A practical approach to the assessment of faltering growth in the infant and toddler

PERSONAL PRACTICE

A practical approach to the assessment of faltering growth in the infant and toddler

Recommendations for referral of faltering growth to paediatrician C C C C C

Nicola Pritchard

C

More than 10% loss of birth weight at day 5 (formula fed) More than 12.5% loss of birth weight at day 5 (breast fed) Sustained weight loss (falling through 2 centile lines) Weight below 0.4th centile Weight below 2nd centile which has failed to improve with primary care intervention Discrepancy of more than 2 centiles between height and weight (generally applicable if >2 years)

Abstract

Table 1

Faltering growth, previously called failure to thrive, in infants and toddlers is a common primary care presentation and reason for paediatric referral. This article suggests an approach to selection of cases for referral, the assessment and investigation required in secondary care and the identification of the less than 5% of cases with an underlying organic disease. A framework is suggested to aid advice to be given to parents with a child who has faltering growth due to inadequate nutritional intake for their energy requirements.

WHO charts available and in the parental held “red book”. WHO charts should be used in preference to older charts as they identify how children should grow when provided with optimal conditions and are based on a longitudinal study data of breast fed infants.

Monitoring preterm infants

Keywords child; infant; child nutrition disorders; failure to thrive; Preterm infants should have their growth parameters plotted according to their corrected gestational age ideally on a Neonatal and Infant Close Monitoring chart, allowance for prematurity should continue until the corrected age of 24 months.

growth disorders; faltering growth; growth monitoring

Introduction Faltering growth is the growth pattern used to describe a child who is failing to reach their full genetic growth potential and who is deviating from the “norm”. It should be used in preference to the older term failure to thrive which implies potential physical and emotional neglect. Weight concern is the commonest presentation under 2 years so this article concentrates on diagnosis and management of poor weight gain in this age group.

Catch down growth At significant proportion of infants with high birth weights (98th centile) show regression to the mean e i.e. return to their genetic potential and appear to be falling across centile lines due to slow weight gain after birth; this is most commonly seen after excessive in utero growth e.g. infant of a diabetic mother. This requires no investigation or treatment in an otherwise healthy infant.

Referral

Small normal

There are clear referral recommendations for primary care teams to identify those children with growth concerns who need further assessment. Many children will not have an identifiable pathology requiring treatment and will after review and assessment be a small or slow-growing normal child. (Table 1)

Infants growing below the 0.4th centile should be assessed as only 1:250 infants fall into this category (UKeWHO 2009) however some normal asymptomatic intrauterine growth restricted infants will fall into this group.

Is it really faltering growth?

Assessment

Inappropriate investigation of normal children can often be avoided with the following strategies:

The key aim of a paediatric review is not simply to improve weight gain but to identify underlying treatable pathology, ensure adequate nutritional intake for the child’s needs and to reassure concerned parents. Investigations should be carefully selected as most cases are due to inadequate intake of nutrition and organic disease is only found in only 5% of cases.

Correct measuring Always ensure accurate measuring by trained staff using calibrated and maintained equipment alongside use of a validated paediatric growth chart. The child growth foundation can provide training and the RCPCH website has fact sheets to aid the plotting and assessment of infants and children on the various

History and examination Clinicians should establish whether there is an antenatal aetiology by enquiring about slow in utero growth, antenatal infection, gestational diabetes, prematurity and birth weight. Family history may identify a particular growth pattern or suggest risk of genetic conditions.

Nicola Pritchard BMBS Nottingham 1994 MRCPCH is a Consultant Paediatrician with the Royal Berkshire Hospital NHS Foundation Trust Reading, UK. Conflict of interest: none declared.

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Please cite this article as: Pritchard N, A practical approach to the assessment of faltering growth in the infant and toddler, Paediatrics and Child Health, https://doi.org/10.1016/j.paed.2019.06.007

PERSONAL PRACTICE

Main Categories of faltering growth Inadequate intake without increased energy requirement

Excess output and or malabsorption

Increased energy requirement

Dietary and feeding history

Quantity and frequency gastric output, diarrhoea and urine output

Not offered Lack of knowledge: incorrect diet or quantities offered C Not available C Parental mental health eg depression C Child protection concern Not accepted C Poor appetite C Food aversion C Discomfort C Behavioural Not swallowed C Anatomical: cleft palate, micrognathia, ankyloglossia C Neurological (poor swallow or hypotonia) Not kept down C Reflux C Obstruction eg pyloric stenosis C Other vomiting cause e raised ICP, overfeeding, infection, intolerance

Abnormal anatomy Short gut C Ileostomy Chronic diarrhoea C Coeliac C Lactose intolerance C Cows milk protein intolerance C Congenital malabsorption C Chronic infection Bowels not opening C Constipation C Ileus Polyuria C Diabetes C Psychogenic polydipsia C Renal disease

Cardiac or respiratory symptoms Physical activity e voluntary and involuntary Recurrent infection Abnormal breathing C Upper airway obstruction eg laryngomalacia, severe sleep apnoea C Infection eg immune-deficiency, cystic fibrosis, aspiration, congenital abnormality C Cardiac eg cardiac failure or hypoxia from congenital or acquired heart disease Increased muscle activity C Seizures C Hyperkinesisa C Behaviour Other C Other infection C Hyperthyroidism C Liver disease C Chronic pain

C

C

Unable to utilise

C Genetic Syndrome eg Russell Silver, PradereWilli C Metabolic C Endocrine e diabetes, growth hormone C Liver pathology

Table 2

Screen for any other symptoms which would suggest an increased energy demand or chronic ill health, include respiratory symptoms, history of infections or excessive voluntary or involuntary activity (e.g. seizures) and past medical history of significant disease. Enquire about excessive crying or sleepiness which may indicate pain or underlying disease.

Assess nutritional intake Take a breast feeding history and supplement with a review by a breast feeding specialist if necessary. Calculate milk intake if formula fed or 24 hour food diary recall (including quantities) for a toddler. Useful online resources include fact sheets from www.infantandtoddlerforum.org or the RCPCH e-learning Healthy child programme. Ask parents to describe a typical mealtime including physical and behavioural difficulties, timing and duration of meals or feeds and whether eating patterns change with different care providers. Estimate fluid intake and type in toddlers as this can impact significantly on appetite. Feeding is a highly emotional experience and parental mental health issues can both cause and result from a child with faltering growth. The socioeconomic environment of the child may also indicate if there are educational, financial or child protection issues contributing to the child’s intake. Assess gastrointestinal losses by vomiting, stool and urine output. Always carefully establish an estimate of volumes as parental experience will influence descriptions given.

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Examination The examination should include assessment for nutritional deficiency; cutaneous fat, anaemia, jaundice, delayed closure of fontanelle (Vitamin D deficiency or hypothyroidism), health of mucosal membranes, hair, skin and nail, dysmorphic features or abnormal head circumference. Assess for cardiac or respiratory abnormalities, hepatomegaly, abdominal masses or distention.

Investigating the cause The most common cause is inadequate intake relative to a child’s specific energy requirements however if the intake is appropriate

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Investigations for faltering growth

Table 4 (continued )

First line investigations

Feeding issues in the Infant

C C C C C C C

Second line investigations

C C C C C

Targeted

C C C C C C C C

FBC Urinalysis Urine culture U&E and creatinine LFTs Ferritin TTG if post weaning HIV antibodies “TORCH” screen Sweat chloride test and Chest xray TFTs. Immunoglobulins and antibody response to primary vaccinations Stool MCS Stool reducing substances Echocardiography Metabolic screen Karyotype/DNA/CGA array Child protection assessment Child developmental assessment Maternal mental health assessment

C

C

C

C

Hydrolysed feed if cow’s milk intolerance suspected Lactose free formula if clear onset of symptoms after gastroenteritis Anti-reflux formula for significant reflux High calorie formula or breast milk fortification if increased energy demand

Feeding issues in the toddler C

Add additional calories eg butter, cream, oil to preferred soft foods

Table 4

it is helpful to subdivide the other causes into broad categories based on the history and examination. (Table 2) Investigations should be guided by history and examination. Routine tests may be considered for children with reduced intake to ensure that there is no organic cause contributing to poor appetite. (Table 3)

Table 3

Management In the small number of cases that have underlying organic disease the aim should be to actively treat the condition alongside increasing energy intake whilst the organic pathology is being treated. In cases where dietary history has identified inadequate intake the nutritional value and calorie content of food intake should be maximised. Management may involve advice about; feeding behaviour, frequency duration and volume of feeds/meals, the ideal composition of food offered and sign-posting family to other resources e.g. breast feeding support, websites, parenting courses or health visitors. Some children require more intensive advice and support from a dietician, psychologist or social care teams. A plan for ongoing monitoring should be made with a clear growth goal identified and a safety net plan if initial management does not improve weight gain. Table 4

Approach to a child with reduced intake Feeding issues in the Infant

C C

C C

C

C

Breast feeding support Establishing regular feeding pattern Ensure adequate volume Consider alternative teat if formula fed Alternative route of enteral feed if unsafe swallow or unable to maintain feed duration Ensure maternal health and nutrition

Feeding issues in the toddler C

C

C

C

C C

C

C

Avoid frequent formula “brand” changes Consider change of formula ONLY with clear diagnosis C Formula top up if breast feeding support unsuccessful or if maternal preference

C

C

C

Establish regular small meal and snack times Carer to eat with child at a table Limit duration of mealtimes to 30 minutes Offer small portions and allow child to self-feed Avoid force feeding Continue to offer new foods even if frequent refusal Reduce fluid intake if excessive Encourage messy play Ensure balance of carbohydrate protein and fruit/vegetables Avoid excess high fibre foods Add daily multivitamin  iron supplement

Summary Faltering growth describes inadequate growth due to a variety of conditions, organic disease is found in only a few cases so careful history taking and assessment should concentrate on assessing reasons for poor intake and investigations should be carefully selected to identify treatable causes. Management should look at all the contributing issues around feeding and the aim should be to provide a nutritional and age appropriate diet adequate for the child’s individual requirements. A FURTHER READING Kirkland R. T., Motil K. J. www.uptodate.com Failure to thrive (undernutrition) in children younger than two years: Etiology and evaluation.

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Please cite this article as: Pritchard N, A practical approach to the assessment of faltering growth in the infant and toddler, Paediatrics and Child Health, https://doi.org/10.1016/j.paed.2019.06.007

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Nutzenadel W. Failure to thrive in childhood. Deutsches Arzteblatt International Sept 2011; 108: 642e9. Sachs M, Dykes F. Growth monitoring of infants and young children in the United Kingdom: Report to NICE, October, 2006. Shields B, Wacogone I, Wright CM. Weight faltering and failure to thrive in early childhood. BMJ 2012; 345: 1756e833. Smith Z. Faltering weight. In: Shaw V, ed. Clinical paediatric dietetics. 4th ed. BDA. Wiley Blackwell, 2015; 764e73. www.rcpch.ac.uk/growthcharts. www.rcpch.ac.uk/HCP healthy child programme 0e5 years E-learning. Module 8: Growth and Nutrition. www.infantandtoddlerforum.org. Health and childcare professionals fact sheets.

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Practice points C

C C

C

C

4

Ensure accurate serial measuring and plotting of height and weight on WHO growth chart Less than 5% of cases are caused by organic disease Investigations should be selected to identify treatable disease Clinicians should be familiar with normal dietary requirement for infants and toddlers Simple behavioural advice can improve quantity and quality of nutritional intake

Crown Copyright Ó 2019 Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Pritchard N, A practical approach to the assessment of faltering growth in the infant and toddler, Paediatrics and Child Health, https://doi.org/10.1016/j.paed.2019.06.007