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Volume 8.07 - 26th April 2018

FALTERING GROWTH Jacqui Lowdon Paediatric Dietitian, Leeds Children’s Hospital Jacqui is a Clinical Specialist in Paediatric Cystic Fibrosis at Leeds Children's Hospital. She previously specialised in gastroenterology and cystic fibrosis. Although her career to date has focused on the acute sector, Jacqui has a great interest in paediatric public health.

In autumn 2017, NICE produced a guideline on faltering growth.1 This article summarises the findings and examines the recommendations for further research arising from the guideline. The NICE guideline includes the recognition, assessment and monitoring of faltering growth in infants and children, as well as a definition of growth thresholds for concern, identifying the risk factors for, and possible causes of faltering growth. It also covers interventions, when to refer, service design and acts as a reference for information and support. Weight loss can occur in the first few days of life, which is due to changes in body fluids. However, sometimes there may be a justified reason for this weight loss, requiring intervention. This is quite different from concerns about inadequate weight gain in older infants and children. Both are looked at in the NICE guideline. NICE defines faltering growth as ‘a slower rate of weight gain in childhood than expected for age and sex’. However, NICE is unable to provide any estimates of prevalence, as various definitions of faltering growth have been used in the past in the UK.

BABY’S EARLY DAYS

A baby’s weight loss usually stops after about three or four days of life, with most infants regaining their birth weight by three weeks of age. It is recommended that if the infant loses more than 10% of their birth weight, they should be clinically assessed for reasons that might account for the weight loss. Reference can also be made to NICE recommendations on postnatal care up to eight weeks after birth.2 Supplementary feeding with infant formula in a breastfed infant can be used to aid weight gain, but this risks the cessation of breastfeeding. NICE provides recommendations regarding this, including supporting the continuation of breastfeeding, advising on expressing breast milk to promote milk supply and feeding the infant with any available breast milk prior to giving infant formula.2 AFTER THE EARLY DAYS OF LIFE

Weight The NICE guideline on faltering growth

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Table 1: Suggestions for discussions with parents or carers Encouraging relaxed and enjoyable feeding and mealtimes. Eating together as a family or with other children. Encouraging young children to feed themselves. Allowing young children to be 'messy' with their food. Making sure feeds and mealtimes are not too brief or too long. Setting reasonable boundaries for mealtime behaviour while avoiding punitive approaches. Avoiding coercive feeding. Establishing regular eating schedules.

recommends using the following as thresholds for concern, with a centile space being the space between adjacent centile lines on the UK WHO growth charts: 1. A fall across one or more weight centile spaces, if birth weight was below the 9th centile. 2. A fall across two or more weight centile spaces, if birth weight was between the 9th and 91st centiles. 3. A fall across three or more weight centile spaces, if birth weight was above the 91st centile. 4. When current weight is below the 2nd centile for age, whatever the birth weight. Height It is recommended that if there are concerns about an infant’s length or a child’s height, to try to obtain the biological parents’ heights and work out the mid-parental height centile. If it is below the predicted range, i.e. more than two centile spaces below the mid-parental centile, this may indicate undernutrition, or a primary growth disorder. Body Mass Index BMI centile can be used in children above two years of age if there is concern about faltering growth. If the BMI is below the 2nd centile, this

can reflect either undernutrition, or a small build. If it is below the 0.4th centile, this is suggestive of probable undernutrition requiring assessment and intervention. Assessment The following is recommended: 1. A full assessment is required, clinically, developmentally and socially. 2. A detailed feeding/diet history. 3. Consider a direct observation of feeding or at mealtimes. 4. Consider investigating for urinary tract infection, coeliac disease and perform further investigations if indicated. Interventions A management plan, with individual goals, should be agreed with the parents and carers (see Table 1). NUTRITIONAL MANAGEMENT

Food first First-line advice should be given on food choices that are appropriate for the child’s developmental stage in terms of quantity, type and food texture to optimise energy and nutrient density. Where a further increase in the nutrient density of the diet is required beyond that achieved through advice on food choices, then short-term advice on dietary fortification using energy-dense foods should be given, along with a referral to a paediatric dietitian. Oral liquid nutritional supplements If faltering growth continues after a food first approach fails, then a trial of an oral liquid nutritional supplement can be considered. The NICE guideline defines an oral liquid nutritional supplement as ‘a high-energy liquid feed designed for enteral use, usually selected and prescribed after specialist advice from a paediatric dietitian’.

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Volume 8.07 - 26th April 2018

NICE also cautions against weighing children more often than is required, as it will only add to parental anxiety, as minor short-term weight changes may cause unnecessary concern. Any infant/child receiving a nutritional supplement requires regular reassessment. The following factors need to be taken into account: • Weight change • Linear growth • Intake of other foods • Tolerance • Adherence • The views of parents or carers Tube feeding The NICE guideline on faltering growth recommends that tube feeding should only be considered when there are serious concerns about weight gain, where an appropriate specialist multidisciplinary assessment for possible causes and contributory factors has been completed and when other interventions have been tried without improvement. The plan will need to include a specific weight target and a strategy for its withdrawal, once the weight goal is achieved. MONITORING

Different factors will need to be taken into consideration, such as the age of the child and the severity of the faltering growth, but the guidance recommends no more often than: • daily if less than one month old; • weekly between one to six months old; • fortnightly between six to 12 months; • monthly from one year of age. NICE also cautions against weighing children more often than is required, as it will only add to parental anxiety, as minor shortterm weight changes may cause unnecessary concern. If there are concerns about faltering growth, length or height should be monitored, but no more often than every three months.

Frequency of monitoring It would be of great benefit to know whether a particular frequency, or schedule of measuring, infants and children would identify faltering growth at an earlier age and contribute to an earlier catch-up in weight. Presently, it is suggested that routine measurements are taken at the time of routine childhood immunisations. It is unclear whether this is most effective for children where there are concerns about their growth. If a different schedule of routine measurement was found to identify faltering growth at an earlier age and contribute to an early catch-up in weight, it would need to be considered how best it should be delivered. Referral NICE recommends that if an infant or child with faltering growth has any of the following, then they should be discussed with, or referred to, an appropriate paediatric specialist care service: • symptoms or signs that may indicate an underlying disorder; • failure to respond to interventions delivered in a primary care setting; • slow linear growth or unexplained short stature; • rapid weight loss or severe undernutrition features that cause safeguarding concerns. NICE also recommends that infants or children with faltering growth should not be admitted to hospital unless they are acutely unwell, or there is a specific indication requiring inpatient care, e.g. tube feeding. RECOMMENDATIONS FOR RESEARCH

The guideline also includes some recommendations for research. These include areas that paediatric dietitians could investigate within their own clinical practice.

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NHD CPD eArticle HIGH ENERGY LIQUID FEED SUPPLEMENTS

The question, “Do high energy liquid feed supplements improve growth in children with faltering growth?” has yet to be answered. It appears logical to treat inadequate dietary intake with high energy liquid dietary supplements. However, despite being widely promoted for use in children, little research has been carried out on their efficacy. NICE reports that experimental research suggests that high energy liquid feed supplements may supress appetite, thus displacing normal diet. NICE also reports one case series where high energy liquid feed supplements were withdrawn, appetite improved, with no impact on weight. It is, therefore, recommended that further research is required to establish whether their effectiveness justifies their cost and the suppressant effect on appetite. BEHAVIOURAL INTERVENTIONS

In the community, primary healthcare staff, such as health visitors and nursery nurses, provide behavioural interventions for faltering growth. However, behavioural interventions are time consuming and costly. Evidence for the specific components of behavioural interventions are scarce and if they are effective, they could have short-term and longer-term preventative results. Standardising approaches to behavioural interventions could both improve clinical practice and save costs.

Volume 8.07 - 26th April 2018 PARENTAL SUPPORT

For parents with a child with faltering growth, it can be a very distressing time, often blaming themselves. It can also have a long-term negative impact on the child/ parent relationship. Presently, no studies exist that describe parental experiences or concerns. Research on this topic would help to improve understanding of the needs and concerns of these parents, which will then enable healthcare professionals to better address them. SUMMARY

The NICE guideline 1 provides us with a guide to the recognition, assessment and monitoring of faltering growth in infants and children. It includes a definition of growth thresholds for concern and identification of the risk factors for, and possible causes of, faltering growth. It also covers interventions, when to refer, service design and information and support. All members of the multidisciplinary team can refer to this guideline, and so too can providers and commissioners of children’s services, parents and carers of children with faltering growth. The NICE guideline of faltering growth is an essential point of reference for anyone involved in the care of infants and children with faltering growth.

References 1 National Institute for Health and Care Excellence (NICE). Faltering growth: recognition and management of faltering growth in children. NICE guideline [NG75]. Published: 27 September 2017. www.nice.org.uk/guidance/ng75 Accessed Jan 18 2 National Institute for Health and Care Excellence (NICE). Postnatal care up to eight weeks after birth. NICE Clinical guideline [CG37]. www.nice.org.uk/ guidance/CG37. Accessed Jan 18

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Volume 8.07 - 26th April 2018

Questions relating to: Faltering growth Type your answers below, download and save or print for your records, or print and complete by hand. Q.1

What does the NICE guideline on faltering growth include?

Q.2

In what instance would a clinical assessment of an infant be recommended to assess for faltering growth?

Q.3

Explain two of the four thresholds for concern as outlined in the NICE guideline.

Q.4

If there is concern about a childâ&#x20AC;&#x2122;s height, what is the recommended course of action?

Q.5

How can BMI be used to assess faltering growth in an infant?

Q.6

If the food first approach fails to manage faltering growth, what are the next steps?

Q.7

When would tube feeding be an appropriate course of action in faltering growth?

Q.8

Describe the guidance recommendations on monitoring.

Q.9

What are the considerations for referral onto specialist care?

Please type additional notes here . . .

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