Paediatric development Flashcards
Breast vs Bottle
Breastmilk:
Pros:
- contains ANTIBODIES
- reduced infections in neonatal period
- lower risk of necrotising enterocolitis
- Better cognitive development
- lower risk of other conditions later in life
- lower risk of sudden infant death syndrome (SIDS)
- linked to less obseity as teens
- reduced risk of breast/ovarian cancer in mum
Tho these could also be due to other socio-economic factors that also link to decision to breastfeed
Cons:
- Inadequate nutrition if difficult to do
Both breast + bottle can lead to OVERFEEDING
Feeding volumes in babies
Formula feed = 150ml/kg of body weight/day (may have to work up from less in the first week)
- may be more if preterm/underweight
Every 2-3 hour intially, then gradually increase till babies’ FEEDING ON DEMAND
Initial weight loss in babies
Up to 10% if breast fed; 5% if formula fed
- any more than this/not regained birth weight by 2 weeks -> hospital
- usually from DEHYDRATION due to under feeding
Weaning
Usually starts ~6 MONTHS
- starts with pureed foods
Progress to normal diet supplemented with milk + snacks to 1 year
Red flags in development
- Lost developmental milestones (REGRESSION)
- No response to carer interactions by 8 wks
- Not smiling by 3 months
- Not able to hold an object at 5 months
- Not sitting unsupported at 12 months (1yr)
- Not standing independently / walking at all by 18 months
- No clear words by 18 months
- No interest in others at 18 months
- Not running at 2.5 years
- Not interested in playing with peer by 3 yrs
Any sign of sidedness before 18 months
Failure to thrive
Poor physical growth + development
Faltering growth
Failure to gain adequate weight or ahieve adequate growth during infancy/early childhood (hight, weight, head circumferance in infancy)
- a significant interruption in the expected rate of growth compared with other children of similar age and sex during early childhood
Fall in weight across:
- One or more centile spaces if their birthweight was below the 9th centile
- Two or more centile spaces if their birthweight was between the 9th and 91st centile
- Three or more centile spaces if their birthweight was above the 91st centile
- when urrent weight is below the 2nd centile for age, whatever the birth weight
May not be representative in neonates due to variations in growth due to antenatal factors (e.g. maternal smoking, gestational diabetes)
Causes of failure to thrive
Anything leading to inadequate energy/nutrition:
- Inadequate nutritional intake
- Difficulty feeding
- Malabsorption
- Increased energy requirements
- Inability to process nutrition
Causes of Inadequate Nutritional Intake
- Maternal malabsorption if breastfeeding
- Family or parental problems
- Neglect
- Availability of food (i.e. poverty)
- Ineffective suckling/bottle feeding
- Feeding aversion
- Physical disorders affecting feeding
Causes of Difficulty Feeding
- Poor suck (e.g. from cerebral palsy)
- Cleft lip or palate
- Genetic conditions with an abnormal facial structure
- Pyloric stenosis (the sphincter becomes thicker)
Causes of Malabsorption
- Cystic fibrosis
- Coeliac disease
- Cows milk intolerance
- Chronic diarrhoea
- Inflammatory bowel disease
- Biliary atresia
- Pancreatic cholestatic conditions
- ANAEMIA
Causes of Increased Energy Requirements
- Hyperthyroidism
- Chronic disease,
-for example congenital heart disease and cystic fibrosis, chronic lung disease of prematurity - Malignancy
- Chronic infections, for example HIV or immunodeficiency
- Inflam conditions (astma, IBD)
- Renal failure
Inability to Process Nutrients Properly
- Inborn errors of metabolism
- Type 1 diabetes
Which key areas need to be assessed when investigating failure to thrive:
- Pregnancy, birth, developmental and social history
- Feeding or eating history
- Observe feeding
- Mums physical and mental health
- Parent-child interactions
- Height, weight and BMI (if older than 2 years) and plotting these on a growth chart
- Calculate the mid-parental height centile
How would one take a feeding/eating Hx
- Ask about breast or bottle
- Feeding times + frequency
- Volume
- Difficulties feeding
Food choices + aversions. Mealtime routines + appetitee.
FOOD DIARY = helpful.
BMI claculation
(weight in kg) / (height in meters)2
Mid parental height calculation
(height of mum + height of dad) / 2.
Outcomes from failure to thrive assessment that would suggest inadequate nutrition or a growth disorder are
- Height more than 2 centile spaces below the mid-parental height centile
- BMI below the 2nd centile
Potential investigations for faltering growth
- Urine dipstick, for urinary tract infection
- Coeliac screen (anti-TTG or anti-EMA antibodies)
Further investigations usually only done if signs suggest underlying diagnosis e.g. CF or pyloric stenosis
What advice should be given to mothers struggling to breastfeed (resulting in failure to thrive)
- Encourage to feed with breastmilk prior to top-up feeds with formula
- Express when not breastfeeding to encourage lactation to continue (oftens stops otherwise)
Management options for kids experiencing inadequate nutrition
- 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
How to determine child’s growth
measure weight and hight/length and plt on UK WHO growth charts
How often does weight need to be monitored in children with suspected 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
When does initial neonatal weight loss usually stop
~ 3/4 days
If infants in the 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).
If more than 2 centile spaces below the mid-parental centile
could suggest undernutrition or a primary growth disorder
Risk factors for faltering growth
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)
Things to consider for why baby may have faltering growth
preterm birth
neurodevelopmental concerns
maternal postnatal depression or anxiety
BMI centiles (in relation to concerns about linear growth)
- BMI< 2nd centile this may reflect either undernutrition or a small build
- BMI < 0.4th centile probable undernutrition that needs assessment and intervention
Feeding related complication in children with neurodisabiling conditions
Intesitinal failure (GI dysmotility) - can be life limiting
- can give parenteral nutrition but at what point? when can it be withdrawn?
When to 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 is one reason babies may refuse to feed
Due to pain from reflux (babies have less developed LOS so reflux more easy)
When is an enteral feeding tube used for kids
- Serious concerns about weight gain
- An appropriate specialist multidisciplinary assessment for possible causes and contributory factors has been completed
- No improvement from other interventions
MUST have a SPECIFIC END GOAL and a STRATEGY FOR its WITHDRAWAL once goal reached
Next level of severeity of treatment if NG feeding isn’t working
Gastrostomy
- can reintroduce oral feeding and reverse over time
