122 faltering growth case study adv

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PAEDIATRIC

FALTERING GROWTH: CASE STUDY Kate Roberts RD Freelance Dietitan Kate is a Freelance Dietitian with a wide range of clinical experience of working with adults and children from previously working in the NHS, her specialities are Diabetes and Allergies.

Faltering growth (FG) was traditionally thought to be associated with low socioeconomic status; however, multiple studies have disproved this notion.3 There is a larger association between neglected children and faltering growth, but not faltering growth with neglect.3 FG is not a disease, it is a diagnosis of sub-optimal growth.

Mild to moderate Faltering Growth (FG) is defined as a fall through two centile spaces on the WHO growth charts; a fall through three centile spaces indicates severe FG.1 There are different growth patterns to help health professionals identify FG:2 • Poor parallel lines

• Marked discrepancies in height and weight centiles • Discrepancies in family pattern • Retrospective rise • Saw tooth pattern The following case study is an example of dietetic input for a child identified with FG.

1 ASSESSMENT

For full article references please email info@ networkhealth group.co.uk

Luke is a 23-month-old toddler who lives with his mum, stepdad and step-brother (seven months old). He has a complex social situation and is currently under a Child Protection Plan. Since birth he has had frequent episodes in hospital. He was diagnosed with FG twice before being referred to the dietitians; both times the Consultant Paediatrician concluded that his poor growth and small stature were probably genetic. Luke was referred to the dietitians at 23 months old, whilst he was an inpatient due to ‘weight and height way below 0.4th centile’. He was on zinc supplements and had a rash around his mouth and nappy area.

At that point it was documented that his weight had dropped three centile spaces.

Biochemistry Table 1: Biochemistry results from in-patient admission prior to dietetic review Age

1 year 9 months

Biochemistry

Result*

Serum zinc (umol/l)

10.4

9.8-20.6

Sodium (mmol/l)

136

135-145

Potassium (mmol/l)

4.9

3.5-5.5

Urea (mmol/l)

4.3

1.6-6.0

Creatinine Enz (umol/l)

23

30-50

Bilirubin (umol/l)

2

<20

Alkaline Phos (U/l)

130

35-353

ALT (U/l)

17

<50

Total Protein (g/l)

74

55-70

45

30-50

Albumin (g/l)

Normal range

Calcium (mmol/l)

2.40

Corrected Calcium (mmol/l)

2.48

*numbers in bold denote results which are not in the normal range

2.2-2.7 Table 1 continued overleaf

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PAEDIATRIC Table 1: Biochemistry results from in-patient admission prior to dietetic review (continued)

1 year 9 months

Globulin (g/l)

29

19-33

PO4 (mmol/l)

1.60

1.0-2.6

Haemoglobin (g/l)

114.0

105-135

Serum iron (umol/l)

3.4

12-25

Transferrin (umol/l)

35.0

20-40

Transferrin saturation (%) B12 (ng/l)

5

20-45

1594

190-910

Ferritin (ug/l)

59

12-55

Folate (ng/l)

11.9

4.6-20.0

*numbers in bold denote results which are not in the normal range

Summary of biochemistry: • Zinc levels are within the normal range; however, plasma zinc is a poor indicator of zinc deficiency due to tight homeostatic and control mechanisms.4 • Iron stores are likely to be normal, but are a signal of intercurrent illness. Serum iron is not a good indicator of iron deficiency. In terms of iron studies, low ferritin would confirm deficiency.5 Luke’s ferritin levels are slightly raised; however, acute inflammation can falsely raise levels and disguise iron deficiency.6 • Creatinine is slightly low which could indicate that he has low amounts of muscle mass, or simply that his kidneys are functioning well.7 • B12 levels are very high. Vitamin B12 is a co-factor for enzymes and high intakes have not been found to be toxic.8 The Reference Nutrient Intake (RNI) for Luke is 0.5ug per day.9 Nutritional history (taken at initial dietetic appointment) Luke was breastfed for one day; he was then started on Cow & Gate Stage 1 formula. Mum reports that it was taken well (although weight gain does not reflect this). Weaning commenced at six months, no issues, but he was fussy and disliked lumps. Mum reported that the Health Visitor (HV) recommended one pint of full cream milk (FCM) per day.

Table 2: Anthropometric measurements Age

Weight (kg)

Centile

Length (cm)

Centile

Head circ (cm)

Centile

Birth

3.67

50th-75th

53.0

75th

35.0

50th

42.0

0.4th-2nd

2/52 For example growth charts for boy 0-4, please click here....

34

50th-75th

32+/52

6.81

2nd

65.0

0.4th-2nd

38+/52

6.71

0.4th-2nd

64.1

0.4th

49+/52

7.34

0.4th

66.0

below 0.4th

1y 1/12

7.40

0.4th

67.4

below 0.4th

1y 3+/12

7.85

0.4th

68.4

below 0.4th

44.2

2nd

1y 7/12

7.61

below 0.4th

1y 9+/12

8.30

below 0.4th

74.0

Well below 0.4th

45.0

2nd

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2 IDENTIFICATION OF NUTRITION AND DIETETIC DIAGNOSIS Faltering growth due to unknown causes, evidenced by a drop through three centile spaces on growth chart and weight and height below 0.4th centile.

Aims: 1. Improve the quality and quantity of Luke’s oral intake to enable him to meet his estimated nutritional requirements required for catch-up growth and development.

2. Investigate whether anything medically, behaviourally or socially is preventing Luke from absorbing the nutrients he is consuming or whether he is receiving enough nutrients.

Objectives: 1. Provide education to Luke’s parents on increasing the calories and protein of Luke’s diet through food and drink fortification.10 2. Monitor Luke’s weight monthly to assess if increased calories and protein are enabling catch-up growth as desired.11 3. Establish if Luke has any symptoms which could indicate any malabsorptive condition at the first consultation through speaking to his parents and looking through the medical notes.

Initial dietetic assessment: Age: 1 year 10 months Weight two weeks before: 8.3kg (below 0.4th centile), length: 74cm (well below 0.4th). Luke appeared slim and pale in complexion his conjuctiva were not well perfused; his younger brother appeared to be thriving.

Table 3: Reported diet history* BF: Rice Krispies/Weetabix/Ready Brek with full cream milk (FCM), double cream or Carnation milk plus cup of water and 4oz FCM MM: Fruit pot plus ½ crumpet with butter or crackers and cheese L: Homemade veg soup or ¼ cheese spread and ham sandwich or 1 slice toast and ½ can of beans plus cheese or small jacket potato with beans.

Tomatoes or carrot sticks MA: Yoghurt mixed with double cream + berries EM: Fish in sauce, mash and broccoli or spaghetti bolognese or whatever the family is eating mashed up Bedtime: 8oz FCM Snacks: Milky Ways and chocolate digestives

Estimated oral intake from diet history - Energy: approximately 800kcals. Protein: approximately 9g *However Luke’s mum reported that he was at his biological father’s on the weekend of his admission and he’d only eaten custard and yoghurt.

Table 4: Daily estimated nutritional requirements9,12 Energy (EAR): 80 x 8.3 = 664kcals Protein (RNI): 1.2 x 8.3 = 9.96g Fluid: 100 x 8.3 = 830ml Calcium (RNI for 1-3 years): 350mg/day Iron (RNI for 1-3 years): 6.9mg/day Vitamin D (RNI for 1-3years): 10ug

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PAEDIATRIC Nutritional assessment: • Exceeding macronutrient and fluid requirements according to diet history, although uncertainty over accuracy of diet history considering low weight.

• Meeting calcium requirements due to high milk consumption.9 • Uncertain whether he is meeting his iron requirements; serum iron is low but this is not a good indicator of iron deficiency; serum ferritin is high but could be falsely raised due to infection.5,6 • Not meeting vitamin D requirements as not taking a supplement.9 3 PLAN AND IMPLEMENT NUTRITION AND DIETETIC INTERVENTION We discussed food fortification, plus nourishing drinks. Recipes were provided. Luke’s mum seemed very motivated to increase his weight. She reported that they have already been fortifying his foods and that the HV recommended one pint of full cream milk per day. Research has shown that encouraging frequent high energy meals and snacks is more effective than oral nutritional supplements for children.10,13 Agreed plan: • Continue with fortified meals and snacks.13 • Start giving nourishing drinks with fortified milkshakes rather than full cream milk to increase the protein and fat content.

• Mum to request Healthy Start vitamin drops from HV.9 • Consultant to consider commencing iron supplements.

• Arranged to review after four weeks.

4 MONITOR AND REVIEW Dietetic review at 1 year 11 months: Good weight and height increase, now on 0.4th centile for weight and following own line below 0.4th centile.

Mum reports following advice and making fortified milk using our recipe sheet. Dad was not aware of the advice and, therefore, hasn’t been doing this. Mum and Dad have been keeping food diaries. Information was given to biological Dad regarding food fortification.

Table 5: Current intake from food diary BF: 2 x Weetabix/Ready Brek with FCM and cream and raspberries/¼ banana MM: fruit and bread sticks (with cream cheese or chocolate spread) and 6oz fortified milkshake L: beans on ½ - 1 slice toast (with butter and cheese) MA: malt loaf with butter and yoghurt EM: Fish pie and peas or sweetcorn/homemade vegetable soup with cream/ spaghetti bolognese, pudding: apple crumble and custard Supper: 8oz fortified FCM milkshake Varied diet reported, with varied textures. Family encouraged with current intake and methods of food fortification. Discussed continued need for catch-up growth through nutrient-dense diet to encourage appropriate health and growth, with brain development. Parents appeared keen to continue with current dietary measures.

Plan: • Continue nutrient-dense diet.

• Review in one month Dietetic review at 2 years and 1½ months: Weight following 0.4th centile, height has stayed static and dipped slightly on the centile chart. Luke is now in nursery for three hours a day and Social Services are not involved as heavily. No concerns with bowels.

Started iron supplements in June which Mum feels has increased his appetite and increased his energy levels. Luke was more lively in clinic.

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PAEDIATRIC Table 6: Diet history BF: Weetabix/Rice Krispies plus banana or apricots MM: fruit pots/chocolate roll/yoghurt (fruity Muller Corner), carrot sticks, chunks of cheese.

L: sandwich/beans on toast/cooked dinner MA: similar to MM EM: pasta dinner (spaghetti bolognese/carbonara)/cottage pie/homemade fisherman’s pie. Puddings: fruit sponge and custard/Angel Delight/mousse Supper: porridge or cereal plus glass of fortified FFM Nutritional assessment: • Gaining weight along centile lines with slight catch-up growth, height static.

Plan: • Continue nutrient dense diet.

• Review in three months for weight and height check.

5 EVALUATION The initial aim was to improve the quality and quantity of Luke’s oral intake to enable him to meet his estimated nutritional requirements required for catch-up growth and development. In practice, this was dealt with by educating Luke’s mum on food fortification13 and to increase the protein and fat in the full cream milk he was already drinking by fortifying it and making it into milkshakes. His mum had described the intensive social input she was receiving and, therefore, I was confident that a month review would be suitable. The diet history she gave indicated that either she knew what she was supposed to be doing or had already started offering him more food.

The diet histories all are high in calories and protein and are examples of good eating behaviours with frequent meals and snacks. It is difficult to determine the accuracy of this reporting and particularly in the initial assessment there was a mismatch between his growth and the amount his mother reported he was eating.

Diet histories can easily be inaccurate due to over or under estimation or poor memory. Luke’s mum might have been saying what she thought she should or could have already made changes to his diet which had not had time to make an impact on his growth yet. This is an area which seems to be sparse in literature with respect to faltering growth.

Since dietetic intervention commenced, his weight has returned to the 0.4th centile, but his height has continued well below the 0.4th centile line. I would have expected his height to increase in proportion with his weight. However, it was found in a longitudinal study that height stunting is chronic in nature and less easily corrected, whereas low weight can be corrected; children with faltering growth at six months were more likely to have a stunted height at three years of age.14 Therefore, we can expect Luke’s height to be slower to catch up. However, as he has just turned two years, he has changed from lying to standing measurement and height is slightly less than length.9 It is difficult to predict what weight and height is to be aimed for. Luke’s Paediatrician mentions catch-down growth in Luke’s notes and states that the timing and pattern of his drop down the centiles was indicative of him meeting his genetically determined potential height as his father had growing issues. Birth weights have increased over the last 80 years and infants born after 1970 had larger body sizes at birth which resulted in catch-down growth.15 There is doubt though as to whether Luke’s father was malnourished as a child which may have stunted his height; we would, therefore, have too low an estimate of Luke’s target height.

In terms of what weight to aim for, the maximum weight centile between four to eight weeks of age is the best indicator for future weight centiles than the birth weight.16 Unfortunately, Luke’s maximum weight centile between four to eight weeks is not known, but you could hypothesise that it would be around the 25th centile if his weight loss was gradual from two weeks of age to seven months. However, if his height is to continue below the 0.4th centile, this would be out of proportion and he would have a high BMI. Therefore, it is important to monitor Luke to ensure his growth is in proportion and he is developing as expected.

One of my aims was to investigate whether anything medically, behaviourally or socially was preventing Luke from absorbing the nutrients that he was consuming or receiving enough nutrients.

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Following the initial dietetic assessment, the medical notes were requested. The first assessment resulted in excellent weight gain through food fortification and from continued input from HVs, social workers and family support workers. It can be concluded again that there is no evidence of malabsorption. Luke’s biochemistry ruled out coeliac vdisease and he had no problems with his bowels which may signal fat or carbohydrate malabsorption. Extra calories, protein and snacks seem to have sufficed for aiding catch-up growth. There was a query over whether he was deficient in iron, but again this could have been dietary as opposed to internal losses.

Luke’s vitamin B12 serum levels were high; it was also noted that the FSW reported that Luke’s mother has a history of not progressing her previous children on from milk and struggling with weaning.

Vitamin B12 bioavailability is good from milk and it is one of the main dietary contributors from the UK diet for adults.17 This could indicate that when Luke was initially referred, his milk intake was high; however, his HV was encouraging his parents to give him a pint per day which could be enough for these raised levels.

In summary, this has been a successful dietetic intervention resulting in Luke’s weight catching up to the centile line that he was previously following. His weight has not caught up as well as yet, but as discussed earlier, it could take longer to respond. Long-term follow-up will be required when Luke has reached his target weight and height. It will be important to re-educate him and his family and encourage healthy eating and activity to try to prevent a high BMI with its associated risks in the future.

A prospective cohort study found that children with catch-up growth between 0-2 years had a higher BMI with more central adiposity in particular at five years of age.18 Table 7: Anthropometric measurements including post-dietetic intervention Age

Weight (kg)

Centile

Length (cm)

Centile

Head circ (cm)

Centile

Birth

3.67

50th-75th

53.0

75th

35.0

50th

65.0

0.4th-2nd 42.0

0.4th-2nd

2/52

50 -75 th

th

32+/52

6.81

38+/52

6.71

0.4 -2

64.1

0.4th

49+/52

7.34

0.4th

66.0

below 0.4th

1y 1/12

7.40

0.4th

67.4

below 0.4th

1y 3+/12

7.85

0.4th

68.4

below 0.4th

44.2

2nd

1y 7/12

7.61

below 0.4th

1y 9+/12

8.30

below 0.4th

74.0

Well below 0.4th

45.0

2nd

1y 10/12

8.52

below 0.4th

1y 10+/12

8.73

0.4th

75.0

below 0.4th

44.9

0.4th-2nd

1y 10+/12

8.80

0.4th

75.5

below 0.4th

2y 1+/12

9.26

0.4th

75.6

below 0.4th

2nd th

nd

The shaded area indicates post-dietetic intervention www.rcpch.ac.uk/growthcharts

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