Faltering growth and nutrition Flashcards
When do concerns about faltering growth usually arise?
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.
What is the definition of faltering growth?
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.
What are the thresholds for concern about faltering growth in infants and children?
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.
What do you do first when trying to investigate faltering growth?
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.
How do we monitor weight if there are concerns about faltering growth?
daily if less than 1 month old
weekly between 1–6 months old
fortnightly between 6–12 months
monthly from 1 year of age
What happens if there is weight loss in early days of life?
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.
What happens if infants in early days of life lose more than 10% of their birth weight?
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).
How do we monitor length and height?
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.
How do we monitor concerns about linear growth?
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
What are things to consider if someone’s showing signs of faltering growth?
preterm birth
neurodevelopmental concerns
maternal postnatal depression or anxiety
RFs for faltering growth? (medical)
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)
RFs for faltering growth (psychosocial)
Disordered feeding techniques
Family stressors
Parental or family history of abuse/violence
Poor parenting skills
Postpartum depression
Poverty
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?
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
What are the features of Intestinal failure in children and young people with neurodisabling conditions?
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
What are the ethical dilemmas in faltering growth and nutrition?
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.
How do we assess a child with faltering growth?
Perform a clinical, developmental and social assessment
Take a detailed feeding or eating history
Consider direct observation of feeding or meal times
When should we consider referral?
symptoms or signs that may indicate an underlying disorder
What are the examination findings in children with faltering growth?
Slide 31 of faltering growth slides
When do we consider referral for faltering growth?
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
What are the 4 main areas of re energy?
Not enough in
Not absorbed
Too much used up
Abnormal central control of growth/appetite
Why is there faltering growth in mil-fed infants (Not enough in)
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
Management for Not enough in?
Initial interventions for faltering growth include strategies to increase energy intake and advice on managing feeding and eating behavior
Food diary
Who is involved in the MDT for faltering growth (Not enough in)
infant feeding specialist
consultant paediatrician
paediatric dietitian
speech and language therapist with expertise in feeding and eating difficulties
clinical psychologist
occupational therapist
What happens in GORD?
Sphincter between oesophagus and stomach open allowing reflux to happen
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.
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).
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
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
12 month old child has Oral aversion &
Gastroesophageal Reflux Disease (GORD)
Whats the plan?
Gastronomy
2y7m old child
Started accepting oral food at 16m
Weight on 25th centile
Off anti-reflux medication
Better with solids
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
Coeliac iceberg
Look at page 59 for faltering growth
