Monitoring progress
Clear goals should be set for the family in terms both of engagement with services and of the expectation of sustained weight catch-up. Dramatic improvement can be seen while still at home and alternative care is not usually needed. While parental co-operation is important neither this alone, nor their reports of their child’s diet, can be used as a robust measure of progress unless they are reflected in actual changes in growth.
Progress should therefore be assessed using a series of weights plotted on centile charts. Any single weight may not be representative so it is important not to let the last weight measured influence decisions in isolation. Children with continuing failure to thrive usually do gain weight over time, but at too slow a rate, with the result that their weight tracks along the low centile they have fallen to. Catch-up weight gain is occurring when a child gains weight more rapidly, with most plotted weights being at a higher centile position than the last. This means that over time the child’s weight moves from their low centile to one more appropriate to their genetic potential.
Catch-up weight gain can begin rapidly after dietary change has occurred, but it is usually two to three months before this can be clearly recognized on a growth chart. Recovery can be said to have occurred when a child’s weight and height have caught up to within two centile spaces of their expected centile, taking into account early weight and height gain and parental heights. Where there has been a long fall in weight this will take between one and three years, and may never be complete. However, if there is continued catch-up over 6–12 months, with one to two centile spaces (or their equivalent) crossed upwards, social services input could probably then be safely withdrawn, with monitor-ing only by health.
Interpretation of progress can be difficult where there is a conflict between the parents’ account and the child’s objective progress. It is important to remember that all foods eaten must be used by the body in some way except in rare medical conditions that will have been excluded before referral. Therefore, whatever parents report, if there has been no catch-up there has not been an overall increase in intake.
Alternatively, if very extensive support is provided for the family and child, any recovery seen may result solely from external input, rather than family change. If this is thought to be the case, there should be a period of continued monitoring after withdrawal of intensive support before the case is closed.
weight faltering need the input of specialists to assess them fully and in a minority of cases faltering growth may be an indicator of global neglect or abuse. These cases require multidisciplinary assessment and management, either as children in need or within the child protection system. Successful management requires an understanding of the underlying growth problem and a healthy scepticism about reported diet, while supporting parents to imple-ment and sustain the necessary dietary and behavioural change.
Messages for practice
· Faltering growth is usually identified through routine weight monitoring by the family health visitor.
· BMI should always be plotted on a centile chart.
· Assessment should be global in relation to feeding. Home visits provide the most complete picture.
· After a medical history, a broad assessment of feeding patterns is necessary.
· Intervention is sometimes obvious after assessment; commonly the assessment itself can result in improved intake.
· Reinforce and commend whatever is already going well.
· Discuss possible changes, and put these in writing.
· Dietary advice and mealtime routine are the most common focus of information giving.
· If there is no sustained improvement more specialist assessment may be needed – from a paediatrician, dietician, clinical psychologist, social worker.
· Careful monitoring of progress is essential.
186
The Theoretical and Practical Issues in Attachment and Neglect
The Case of Very Low Birth Weight Infants
Gill Watson and Julie Taylor
Introduction
I couldn’t really see his face because of the eye pads on and erm…his little body was covered in all these tubes, so I couldn’t really see him very well…
what a mass of wires, ha, an absolute mass of wires and he was in bubble wrap.
I was just, erm, just amazement…it was quite dark as well and he looked sore, so red and sore, I was scared to touch ’cause he looked so sore.
(Mother of very low birth weight infant, Scotland, 2003) Usually babies are born weighing around 3200g (7lbs). If they arrive earlier than expected, and/or if there have been ante-natal complications, they may be born weighing very much less than this, putting them at risk from a whole gamut of biological, social and developmental challenges. Very low birth weight (VLBW) infants are those who are born, usually preterm, weighing less than 1500g – less than half the weight expected. It is this group of infants in particular whose defencelessness affords a potential for child neglect. Our argument explores the pluralistic nature of this vulnerability, a kind of ‘double whammy’: not only do the circumstances and consequences of being born with a very low birth weight provide a potential for neglect, but also the antecedents of VLBW may in and of themselves also have associations with neglect.
Issues of neglect within the very low birth weight population have received little recent attention. Over the past thirty years changes in medical technology, combined with clinical developments, have led to the increasing survival of preterm, very low birth weight infants born at the lower extremes of
pre-maturity. The degree of physiological fragility experienced by this vulnerable population often creates a different set of outcomes compared with those infants born at the end of a full term pregnancy. This is an issue for a range of professionals in health, social care and education across the lifespan of the child. Yet it does not appear to be an area that attracts interprofessional interest (except perhaps from a medical or technologically oriented perspective), nor consideration within any child care and protection assessment framework.
A major outcome considered in this chapter is the overall effect of the cir-cumstances of VLBW that can impinge on the attachment process between compromised infants and their parents. A secure attachment relationship can do much to enhance the overall development of VLBW infants as they progress into childhood. The road can be fraught with challenges for many parents as their infants continue to experience chronic disease and in some cases disabili-ties. This is a vulnerable infant population, potentially exposed to numerous biopsychosocial challenges. All of these are individually worrying, but a direct consequential factor of VLBW is the unnatural, but at times necessary, physical and psychological separation between the infant and the parents. This separa-tion experience has the ability to affect the attachment process, therefore influ-encing the security of the infant–parent attachment relationship (Goldberg and Di Vitto 2002). This poses a number of challenges in relation to the global development of the child. For some parents taking their fragile infant home from hospital does not lead to the much longed for security of normality, because more frequent feeding and other specialist requirements have to be considered within the context of other family commitments. This situation can increase tension and conflict relating to roles and expectations of other family members. Within such a context are many factors that may lead to neglectful child care, whether intentional or otherwise.
For committed and sensitive parents with appropriate support networks the challenge of parenting is awesome. For less resilient parents, or for those whose social, psychological or environmental circumstances are compromised, there is the potential for an increased chance that their preterm, VLBW infant’s needs will not be safely met. There are those who will argue that there is little point in spending valuable resources on the study of this population because they account only for approximately 2% of national births. While this may be the case, we would argue that although the actual numbers may be low, the antecedent risk factors and resulting consequences in delivery of the preterm, VLBW infant need to be addressed in practice. Many of the risk factors relating to neglect and preterm births are reducible and in some cases avoidable.