Development: Nutrition, Growth Charts & Failure to Thrive

Question 1

How long is breastfeeding recommended for?

Answer 1

WHO recommend exclusive breastfeeding for the first 6 months of life.

Question 2

Is overfeeding more common in bottle or breastfed babies?

Answer 2

Bottle fed

Question 3

General foetal benefits of breastfeeding?

Answer 3

1) Breast milk contains antibodies that can help protect the neonate against infection.

2) Has been linked to reduced infections in the neonatal period

3) Linked to better cognitive development

4) Linked to lower risk of certain conditions later in life

5) Reduced risk of sudden infant death syndrome (SIDS)

6) Linked to less obesity

Question 4

What 2 cancers is breastfeeding protective against?

Answer 4

Breast & ovarian

Question 5

On formula feed, how much milk per kg of body weight should babies receive?

Answer 5

150ml of milk per kg of body weight

Note - Preterm and underweight babies may require larger volumes.

Question 6

How does weight change in first 10 days of life?

Answer 6

It is acceptable for breast fed babies to lose up to 10% and formula fed babies to loose up to 5% of their body weight by day 5 of life.

They should be back at their birth weight by day 10.

If they lose more weight than this or do not regain their birth weight by two weeks, they need admission to hospital and assessment for possible causes.

Question 7

What is the most common cause of excessive weight loss or not regaining weight in the neonatal period?

Answer 7

Dehydration due to underfeeding (even when they do not clinically look dehydrated)

Question 8

What is the most reliable sign of dehydration in babies?

Answer 8

Weight loss

Question 9

Define weaning

Answer 9

The gradual transition from milk to normal food

Question 10

When does weaning normally start?

Answer 10

Around 6 months of age.

Over 6 months this will progress towards a healthy diet resembling an older child, supplemented with milk and snacks to 1 year of age.

Question 11

What are growth charts?

Answer 11

Growth charts are used to plot a child’s weight, height and head circumference against the normal distribution for their age and gender.

The child’s measurements are plotted on a graph using a dot.

The age is plotted on the x-axis and the weight, height and head circumference are plotted on the y-axis.

Question 12

What 3 measures are taken on a growth chart?

Answer 12

1) weight
2) height
3) head circumference

Question 13

If a child is on the 50th centile on the growth chart, what does this mean?

Answer 13

They are basically exactly average height for their age.

Question 14

If a child is on the 1st centile on the growth chart, what does this mean?

Answer 14

They are shorter than 99% of children their age.

Question 15

If a child is on the 91st centile on the growth chart, what does this mean?

Answer 15

They are taller than 91% of children their age.

Question 16

What is the important thing to consider when assessing a child where there are concerns about not gaining weight or height?

Answer 16

Establish whether they are maintaining their centile.

If a child is on the 9th centile, but they have always been on the 9th centile, that is much less concerning than a child that was on the 91st centile and is now on the 9th.

Question 17

Children go through three phases of growth.

What are they?

Answer 17

Infancy: from birth to 2 y/o

Childhood: from 2 y/o to 11 y/o

Puberty: from 11 y/o to 18 y/o

Question 18

In infancy, what are the 2 major drivers of growth?

Answer 18

1) nutrition

2) insulin

Question 19

How does insulin drive growth in infancy?

Answer 19

In a mother with poorly controlled diabetes they will have high blood glucose and as a result, the baby will produce high amounts of insulin.

At birth this high fetal insulin will continue resulting in hypoglycaemia.

They will also be macrosomic thus showing how insulin drives growth.

Question 20

In childhood, what are the 2 main drivers of growth?

Answer 20

1) Growth homrone

2) Thyroxine

Question 21

In puberty, what are the 2 main drivers of growth?

Answer 21

1) GH - high amounts are important in growth spurts

2) Sex steroid

Question 22

What is the most important determinant of final adult height?

Answer 22

Genetic factors

Question 23

Define ‘overweight’ and ‘obese’

Answer 23

Overweight: BMI above the 85th percentile

Obese: BMI above the 95th percentile

Question 24

How often is growth monitored in the first 2 years of life?

Answer 24

Aged 0-1: should have at least 5 recordings of weight

Aged 1-2: should have at least 3 recordings of weight

Question 25

How often is growth monitored in children aged >2 y/o?

Answer 25

Should have annual recording of weight

Question 26

What growth chart should be used for pre-term infants born <32 weeks gestation?

Answer 26

Neonatal and infant close monitoring (NICM) chart

Question 27

What growth chart should be used for pre-term infants born 32-27 weeks gestation?

Answer 27

Plot all measurements in the preterm section until 42 weeks gestation.

Then plot on the 0-1-year chart using gestational correction.

Question 28

What is gestational correction?

Answer 28

Plot measurements at the child’s actual age, then draw a line back the number of weeks the infant was preterm.

Mark the spot with an arrow: this is child’s gestationally corrected centile. This should continue until at least 1 year of age.

(see geeky medics)

Question 29

On growth charts, if the point is within 1/4 of a space of the line, what does this mean?

Answer 29

They are on the centile

Question 30

On growth charts, if the point is not within 1/4 of a space of the line, what does this mean?

Answer 30

They are described as being between the two centiles.

Question 31

A sustained drop in how many centiles is unusual and should be investigated?

Answer 31

A sustained drop through two or more weight centiles is unusual and should be investigated.

Question 32

Between 2-18 years, what criteria indicates the need for further assessment in regard to growth charts?

Answer 32

1) Weight or height or BMI is below the 0.4th centile (unless already fully investigated at an earlier age)

2) The height centile is more than 3 centile spaces below the mid-parental centile

3) A drop in the height centile position of more than 2 centile spaces.

4) Any other concerns about the child’s growth.

Question 33

What is the mid-parental centile?

Answer 33

The average adult height centile to be expected for all children of these particular parents.

Question 34

How can the mid-parental centile be calculated?

Answer 34

1) If possible, measure both the parent’s heights. If not available, use reported heights.

2) Mark their heights on the relevant Mother and Father scales.

3) Join the two points with a line between them.

4) The mid parental centile is where this line crosses the centile line in the middle.

(see geeky medics)

Question 35

How can the mid-parental centile be used in the assessment of the growth of a child?

Answer 35

Compare the mid-parental centile to the child’s current height centile (this may help assess whether the child’s growth is proceeding as expected).

If a large discrepancy exists between the mid-parental centile to the child’s current height centile, the more likely it is that the child has some sort of growth disorder.

9 out of 10 children’s height centiles are within +/- 2 centile spaces of the mid-parental centile.

Question 36

What is the adult height predictor chart?

Answer 36

This allows for a prediction of the child’s adult height based on their current height (adjusted to allow for very tall and short children to be less extreme as adults).

Question 37

What is Tanner stage 1 for girls?

Answer 37

Pre-puberty: no signs of pubertal development.

Question 38

When is puberty considered delayed in girls?

Answer 38

If there are no signs of puberty by 13 years of age

Question 39

When is menstruating considered delayed in girls?

Answer 39

If the patient is older than 16 years old and not in the “completing puberty stage”, maturation is delayed, and further investigation is required.

Question 40

Typical age of puberty in girls?

Answer 40

8-13

Question 41

Typical age of puberty in boys?

Answer 41

9-14

Question 42

When is maturation considered delayed in boys?

Answer 42

If the patient is older than 17 years old and not in the “completing puberty stage”, maturation is delayed, and further investigation is required.

Question 43

What does failure to thrive refer to?

Answer 43

Poor physical growth and development in a child.

Question 44

Define faltering growth in children

Answer 44

A fall in weight across:

1) One or more centile spaces if their birthweight was below the 9th centile

2) Two or more centile spaces if their birthweight was between the 9th and 91st centile

3) Three or more centile spaces if their birthweight was above the 91st centile

Question 45

What are centile spaces?

Answer 45

The distance between two centile lines on a growth chart.

The distance between the 75th and 50th centile lines is a centile space.

Question 46

What are the categories of causes of failure to thrive?

Answer 46

1) Inadequate nutritional intake

2) Difficulty feeding

3) Malabsorption

4) Increased energy requirements

5) Inability to process nutrition

Question 47

What are some causes of inadequate nutritional intake causing failure to thrive?

Answer 47

1) Maternal malabsorption if breastfeeding

2) Iron deficiency anaemia

3) Family or parental problems

4) Neglect

5) Availability of food (i.e. poverty)

Question 48

What are some causes of difficult of feeding cause failure to thrive?

Answer 48

1) Poor suck, for example due to cerebral palsy

2) Cleft lip or palate

3) Genetic conditions with an abnormal facial structure

4) Pyloric stenosis

Question 49

What are some causes of malabsorption causing failure to thrive?

Answer 49

1) CF

2) Coeliac disease

3) Cows milk intolerance

4) Chronic diarrhoea

5) IBD

Question 50

What are some causes of increased energy requirements causing failure to thrive?

Answer 50

1) Hyperthyroidism

2) Chronic disease e.g. congenital heart disease and cystic fibrosis

3) Malignancy

4) Chronic infections e.g. HIV or immunodeficiency

Question 51

What are some causes of an inability to process nutrients properly causing failure to thrive?

Answer 51

1) inborn errors of metabolism

2) T1D

Question 52

When assessing failure to thrive, what key areas need to be assessed?

Answer 52

1) Pregnancy, birth, developmental and social history

2) Feeding or eating history

3) Observe feeding

4) Mums physical and mental health

5) Parent-child interactions

6) Height, weight and BMI (if older than 2 years) and plotting these on a growth chart

7) Calculate the mid-parental height centile

Question 53

What does a feeding history involve?

Answer 53

Asking about breast or bottle feeding, feeding times, volume and frequency and any difficulties with feeding.

Question 54

What does an eating history involve when assessing failure to thrive?

Answer 54

Asking about food choices, food aversion, meal time routines and appetite in children.

Asking the parent to keep a food diary can be helpful.

Question 55

How is BMI calculated?

Answer 55

BMI = weight (kg) / height (m)2

Question 56

How is mid parental height calculated?

Answer 56

Mid parental height is calculated as: (height of mum + height of dad) / 2.

Question 57

What 2 outcomes from assessment would suggest inadequate nutrition or a growth disorder?

Answer 57

1) Height more than 2 centile spaces below the mid-parental height centile

2) BMI below the 2nd centile

Question 58

What 2 investigations are indicated if faltering growth is suspected?

Answer 58

1) Urine dipstick, for urinary tract infection

2) Coeliac screen (anti-TTG or anti-EMA antibodies)

Question 59

What are some management options where inadequate nutrition is the cause of failure to thrive?

Answer 59

• Encouraging regular structured mealtimes and snacks
• Reduce milk consumption to improve appetite for other foods
• Review by a dietician
• Additional energy dense foods to boost calories
• Nutritional supplements drinks

Question 60

Define short stature

Answer 60

Short stature is defined as a height more than 2 standard deviations below the average for their age and sex. This is the same as being below the 2nd centile.

Question 61

Causes of short stature in children?

Answer 61

1) Familial short stature

2) Constitutional delay in growth and development

3) Malnutrition

4) Chronic diseases, such as coeliac disease, inflammatory bowel disease or congenital heart disease

5) Endocrine disorders, such as hypothyroidism

6) Genetic conditions, such as Down syndrome

7) Skeletal dysplasias, such as achondroplasia

Question 62

What is constitutional delay in growth and puberty (CDGP)?

Answer 62

A variation on normal development.

It leads to short stature in childhood when compared with peers but normal height in adulthood. Puberty is delayed and the growth spurt during puberty lasts longer. They ultimately reach their predicted adult height.

Question 63

What is a key feature of CDGP?

Answer 63

Delayed bone age (can get XR)