The Grow Clinic at Boston Medical Center
Julia Hilbrands
Failure to thrive (FTT) is a condition in infants and young children that is associated
with poor weight (and often height) gain during critical periods of growth1. The actual
definition and clinical cut-points of a FTT diagnosis vary widely, but a common set of
anthropometric criteria include body mass index (BMI), length, or weight for age below the 5th
percentile or weight deceleration that crosses two major percentile lines2. The overarching
causes of FTT are most often nutrition-related and include inadequate caloric intake,
inadequate caloric absorption, and excessive caloric expenditure. These three causes can be
further divided into two groups: organic, or medical, causes, and inorganic, or
behavioral/environmental causes2. Examples of organic causes of FTT include cystic fibrosis,
inflammatory bowel disease, or an inborn error of metabolism, while inorganic causes include
lack of food availability, breastfeeding problems, mood disorders, and parental neglect2,3. It has
been reported that over 90% of children diagnosed with FTT have a nonorganic cause of the
illness, and poverty has been identified as the single greatest risk factor of FTT2,4.
Treatment and diagnosis of FTT in early childhood is essential because inadequate
nutrition has been linked to several adverse health outcomes later in life, ranging from
psychosocial problems, learning difficulties and short attention spans to weaker immune
systems and poor motor and neural development1,4,5,6,7. While the exact repercussions of
untreated FTT are inconclusive and data is lacking, physicians and researchers alike agree that
it is a serious condition that needs to be addressed as soon as possible in affected children4.
FTT affects children both nation- and worldwide, and it’s estimated that in the United
States between 5-10% of children seen in primary care offices are diagnosed with FTT2.
Because the cause of the condition is complex and multifactorial, it often takes extensive
efforts to treat and monitor affected children. In an effort to oversee and coordinated care and
eventually minimize the prevalence of the condition, the Massachusetts Department of Public
Health has established the Growth and Nutrition Program8. The program was started in 1984
and runs clinics out of eight medical centers throughout the state8. One of theses clinics, held
at Boston Medical Center, is The Grow Clinic.
The Grow Clinic services children from birth to six years of age who have been
diagnosed by their primary care physician (PCP) as having FTT6. The majority of children
referred to the clinic are of low socioeconomic status: 10% are homeless or live in shelters and
85% depend on public health insurance6. Many of them also have trouble accessing food; the
Great Boston Food Bank reports serving 9,000 children monthly, on average, and the food bank
saw a 17% increase in the distribution of food in 20139. Beside having poor access to food,
children referred to The Grow Clinic might have food allergies or aversions, “picky” food
preferences, gastrointestinal disorders, developmental delays, and genetic syndromes, all of
which can interfere with proper food intake but can also be addressed at the clinic6.
Prior to the first appointment at the clinic, parents are asked to complete a food and
beverage diary that will aid in assessing the child’s eating habits7. Once at The Grow Clinic, the
children are exposed to a multidisciplinary team of practitioners that includes a physician, a
dietician, a nurse, social worker, and a psychologist or case manager6. At the initial visit, care
team members assess height, weight, and eating habits as well as social and environmental
components10. Afterwards, the child might be exposed to unique behavioral services related to
feeding, such as speech therapy to work on oral-motor skills or occupational therapy to work on
sensory issues10. Additionally, the family might also be referred to Boston Medical Center’s
Preventative Food Bank or enrolled in a food stamp program if food access is a concern, or a
social worker might work with the family on issues such as housing or transportation6,7. At the
conclusion of the visit, parents or caretakers are given written recommendations that are
tailored specifically to the needs of their child and their situation.
A referral to The Grow Clinic also includes a home visit and often a school or daycare
visit6. During these visits, nurses, social workers, and caseworkers assess the child’s home and
school environment, identify parental concerns, and observe the child’s behavior. All of these
details aid in determining the most beneficial care recommendations for the child. After
recommendations are given, follow-up appointments are scheduled at The Grow Clinic; these
appointments are imperative to ensuring growth progress for the child.
The staff at The Grow Clinic is also involved in public policy issues, especially those
that influence a family’s ability to provide nutritious food for children. Children’s
HealthWatch is the outreach and research arm of The Grow Clinic, and staff here work to
identify the need for additional services for children with FTT, determine policies and promote
or interfere with adequate child nutrition, and work to change policies if the need arises6.
For patients who are referred to The Grow Clinic, they can expect to spend an average
of 18 months within the program6. This time includes the initial visit, home and school visits,
various interventions, and enough follow up to ensure that the child is well on their way to
health. Since the program was established in 1984, more than 1700 kids have been treated at
The Grow Clinic6. The program is supported in part by funding from the Massachusetts
Department of Public Health, but over 75% of funding must come from charitable donations7.
Because much of the work done at the clinic is not strictly medical according to insurance
companies, the clinic cannot rely on procedure reimbursements for much of their funding.
Once a patient is referred to The Grow Clinic, the primary goal of their team is to
ensure that the parents or caretakers of that child have adequate and sufficient access to healthy
food. They accomplish this by referring families to Boston Medical Center’s Preventative
Food Bank, where families can receive free food as often as once every two weeks, or by
enrolling families in food supplement programs such as food stamps or WIC7. A second goal of
the clinic is seeing that patients receive any medical attention that they might need in a timely
manner, and if this attention cannot occur within The Grow Clinic, the patient is referred to an
outside office. A third primary goal is ensuring that parent’s of children with FTT have
adequate social support and educational resources. The clinic accomplishes this in part by
assigning a caseworker or social worker to each patient. It is these staff that conduct the home
visit and can aid parents in solving problems regarding food access, food preparation,
transportation, or housing issues.
Once these immediate needs are met, the next goal of The Grow Clinic is that each
patient move past the thresholds of FTT and experience healthy, age-appropriate weight and
height gain. If a child experiences normal growth, they will have a better chance of normal
cognitive and physical development. The clinic also wants to ensure that each child will
continue to have access to the healthy foods they need even after they leave the care and
oversight of the clinic staff.
If children that were once diagnosed with FTT are treated and able to develop normally,
the effects of this development will extend into adolescence and early adulthood. There is then
a better chance that cognitive and behavioral problems can be avoided, and children will have a
better chance at success and carry less of a health burden in the future.
FTT is a relatively common child development issue, and The Grow Clinic as thus far
been largely successful in dealing with the issue within the Boston area. Their methodology
and procedures have also been proven to be effective. Researchers have established that home
visiting programs are an effective way of increasing the quality of the home environment, and
early home intervention often mitigated the negative effects of FTT11,12. It’s also been shown
that in communities with social safeguards and strong public assistance programs, the
prevalence of severe and detrimental FTT is reduced12. In addition to medical treatment, The
Grow Clinic incorporates services such as home visits and navigating public assistance
programs; these strategies have been proving effective in the treatment of FTT.
One of the obvious strengths of The Grow Clinic is its multidisciplinary approach to
treating FTT. FTT is not just a medical issue that can be treated in a doctor’s office, but it’s a
community, educational, environmental, and social justice issue. The Grow Clinic is able to
address all of these causes because of the diversity of their staff. The doctors treat medical
issues and monitor growth, nutritionists develop appropriate meal plans, and social workers and
caseworkers identify environmental factors and devise a plan to address them. The
combination of these strategies creates a more successful treatment of FTT than any one of
them could accomplish on their own.
As a program, the largest thing hurting The Grow Clinic is a lack of consistent funding.
Because they depend primarily on philanthropy, their budget and therefore their ability to offer
services is largely in the hands of others. Finding a firmer financial base, whether it is from
more government funding, grants, or other, will ensure that the program will be an available
and effective resource for years to come.
References
1
Olsen, Else M., Anne M. Skovgaard, Birgitte Weile, and Torben Jorgensen. "Risk factors
for failure to thrive in infancy depend on the anthropometric definitions used: The
Copenhagen Country Child Cohort." Paediatric and Perinatal Epidemiology21 (2007):
418-31. Web. 11 Feb. 2015.
2 Cole, Sarah Z., and Jason S. Lanham. "Failure to Thrive: An Update." Am Fam
Physician 83.7 (2011): 829-34. Web. 11 Feb. 2015.
3 Truong, Jennifer. "Infant Nutrition: birth to 6 months." Tufts University. Boston. 27 Jan.
2014.
4 Rudolf, C J., and S Logan. "What is the long term outcome for children who fail to thrive?
A systematic review." Arch Dis Child 90 (2005): 925-31. Web. 15 Feb. 2015.
5 Wilson, E M., et. al. "Failure to thrive: the prevalence and concurrence of anthropometric
criteria in a general infant population." Arch Dis Child 92 (2007): 109-14. Web. 15 Feb.
2015.
6 Pediatrics--The Grow Clinic. Boston Medical Center, 2014. Web. 15 Feb. 2015.
<http://www.bmc.org/pediatrics-growclinic.htm>.
7 Berdik, Chris. "Grow Clinic and Food Pantry See Too Many." BU Today. Ed. John
O'Rourke. Boston University, 28 Sept. 2009. Web. 13 Feb. 2015.
8 Shaeffer, Julie. "Growth and Nutrition Program ." Health and Human Services.
Massachusetts Department of Public Health, 2015. Web. 15 Feb. 2015.
<http://www.mass.gov/eohhs/consumer/community-health/family-health/earlychildhood/growth-and-nutrition-prog.html>.
9 "Hunger in Eastern Massachusetts 2014: Executive Summary." The Greater Boston Food
Bank, Aug. 2014. Web. 15 Feb. 2015.
<http://www.gbfb.org/perch/resources/hia2014localexecsummaryfinal-1.pdf>.
10 "Feeding a Child is One of Life's Simple Pleasures." Massachusetts Growth and Nutrition
Clinics. Massachusetts Department of Public Health, June 2013. Web. 11 Feb. 2015
11 Kendrick, Denise, and Ruth Elkan. "Does home visiting improve parenting and the quality
of the home environment? A systematic review and meta analysis." Arch Dis Child 82
(200): 443-51. Web. 11 Feb. 2015.
12 Black, Maureen M., and Howard Dubowitz. "Early Intervention and Recovery Among
Children With Failure to Thrive: Follow-up at Age 8." Pediatrics 120.1 (2007): 59-69.
Web. 18 Feb. 2015.
Appendix 1: Logic Model