Issue 141 Faltering Growth

PAEDIATRIC

FALTERING GROWTH Faltering growth is an area where dietitians can provide invaluable support. This article looks at the underlying problems/causes, recommendations and guidance, as well as the assessment and management of faltering growth.

As a freelance dietitian, I receive all sorts of enquiries from people about diet and nutrition, including questions from parents who are extremely concerned that their children are not gaining weight and are smaller than their peers. The majority of the enquiries are from parents of babies, but I also receive concerns from parents of older children and all are extremely worried about the situation.

Normally, I advise that they seek support from a dietitian locally, but occasionally, if they have already seen a dietitian and require extra support, I will get involved.

On occasion, I am also asked for an opinion from social workers and others concerned about children who appear not to be growing as expected. The area of faltering growth is one in which many NHS dietitians are asked for advice by other healthcare professionals and, certainly, this was my experience when I worked in the NHS. A SYMPTOM OF UNDERLYING PROBLEMS

Faltering growth is defined as a significant interruption in the expected rate of growth, of height and/or weight of a child compared to other children of similar age and sex during early childhood. It is often a gradually evolving situation that can go undetected, particularly in children whose parents do not frequently access healthcare for them.

In the 1940s, it was suggested that the condition could be due, not just to poor nutrition, but also emotional deprivation and under

Dr Mabel Blades Independent Freelance Dietitian and Nutritionist

stimulation.1 Medical conditions, such as gastrointestinal and neurological disorders, congenital heart disease, metabolic disorders, food allergies and intolerances and cystic fibrosis, can all be a cause of faltering growth.

It is also well documented that no reason for faltering growth may be found. However, the most common cause of faltering growth tends to be undernutrition compared with the child’s nutritional needs. While the causes of this tend to be multifactorial, they are normally related to diet and feeding behaviour.2 Looking back over the last year through my contacts, poor feeding in breastfed babies was due to the baby being ‘tongue tied’ and in formula-fed babies, inappropriate milk was being used. On one occasion, faltering growth was due to inappropriate weaning behaviour. Occasionally, poor growth can be due to neglect of the child due to parental issues, such as bereavements, addictions and stress, as well as lack of knowledge.

Faltering growth is not really a diagnosis; rather a symptom of other underlying problems. An early recognition of the issue and a full investigation and diagnosis of the underlying causes of the faltering growth rely on good awareness by

Mabel is a Registered Dietitian, a member of the BDA and NAGE, Food Counts, Older people Specialist Group and the Freelance Dietitians Group.

All aspects of nutrition enthuse her and she is passionate about the provision of nutritional information to people in assisting their understanding of any diet.

REFERENCES Please visit the Subscriber zone at NHDmag.com

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For parents who are concerned about the lack of growth of their infant, it is important that their concerns are treated seriously and that the infant’s growth is properly measured and compared with standards. healthcare professionals, especially health visitors who are likely to see an infant more regularly than others. When parents seek advice about their offspring’s health, they may not consider that their infant has faltering growth, but another issue, such as gastrointestinal symptoms. Thus, it is important that healthcare professionals are aware of the need to assess the child. For parents who are concerned about the lack of growth of their infant, it is important that their concerns are treated seriously and that the infant’s growth is properly measured and compared with standards.

If not properly assessed, faltering growth can persist. It is associated with reduced adult height, impaired academic performance and an increased incidence of behavioural and psychological disturbances.

SIZE OF THE PROBLEM

There is a great variation in the reported prevalence of faltering growth in paediatric patients. On the Danone Nutricia Research website, a range of 5-50% is quoted and those at highest risk are said to be below the age of five.3 Faltering growth used to be called failure to thrive which was unfortunate, as many parents could feel that they were failing in the way they looked after their children and could feel that they were being blamed for their children

not growing. The term failure to thrive is still occasionally used today, which can be upsetting for parents.

The extremely popular website ‘Mumsnet’, which provides advice on parenting and all aspects of childcare, has numerous discussions about faltering growth, plus it was noted that reassurance was given to mothers who were anxious about being told that their infant was failing to thrive.4 WEIGHTS OF BABIES AFTER BIRTH

During the first few days of life, weight loss is normal but this usually stabilises after three to four days and the baby normally returns to the birth weight by three weeks of age. If this does not occur, a full clinical assessment is required along with a feeding assessment. It is vital that support is given to the mother regarding breastfeeding, or feeding with infant formula or a combination of both.

ASSESSMENT OF FALTERING GROWTH

Normally in the UK, an assessment of growth is made using the UK WHO growth charts advocated by the Royal College of Paediatrics and Child Health (RCPCH).5 The RCPCH provides charts and information for healthcare professionals and information is also provided for other visitors to their website, such as parents. www.NHDmag.com February 2019 - Issue 141

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PAEDIATRIC The UK WHO growth charts are based on WHO Child Growth Standards, and describe the optimal growth with regards weight and height for healthy breastfed children and allow both weight and height to be plotted on the charts.

There are charts for 0-4 years designed to be used for preschool infants and toddlers (boys and girls), requiring plotting of growth data in primary or secondary care up to age four. The charts are also suitable for moderately preterm infants (32-36 weeks gestation) and include a BMI centile lookup and an adult height predictor. There are additional charts available for boys and girls from aged two to 18. Other charts are available for children who need close monitoring (up to 20 years) and children with Down’s syndrome. The centile lines on the charts have been derived from extensive data on infants and children and the lines show how one child compares with other children of the same age and sex. Any weights and heights that are positioned within the centile lines are considered to be in the normal range.

The centile lines start from two weeks of age due to the weight fluctuations described after birth.

The usage of the growth charts is central to the assessment of faltering growth and generally for infants of a normal birthweight, a fall of two or more centile spaces is considered as indicative of faltering growth.

a full clinical assessment is required to exclude issues such as coeliac disease, plus a detailed feeding and eating history with possible observations of this.

Support for the parents is required to provide a realistic management plan with goals. For babies, supplementation of breast feeds with an infant formula may be required, or a change of formula to provide a more energy-dense feed may be provided. An alternative formula may be highlighted too, for any child established as having an allergy or intolerance. Adequate time for feeds needs to be encouraged.

For older children, encouraging them to feed themselves and having positive mealtimes where families eat together on a regular basis, can be helpful. A regular meal pattern and snacks needs to be established.

Regular monitoring is required and NICE advises daily, if less than a month old, weekly for those between one and six months of age, fortnightly for those 6- 12 months of age and then monthly thereafter.

For those babies and children who do not improve, further investigations and support are required. Usually, such support is from a multidisciplinary team, which includes a dietitian.

GUIDANCE AND RECOMMENDATIONS

Registered dietitians can play a key role in the assessment and management of faltering growth, whether it be directly with a child, their parents and carers, or by providing support, training and to other healthcare professionals.

Paediatric dietitians will have undertaken significant training in the management of faltering growth and are invaluable in providing information in very specialised areas like suitable infant formulae and should be able to advise GPs and community nurses about this.

They should also be able to provide expert input into any documents and policies covering the subject. Paediatric dietitians belonging to the Paediatric Specialist Group of the BDA are able to keep up to date on related topics via this specialist network.9 Dietitians working in the community settings with infants and children should be aware of faltering growth and how it is assessed in order to provide a basis of support to families.

The NICE Guidance on Faltering Growth6 gives clear information and the different assessments to be used depending on the birthweight of the baby. For example: • a fall across one or more weight centile spaces if birthweight was below the 9th centile; • a fall across three or more centile spaces if birthweight was above the 91st centile.

Often hospitals and hospital Trusts produce local guidelines for the establishment, investigation and management of faltering growth, which are published on hospital websites for the use of not just NHS staff, but also parents and others including nursery staff involved in the care of children.7 MANAGEMENT OF FALTERING GROWTH

Unless a child is very ill, normally faltering growth is managed in the community. Initially, 20

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Date of preparation: September 2018 UK/NUT/18/0060i