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1. Campus How Does Breast Feeding Compared to Bottle Feeding
Campus How Does Breast Feeding Compared to Bottle FeedingCampus How Does Breast
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Further reproduction prohibited without permission. Continuing Nursing Education A Case
Report of Failure to Thrive in an Exclusively Breastfed 6-Month-Old Infant Pamela H.
Bryant, Cathy Roche, Laura Debiasi, Steadman McPeters, and Patricia M. Speck B
reastfeeding is strongly recommended as the exclusive nourishment for the longterm health
and well-being of mothers and their infants to 6 months of age (Bai et al., 2009; de Jager et
al., 2014). Challenges faced by breastfeeding mothers include infant oral difficulties
(ankyloglossia), nipple pain, blocked ducts, inadequate infant weight gain, excessive infant
fussiness, and inconsistent infant stools (Amir & Berazzatto, 2016). Primary care provider
(PCP) guidelines mandate analysis and implementation of quality improvement strategies
addressing maternal-infant challenges to provide evidence-based care and education to of
the breastfeeding mother (National Association of Pediatric Nurse Practitioners [NAPNAP],
2013). Since the 1980s, there has been interest in breastfeeding and breastmilk, including
understanding breastmilk composition during the stages of lactation. Lactation stages
include Lactogenesis 1, where colostrum is found mid-pregnancy to day 1 to 2 postpartum
(Stage 1); Lactogenesis 2 is transition to activation of increasing amounts of milk, beginning
about postpartum day 3 to about day 8 after birth (Stage 2); Lactogenesis 3 is galactopoiesis
or milk maturity, beginning about day 9 and until weaning (Stage Instructions for CNE
Contact Hours PNJ 2017 Continuing nursing education (CNE) contact hours can be earned
for completing the learning activity associated with this article. Instructions are available at
pediatricnursing.net Deadline for submission: October 31, 2022 1.1 contact hour(s) Bryant,

2. P.H., Roche, C., Debiasi, L., McPeters, S., & Speck, P.M. (2020). A case report of failure to
thrive in an exclusively breastfed 6-month-old infant. Pediatric Nursing, 46(5), 225-
232. Campus How Does Breast Feeding Compared to Bottle FeedingORDER NOW FOR
CUSTOMIZED, PLAGIARISM-FREE PAPERSFailure to thrive (FTT) is a complex problem
affecting the infant, the biological mother, and their family. Discovering the cause of FTT is a
complex process for the primary care provider (PCP), and involves clinical observation of
feedings, and aggressive monitoring of growth and development with laboratory testing.
The case presented addresses the systematic review of FTT diagnostic criteria and
interventions. In this case, a simple and inexpensive creamatocrit measurement of
breastmilk fat may find subtle deficiencies in nutrition at the first signs of FTT, possibly
preventing expensive hospitalizations and accusations of child maltreatment. For the PCP,
simple increase in caloric intake with aggressive evaluation and monitoring is necessary to
improve weight gain of the infant with FTT before a hospital referral. Key Words: Failure to
thrive, breastmilk, creamatocrit (CRCT), child maltreatment, child abuse, adverse childhood
experiences, munchausen by proxy, mandatory reporting. 3) (Ballard & Morrow, 2013).
Breastmilk fat composition changes throughout the course of the time spent breastfeeding,
with higher fat content in the beginning, and as milk matures, fat content decreases. The
dynamic change in human breastmilk varies over time between mothers, among
populations, and with dietary intake (Ballard & Morrow, 2013). Although breastfeeding is
preferred, breastfeeding obstacles remain, even with significant (Campbell et al., 2014).
Occasionally, breastfeeding is linked to failure to thrive (FTT) (Block & Krebs, 2005;
Leventhal et al., 1989). FTT is a result of diminished caloric intake or use (such as
malabsorption) and has at least one of three distinct criteria for children age 2 years or
younger. Criteria include consideration of the child’s age and 1) at least one occasion where
the infant/child Pamela H. Bryant, DNP, CRNP-AC, CRNP-PC, is an Assistant Professor and
Specialty Track Coordinator for Pediatric Primary Care Program, Family/Community and
Health Systems, The University of Alabama at Birmingham, School of Nursing, Birmingham,
AL. Cathy Roche, PhD, RN, is an Associate Professor, Health Care Educators Academy
Mentor, Acute, Chronic and Continuing Care, The University of Alabama at Birmingham,
School of Nursing, Birmingham, AL. Laura Debiasi, DNP, CRNP, FNP-C, CNE, is a Pulmonary
Resident Service Nurse Practitioner, the Children’s Hospital of Alabama, Birmingham, AL.
Steadman McPeters, DNP, CRNP-AC, RNFA, is an Assistant Professor, Family/Community
and Health Systems, The University of Alabama at Birmingham, School of Nursing,
Birmingham, AL. Patricia M. Speck, DNSc, APRN, FNP-BC, DF-IAFN, FAAFS, DF-AFN, FAAN, is
a Professor and Coordinator of Advanced Forensic Nursing, Family/Community and Health
Systems, The University of Alabama at Birmingham, School of Nursing, Birmingham, AL.
PEDIATRIC NURSING/September-October 2020/Vol. 46/No. 5 225 Table 1. Possible Non-
Organic and Organic Causes of Failure to Thrive Source Causes Cardio-RespiratoryDigestive
Disorders Respiratory disease intersecting with digestive disorders Sensory food aversion
Cardiovascular System Congestive heart failure Malformation or developmental immaturity
(e.g., VSD, ASD, TOF, and others)Campus How Does Breast Feeding Compared to Bottle
FeedingGastrointestinal System Celiac disease Necrotizing enterocolitis Malabsorption
syndrome Formula intolerance Crohn’s/Hirschsprung disease Ankyloglossia Immune

3. System Allergies Environmental Intolerances Metabolic disorder Endocrine System
Diabetes mellitus Thyroid disease Adrenal disease Genetic Cystic fibrosis Down syndrome
Celiac disease Congenital heart disease Child Maltreatment Neglect* Munchausen by proxy*
Maternal Issues Post-partum depression* Maternal stress* Breast milk deficiencies* Non- *
Knowledge deficit (e.g., ineffective and infrequent feedings*) System Issues Social
Determinants of Health* *Non-organic causes of FTT. Notes: ASD = atrial septal defect, VSD
= ventral septal defect, TOF = tetralogy of Fallot. Sources: Cole & Lanham, 2011; Homan,
2016; Jeong, 2011. weight is below the 5th percentile; 2) minimally, the child meets 80%
ideal weight; or 3) the child’s weight spirals downward across 2 percentiles, documented on
a standardized growth grid (Homan, 2016; Jaffe, 2011; Nützenadel, 2011; Rabinowitz et al.,
2016; Thompson et al., 2013). Pediatric hospital admissions reflect FTT in children 2 years
or younger are 226 as high as 10% of all pediatric hospital admissions (Thompson et al.,
2013). FTT in infants occurs infrequently, and when discovered, the medical workup is
expensive, costing between $1,307 and $2,195, depending on the day of admission, with
increasing costs of $1,238 when admitted on weekends (Thompson et al., 2013). When FTT
occurs, the community primary care provider (PCP) implements the standard of care for
their pediatric patients that includes “to do no harm” and “protect” through trauma-
informed measures of physical, psychological, and emotional safety (Substance Abuse and
Mental Health Services Administration, n.d.). PCPs also have a responsibility to implement a
structured diagnostic algorithm for the protection of the child (Cole & Lanham, 2011;
Karniski et al., 1986), which helps in the search for organic health-related causes and may
include hospitalization (Xu et al., 2016). Campus How Does Breast Feeding Compared to
Bottle FeedingThe algorithm should include organic and non-organic causes (see Table 1).
Organic causes of FTT in the young breastfeeding infant include malabsorption syndromes
in the gastrointestinal track, and undetected pulmonary (e.g., cystic fibrosis) and cardiac
(e.g., ventricular septal defect) genetic or congenital diseases (Bar-Zohar et al., 2004; Cole &
Lanham, 2011). Non-organic causes, such as social and maternal-infant feeding problems
related to disparities of health, also include caregiver feeding style (Rybak, 2015; Wright et
al., 2006) and (Campbell et al., 2014). Organic medical and congenital causes of FTT
include body system failures, as shown in Table 1 (Casey et al., 1984; Cole & Lanham, 2011;
Jaffe, 2011; Wright et al., 2006). Recommendations for the PCP include skill development of
FTT and FTT management related to the pediatric medical diagnosis. For instance, the PCP
needs a record of each infant visit when evaluating FTT, and a record of the pregnancy and
birth experience, which may be through the birth history from the mother. Serial infant
assessments include a developmental evaluation of the child’s temperament and
interaction, oromotor functioning, and nutritional needs and deficits, as well as family and
social (Jaffe, 2011). Feeding history, including feeding frequency and elimination history,
should be obtained at each visit. With negative tests for all organic medical or congenital
causes, maltreatment becomes a diagnosis of elimination (Children’s Bureau, 2012; Cole &
Lanham, 2011; Rabago et al., 2015), where disparities of health and chaotic home
environment may provide the window to a clinical diagnosis. Therefore, the social and
family history is a pertinent component of the newborn infant’s initial workup (Cole
PEDIATRIC NURSING/September-October 2020/Vol. 46/No. 5 & Lanham, 2011; Jaffe, 2011;

4. Wright et al., 2006). For all child maltreatment, the prevalence is between 698,000 (2010)
to 702,000 (2014) children each year. “For FFY 2018, a national estimate of 1,770 children
died from abuse and neglect at a rate of 2.39 per 100,000 children in the population.
Campus How Does Breast Feeding Compared to Bottle FeedingThe 2018 national estimate
is an 11.3 percent increase from the 2014 national estimate of 1,590” (U.S. Department of
Health & Human Services, Administration for Children and Families, Administration on
Children, Youth and Families, Children’s Bureau, 2020, p. 47). A child maltreatment report is
not typical in FTT because the diagnosis of child maltreatment occurs following elimination
for all FTT causes except neglect (Pietrantonio et al., 2013). When the suspicion of child
maltreatment is present, there is mandatory reporting (Pietrantonio et al., 2013). The PCP is
a mandatory reporter in every state and territory and notifies Child Protective Services
(CPS) or law enforcement (Pietrantonio et al., 2013). PCPs may not notify parents of their
suspicions until the agents from legal systems appear, which creates stress between the PCP
and parent(s) (Ghaffar et al., 2011), and is traumatic to families regardless of non-
involvement in or complicit criminal behaviors (Ghaffar et al., 2011; Jones et al., 2015).
Multiple models of determining child wellbeing exist when involvement of CPS is necessary.
The purpose of this case study is to illuminate one simple but rare cause of failure to thrive
– breastmilk quality (Livingstone, 1997), where problems with breastfeeding are a common
reason to terminate breastfeeding early (Campbell et al., 2014; Motil et al., 1989) or to use
supplemental feeding to augment nutrition (Walker, 2015). Case Presentation A 26-year-
old, first-time mother with a female infant presents to the rural clinic 2 hours from her
home. The mother reports that her infant is entirely breastfed from birth. Her pregnancy
and birth were without complications, and the infant was a term baby. The father is in the
home, works in construction intermittently, but is currently out of work. The mother works
as office manager during daytime hours. The couple sees the local rural PCP who knows the
entire family. Campus How Does Breast Feeding Compared to Bottle FeedingThe medical
record shows the infant at the 2-week visit at birth weight of 6 lbs. 2 oz. and at the 2month
visit, gaining 3 pounds, weighing in at 9 lbs., 2 oz. The record noted the mother was breast
feeding the infant during the visit, and the infant was quietly and effectively feeding from
the breast. The infant received all immunizations, and the mother received instructions to
return at 4 months of age for her infant’s well-child visit and immunizations. At the 4-month
visit, the mother complained that the infant was not gaining weight and was hungry all the
time, and not easily consoled with the breast. The infant gained 4 oz, weighing 9 lbs., 6 oz.
The PCP reassured that because mother and father were short and small, the slow growth
pattern may be due to genetics and to continue to breastfeed the infant solely as before with
as much breastmilk as could be pumped. The mother reported the amount of breastmilk
pumped was now 24 to 30 oz per day. When asked, the mother reported she thinks the
father is feeding their child because the bottles are empty. The PCP recommended no
supplemental food until 6 months and to feed the infant when she returned from work,
nursing on cue as before. While in the office with the PCP, the infant is eagerly bottle-
feeding, so the PCP could observe the breastpumping outcome, which was 6 oz. However,
the PCP decided to act on the mother’s concern with an assessment that included the
following: review of the genogram (no genetic abnormalities in family history); and

5. complete blood count (CBC), HCT/ hemoglobin, and urine, which were normal. The child
returned home with the mother with instructions to return in 2 months. The mother, father,
grandparents, and child returned to the clinic for the infant’s 6-month visit and
immunizations. The PCP’s record indicated the infant lost 4 oz., and is now weighing 9 lbs. 2
oz. With poor skin turgor, increasingly sluggish muscle tone, and sunken eyes, the record
reflected the mother verbalized concern that she “wants answers – now!” The rural PCP
responded by referring the infant to the regional children’s hospital, a 3-hour drive from
their home, to begin a more complete workup for FTT. PEDIATRIC NURSING/September-
October 2020/Vol. 46/No. 5 Initial Hospital Workup and Clinical Findings The infant was
admitted to the hospital’s general floor to a video monitoring room designed to observe the
infant and parent interactions. Campus How Does Breast Feeding Compared to Bottle
FeedingThe rural PCP’s health care records documented FTT, meeting 2 of the 3 distinct
criteria: less than the 5th percentile for weight and spiraling weight loss downward across 2
percentiles. The admitting hospital provider perceived a delay in seeking help by the
parents, although the record documented continuation with the PCP follow up of every 2
months, a well-child evaluation and immunization visit with rural primary provider who
was 2 hours away from the parent’s home. The hospital PCP referred to the
multidisciplinary team, consisting of social work, nutrition, occupational therapy, physical
therapy, and child life. Recordings of the interactions between the infant and the
grandparents, mother, father, and visitors were monitored and found appropriate. The
infant was placed on supplemental feedings of formula, and a rapid weight gain occurred
over the next 3 days. Tests were ordered, and the laboratory outcomes of the CBC,
urinalysis (UA), electrolytes, barium swallow, skin turgor assessment, metabolic studies,
thyroid, muscle biopsy, serial weights, and InputOutput measurements were normal. With
negative labs and the rapid weight gain after 3 days, the hospitalist diagnosis of elimination
was FTT neglect, which was reported to CPS and indicated child maltreatment, specifically
neglect that endangered the infant’s life. CPS completed their investigation and “founded”
the case, finding evidence of neglect, basing their decision on the physician’s report and
hospital records. CPS named the parents as the responsible persons. CPS recommended
continuing hospitalization and observation until placement was adjudicated in family court.
The multidisciplinary team met on Day 10 to evaluate the patient’s case, taking the
recommendation from the lactation nurse specialist that the mother’s breastmilk be
evaluated. On Day 10 of the hospitalization, the breastmilk was collected randomly from
stored pumped milk from both breasts during hospitalization and evaluated with the
creamatocrit 227 (CRCT) according to the multidisciplinary team’s recommendation.
Campus How Does Breast Feeding Compared to Bottle FeedingThe clinical outcome was the
breastmilk was deficient in milkfat by 80%. CPS “unfounded” the case, and following
another adjudication hearing, the child was discharged to the mother and father on Day 12.
Timeline Relevant data from the patient’s history organized as a timeline: 1. Normal term
birth. 2. ive multi-generational family. 3. Not affected by social determinants of health. 4.
Exclusively breastfed and maternal commitment to breastfeeding. 5. Rural PCP
developmental and family assessment at 2-week and 2-month visits. 6. Rural PCP reassured
at 4-month visit that infant size was genetic, screening labs negative. 7. At 6-month visit,

6. infant met 2 of 3 criteria for FTT, and at mother’s insistence, referred to children’s hospital.
8. Placed in virtual monitoring room, admitted for observation. 9. History: Genetic profile
(genogram) of parents normal; infant genetic profile normal. 10. Labs: Negative tests: CBC,
UA, electrolytes, barium swallow, skin turgor assessment, metabolic studies, thyroid, muscle
biopsy; and Input and Output measurements. 11. Rapid weight gain with supplemental
feedings and formula. 12. Referral to CPS; case “founded” and infant placement away from
parent planned upon discharge. 13. Multidisciplinary internal case review with
recommendations for breastmilk evaluation. 14. Positive tests: CRCT – Mother’s milk tested
and found deficient with less than 80% milk fat. 15. CPS “unfounded” case; case closed;
infant discharged to parents. 16. Followed in community until 1st birthday by CPS.
Diagnostic Assessment Differential diagnosis of FTT is complex requiring clinical
observation of the feedings, growth, and development monitoring, and appropriate lab
testing. Clinical charac228 teristics of FTT include an engaged infant, moist mucous
membranes, and adequate numbers of diapers, along with the absence of fluid loss history.
Additionally, the infant is hungry and feeds eagerly, until the last stages of FTT (Nützenadel,
2011; Willer et al., 2017). One of the first distinguishing differentials is dehydration,
although it is often confused with FTT. Clinical distinguishing characteristics of dehydration
include lethargy and tenting of skin with dry mucous membranes, and a history of
decreased wet diapers and fluid loss, e.g., diarrhea or vomiting (Willer et al., 2017). Other
etiology for differential diagnosis of FTT may also include digestive disorders (e.g., food
aversion, gagging, and fixation) and social dysfunction (e.g., abnormal feeding practices, a
stress response, resulting irritability Campus How Does Breast Feeding Compared to Bottle
Feeding