times more at risk of having FTT than breast-fed children. This result is in line with the findings of other Iranian studies (14, 21). Another study from Iran did not find any significant association between feeding schedule and children’ growth (4). Implementing future prospective studies could be helpful in this regard.
Finally, the current study revealed no significant relationship between FTT and variables, including birth weight, birth height, and head circumference at birth. These results are in agreement with the findings of previous Iranian studies (3, 22). Although this was not consistent with the results of some studies from Iran (4, 13) and other countries (23, 24). These discrepancies could be attributable to differences in the definition of control and case groups in various studies.
In Conclusion, this study showed that FTT in children was significantly associated with factors, including lower education level of the mother, mothers’ BMI of less than 18.5 before pregnancy, parental consanguinity, and bottle feeding. These results indicate the importance of non-nutritional factors in the prevention of malnutrition and FTT. Experiences of some countries have shown that successful planning aimed at controlling malnutrition is to some extent dependent on improved children’s healthcare system, increased knowledge and attitude towards nutrition, and improved health behaviors. There are some suggestions to control growth disorders in children, such as promoting pre-pregnancy care, improving the educational level of females, training parents regarding proper nutrition of children, and appropriate pregnancy.
