Failure to thrive (FTT) is a sign of inadequate nutrition for optimal growth and development. FTT has multiple definitions, which include the following: weight-forage below the third percentile; a rate of weight gain that is disproportionate to the rate of length gain; weight-for-length less than 10th percentile (in children <24 months); and a decrease in 2 or more major growth percentile curves. 1,2 FTT more commonly presents in children less than 18 months of age. 2 In the United States, children with FTT account for 5% to 10% of primary care pediatric patients and 3% to 5% of pediatric hospital admissions. 2 Previous studies have described patient characteristics of children with failure to thrive. 3-8 These studies often made a distinction between "organic" (with an underlying medical pathology) and "nonorganic" (underlying behavioral and psychological) causes. 4,8-10 However, some researchers have advocated to abandon the use of the dichotomous "organic" versus "nonorganic" description of FTT. 1,11,12 The dichotomous division is thought to be too simplistic for clinical and research purposes and does not capture the complexity of patients presetting with FTT. Several researchers make the case that FTT is explained by multiple biopsychosocial factors and arises from the interaction between these factors. 9,11 Feeding difficulties are common in children with FTT. 13 The term "feeding difficulties" is commonly used as an umbrella term that refers to a "feeding problem of some sort." 14(p345) These problems can include 858526G PHXXX10.

The coronavirus disease 2019 (COVID-19) pandemic has changed the medical landscape, and the field of child abuse pediatrics has not been exempt from the reach of this disease. Previous widespread disease outbreaks and natural disasters have been associated with increased violence toward women and children, 1 and child abuse programs noted increased rates of abusive head trauma during the 2007-2009 recession. 2 The COVID-19 pandemic has led to increases in similar risk factors for child maltreatment, including employment instability, financial strain, reduced child care, and fewer available support structures. [3][4][5][6] Marginalized populations (eg, those in child protection systems, who already experience preexisting disparities) may be at particular risk because of widening inequalities with the pandemic. 7 Child abuse programs across North America have reported variable impacts of the COVID-19 pandemic, including changes to incoming referrals and modifications to clinical and educational activities. These impacts have yet to be described in the medical literature and are crucial to understand as child abuse clinicians and pediatric hospitalists adapt to the current context. In this commentary, we describe the impacts of the pandemic experienced by 1 interdisciplinary child abuse program practicing in a 300-bed tertiary care academic pediatric urban hospital in North America. This will include a discussion of necessary adjustments made by the program related to clinical practice, team functioning, clinician wellness, and medical education. CHANGES EXPERIENCED BY THE CHILD ABUSE PROGRAM Clinical PracticeThis interdisciplinary child abuse program is composed of pediatricians, nurse practitioners, social workers, and psychologists. The program provides 24-hour per day service, including inpatient, outpatient, and emergency department consultations. After closures in March 2020, the program documented a substantial reduction in incoming consultations (see Figs 1 and 2). A trend was also seen of fewer acute sexual assaults and more disclosures of historic sexual abuse. As communities reopened in May 2020, patient numbers gradually increased, and, anecdotally, there was a pattern of consultations for infants with positive workup for occult injuries who had bruising during the lockdown period that was not addressed. The pandemic highlighted the importance of early case planning, which involved planning discussions between clinicians and child protection workers and/or law enforcement before patient assessments. Although early case planning was already being used before the pandemic, it was expanded to include considerations of visitor restrictions and virtual assessment in select cases.

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