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Faltering growth and nutrition Flashcards

1
Q

When do concerns about faltering growth usually arise?

A

Concerns about faltering growth arise up to 5% of infants and preschool children depending on the definition used.

Concerns are usually raised in primary care, by parents, health visitors or GPs.

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2
Q

What is the definition of faltering growth?

A

Failure to gain adequate weight or achieve adequate growth during infancy or early childhood.

Faltering growth is a significant interruption in the expected rate of growth compared with other children of similar age and sex during early childhood.

Faltering growth is a descriptive term and an underlying cause must be considered.

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3
Q

What are the thresholds for concern about faltering growth in infants and children?

A

a fall across 1 or more weight centile spaces, if birth weight was below the 9th centile.

a fall across 2 or more weight centile spaces, if birth weight was between the 9th and 91st centiles.

a fall across 3 or more weight centile spaces, if birth weight was above the 91st centile.

when current weight is below the 2nd centile for age, whatever the birth weight.

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4
Q

What do you do first when trying to investigate faltering growth?

A

weigh the infant or child.

measure their length (from birth to 2 years old) or height (if aged over 2 years).

plot the above measurements and available previous measurements on the UK WHO growth charts to assess weight change and linear growth over time.

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5
Q

How do we monitor weight if there are concerns about faltering growth?

A

daily if less than 1 month old
weekly between 1–6 months old
fortnightly between 6–12 months
monthly from 1 year of age

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6
Q

What happens if there is weight loss in early days of life?

A

it is common for neonates to lose some weight during the early days of life.
this weight loss usually stops after about 3 or 4 days of life.
most infants have returned to their birth weight by 3 weeks of age.

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7
Q

What happens if infants in early days of life lose more than 10% of their birth weight?

A

perform a clinical assessment
take a detailed history to assess feeding
consider direct observation of feeding
perform further investigations only if they are indicated based on the clinical assessment
provide feeding support (by a person with appropriate training and expertise).

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8
Q

How do we monitor length and height?

A

Obtain the biological parents’ heights and work out the mid-parental height centile.
If more than 2 centile spaces below the mid-parental centile this could suggest undernutrition or a primary growth disorder.

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9
Q

How do we monitor concerns about linear growth?

A

In a child over 2 years of age determine the BMI centile:

BMI< 2nd centile this may reflect either undernutrition or a small build
BMI < 0.4th centile probable undernutrition that needs assessment and intervention

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10
Q

What are things to consider if someone’s showing signs of faltering growth?

A

preterm birth
neurodevelopmental concerns
maternal postnatal depression or anxiety

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11
Q

RFs for faltering growth? (medical)

A

Congenital anomalies (cerebral palsy, autism, trisomy 21)
Developmental delay
Gastroesophageal reflux
Low birth weight (<2.500g)
Poor oral health, dental caries
Prematurity (<37w)
Tongue-tie (controversial)

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12
Q

RFs for faltering growth (psychosocial)

A

Disordered feeding techniques
Family stressors
Parental or family history of abuse/violence
Poor parenting skills
Postpartum depression
Poverty

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13
Q

Child 15 years old
Undiagnosed neurological condition- chronic inflammatory polyneuropathy treated with IV immunoglobulins
Chronic feed intolerance (vomiting, gagging, intermittent diarrhoea)
Gastrostomy feeds no improvement
Trial of jejunal (PEG-J) feeds better tolerated but jej extension kept flicking back into the stomach
Active issues
on-going weight loss ( <0.4th centile)
Vomiting even on jejunal feeds
On-going issues with PEG-J
What can be offered?

A

Admission to the hospital for nutritional rehabilitation
Cachectic
Decision
MDT: Decision - parenteral nutrition and gut rest
Nutritional blood tests

End result:
On PN for over a year
Enjoys a reasonable quality of life

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14
Q

What are the features of Intestinal failure in children and young people with neurodisabling conditions?

A

Development in managing neurodisabling conditions have let to improved outcomes
CP: increase of the median age of survival from 11y to 17y over the past 3 decades
GI dysmotility may evolve over time potentially becoming a life-limiting factor

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15
Q

What are the ethical dilemmas in faltering growth and nutrition?

A

When is it justified to commence PN in a child with a life-limiting condition who develops IF?
If commenced, when is it appropriate to withdraw PN?

RCPCH suggest careful consideration to the role of PN as a life- sustaining treatment (LST) for children with neurodisabling conditions and to discuss decision fully with the family.

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16
Q

How do we assess a child with faltering growth?

A

Perform a clinical, developmental and social assessment
Take a detailed feeding or eating history
Consider direct observation of feeding or meal times

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17
Q

When should we consider referral?

A

symptoms or signs that may indicate an underlying disorder

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18
Q

What are the examination findings in children with faltering growth?

A

Slide 31 of faltering growth slides

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19
Q

When do we consider referral for faltering growth?

A

symptoms or signs that may indicate an underlying disorder
a 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

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20
Q

What are the 4 main areas of re energy?

A

Not enough in
Not absorbed
Too much used up
Abnormal central control of growth/appetite

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21
Q

Why is there faltering growth in mil-fed infants (Not enough in)

A

ineffective suckling in breastfed infants
ineffective bottle feeding
feeding patterns or routines being used
the feeding environment
feeding aversion
parent/carer–infant interactions
physical disorders that affect feeding

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22
Q

Management for Not enough in?

A

Initial interventions for faltering growth include strategies to increase energy intake and advice on managing feeding and eating behavior

Food diary

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23
Q

Who is involved in the MDT for faltering growth (Not enough in)

A

infant feeding specialist
consultant paediatrician
paediatric dietitian
speech and language therapist with expertise in feeding and eating difficulties

clinical psychologist

occupational therapist

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24
Q

What happens in GORD?

A

Sphincter between oesophagus and stomach open allowing reflux to happen

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25
What happens if there if there is feed refusal?
Enteral tube feeding for infants and children with faltering growth If there are serious concerns about weight gain. An appropriate specialist multidisciplinary assessment for possible causes and contributory factors has been completed. Other interventions have been tried without improvement.
26
Features of enteral tube feeding?
the goals of the treatment (reaching a specific weight target). the strategy for its withdrawal once the goal is reached (for example, progressive reduction together with strategies to promote oral intake).
27
12 Month old child Second opinion Term baby BF for 5m- vomiting with satisfactory weight gain Unsettled, crying Gaviscon, Ranitidine, Omeprazole On- going vomiting and chocking episodes Feeding History: Different formulas Amino acid formula Admission at 5m and NG tube SALT assessment (report pending) NG dependent Refuses to take food orally or keeps the food in her mouth without swallowing it Becoming increasingly distressed with NG tube replacements What would you suggest?
Assess severity of reflux ? CMA Dietetic review/ food diary Chase SALT report Consider gastrostomy insertion
28
12 Month old child Second opinion Term baby BF for 5m- vomiting with satisfactory weight gain Unsettled, crying Gaviscon, Ranitidine, Omeprazole On- going vomiting and chocking episodes Feeding History: Different formulas Amino acid formula Admission at 5m and NG tube SALT assessment (report pending) NG dependent Refuses to take food orally or keeps the food in her mouth without swallowing it Becoming increasingly distressed with NG tube replacements Letter from local hospital raising concerns about parents and over reporting.., Letter from local hospital raising concerns about parents and over reporting - what should you do next?
With MDT Plan: Admission for observations Outcome Parents: appropriate behaviour CW: orally aversed
29
12 month old child has Oral aversion & Gastroesophageal Reflux Disease (GORD) Whats the plan?
Gastronomy
30
2y7m old child Started accepting oral food at 16m Weight on 25th centile Off anti-reflux medication Better with solids
31
What are the causes of inadequate nutrient absorption? (Not absorbed)
Anemia (iron deficiency) Biliary atresia Coeliac disease Chronic GI conditions (infections, IBS) Cystic fibrosis Inborn errors of metabolisms Milk protein allergy Pancreatic cholestatic conditions
32
Coeliac iceberg
Look at page 59 for faltering growth
33
What is involved in coeliac disease?
Coeliac screen includes IgA- antibodies against transglutamisane- 2 (TGA-IgA) and total serum immunoglobulin A. A serological test for coeliac disease is only accurate if a gluten-containing diet has been followed for at least 6 weeks. As a positive serological result for coeliac disease is not sufficient to confirm diagnosis, people should be referred to a specialist for assessment and further investigation.
34
How do we diagnose coeliac disease?
Upper GI endoscopy and small bowel biopsy If TGA- IgA is equal or >10 times the upper limit of normal (10xULN) and the family agrees, the no-biopsy diagnosis may be applied provided endomysial antibodies (EMA- IgA) will test positive in a second blood sample. HLA DQ2-/DQ8 determination and symptoms are not obligatory criteria.
35
What are infective causes of not enough nutrients in?
Enteroviruses Rotavirus; adenovirus; picornavirus etc Bacterial Toxins - clostridium difficile; staphylococcal Secretagogues - cholera Inflammatory – salmonella; campylobacter Parasitic Giardia; entamoeba histolytica Others TB; opportunistic in immunocompromised host Herpes; CMV; HIV
36
What is Giardia?
Only 20% pick up rate on immediate stool examination May last for years: foreign travel not necessary Giardia stool ELISA
37
How do we treat Giardia?
Practically: treat empirically with metronidazole 15mg/kg 3x a day for 7 days
38
What are the post-infective causes of faltering growth?
Infection-related mucosal disintegrity > Immunological antigen exposure > Mucosal (allergic) inflammation > Secondary disaccharidase deficiency > Diarrhoea
39
Features of (cow) milk protein allergy?
Swelling of eye or eye lids Vomiting Asthma Eczema Wheezing & coughing Refusal to feed Diarrhoea Blood in poop Skin rash
40
What are the causes of increased metabolism? (Too much used up)
Chronic infections (HIV, tuberculosis) Chronic lung disease of prematurity Congenital heart disease Hyperthyroidism Inflammatory conditions (e.g. asthma, IBD) Malignancy Renal failure
41
13y boy Transferred from local hospital Diagnosed with eating disorder Poor appetite Weight 75th centile 9th centile in 5 months Intermittent loose stools ESR 25, CRP 14 What interventions would you suggest?
Upper and lower GI endoscopy Wireless capsule enteroscopy
42
What are the treatments for Crohn's disease
Induction treatment: exclusive enteral nutrition Maintenance treatment: Infliximab (top down treatment)
43
What can cause abnormal growth control
RARE! GH Thyroid Psychosocial influence
44
What is Avoidant or Restrictive Food Intake Disorder (ARFID)?
significant weight loss (or failure to meet expected weight and height trajectories in children and adolescents) nutritional deficiencies (such as iron deficiency anemia) a dependence on nutritional supplements, (i.e., oral or enteral formulas), to meet energy requirements without an underlying condition necessitating this significant interference with day-to-day functioning due to the inability to eat appropriately.
45
What are the challenges to management of faltering growth?
Faltering growth is complex and often multifactorial and a specific underlying cause may not be identified. Children may undergo excessively frequent monitoring or unnecessary investigations looking for an underlying disorder. Parents may feel blamed for their child’s slow weight gain, whereas neglect is an uncommon cause of faltering growth. Healthcare professionals should remain alert to the possibility of safeguarding concern, but should be sensitive to the emotional impact of caring for a child with faltering growth.
46
What do we consider investigating for in faltering growth according to NICE guidelines 2017
urinary tract infection coeliac disease, if the diet has included gluten-containing foods Perform further investigations only if they are indicated based on the clinical assessment.
47
Why should we measure children?
Growth is a sensitive indicator of health in childhood Growth rates are narrowly defined in healthy children with adequate nutrition and an emotionally supportive environment Changes in growth rates can provide an early and sensitive pointer to health problems in children
48
What are the important determinants of growth?
Nature: Parental phenotype and genotype Specific system and organ integrity Growth promoting hormones and factors Nurture: Quality and duration of pregnancy Nutrition Psycho-social environment
49
In terms of body and head shape - what is the difference between newborns and adults?
Newborns: larger head, smaller mandible, short neck, chest rounded, abdomen prominent, limbs short Adults: relative growth of limbs compared to trunk
50
What clues about disproportion can give us our diagnosis?
Short limbs > hypochondroplasia Short back & long legs > delayed puberty
51
What does the interpretation of head circumference depend on?
Centile position Serial measurements Relation to body size Familial factors Features of sutures and fontanelles Clinical signs of abnormal intracranial pressure
52
What is the normal range in a standard UK growth chart?
3rd-97th centile
53
What do we use to interpret a childs centile position?
Mid parental height
54
How do we use the parents heights predict a child's height?
Boys: Father’s height + (mother’s ht +12.5cm)/2 Boys: Father’s height + mother’s ht/2 +7 Girls: Mother’s height + (father’s ht - 12.5cm)/2 Girls: Father’s height + mother’s ht/2 +7 95% CI = mid-parental ht +/- 8.5cm OR +/- 8cm for girls, +/- 10cm for boys
55
How do we measure Height velocity?
Height velocity = change in height / years between measurements
56
What are the averages for height velocity?
Age 5 yr 105cm Age 6.2 yr 111cm Velocity 5 cm/year
57
How do we interpret height and velocity centiles
Height centile Velocity Centile 3 25 50 50 97 75
58
Whats the hypothalamic - pituitary axis?
GnRH (Hypothalamus) > LH, FSH (Pituitary)> Gonadal sex hormones (Gonads) > Sex hormone action (Periphery)
59
Stage 1 Puberty boys
Prepubertal: No pubic hair Testicular length <2.5 cm Testicular volume <3.0 mL
60
Stage 2 Puberty boys
Sparse growth of slightly curly pubic hair, mainly base of penis Testes > 3 mL (>2.5 cm in longest diameter) Scrotum thinning and reddening
61
Stage 3 puberty
Thicker, curlier hair spread to mons pubis Growth of penis in width and length; further growth of testes
61
Stage 4 puberty boys
Adult-type hair, not yet spread to medial surface of thighs Penis further enlarged; testes larger, darker scrotal skin colour
62
Stage 5 puberty
Adult-type hair spread to medial surface of thighs Genitalia adult size and shape
63
Stage 1 puberty girl
Prepubertal: No pubic hair Elevation of papilla only
64
Stage 2 puberty girl
Sparse growth of long, straight or slightly curly, minimally pigmented hair, mainly on labia Breast bud noted/ palpable; enlargement of areola
65
Stage 3 puberty girl
Darker, coarser hair spreading over mons pubis Further enlargement of breast and areola, with no separation of contours
66
Stage 4 puberty girl
Thick adult-type hair, not yet spread to medial surface of thighs Projection of areola and papilla to form secondary mound above level of breast
67
Stage 5 Puberty girl
Hair adult-type and distributed in classic inverse triangle Adult contour breast with projection of papilla only
68
What are the categories for delay in puberty?
Tertiary - hypothalamus Secondary - Pituitary Primary - Gonads
69
What is Klinefelter syndrome?
Affects approx. 1 in 1,000 males (underrecognised) 47, XXY Primary hypogonadism Azoospermia, Gynaecomastia Reduced secondary sexual hair Osteoporosis Tall stature Reduced IQ in 40% 20-fold increased risk of breast cancer
70
What is Turner syndrome?
Short stature At birth oedema of dorsa of hands, feet and loose skinfolds at the nape of the neck Webbing of neck, low posterior hairline, small mandible, prominent ears, epicanthal folds high ached palate, broad cheast, cubitus valgus, hyperconvex fingernails Hypergonadotrophic hypogonadism, streak gonads Cardiovascular malformations Renal malformations (horseshoe kidney) Recurrent otitis media
71
Look back at slide 26 of growth and puberty
72
What are the most common causes of hypogonadism? (Primary gonadal failure)
Males - Klinefelter's syndrome (47XXY) Females - Turner's syndrome and its variants Both sexes - Chemotherapy/ Radiotherapy Galactosemia Trauma/ surgery
73
What are the most common causes of hypogonadism? (Secondary/ tertiary gonadal failure)
Intracranial tumours Chemotherapy / Radiotherapy Congenital enzyme / receptor mutations Prader-Willi syndrome Sport Eating disorders Malnutrition Chronic disease Marijuana
74
Epidemiology of precocious puberty?
Incidence 1 in 5,000 to 10,000 90% of patients female Idiopathic CPP - Up to 80% female - Only 30% male
75
What can precocious puberty be caused by?
Increased hCG possibly secreting tumours, gonads, brain, liver, retroperitoneum, mediastinum Increased hCG caused increased production Gonadal sex hormones and Increased adrenal sex hormones causing increased sex hormone action
76
What happens in True precocious puberty?
Stimulation pubertal range Stimulated LH:FSH ratio > 1
77
What happens in precocious pseudo puberty
Stimulation pre-pubertal range or suppression Stimulated LH:FSH ratio < 1
78
What does bone age show?
Skeletal maturity
79

3A Paediatrics (19 decks)

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