The toddler who is falling off the growth chart

Question 1

How should growth be monitored?

Answer 1

WHO growth charts

Question 2

What is normal in terms of growth percentiles?

Answer 2

It is normal for children to change percentiles in their first 2-3y to adjust toward their genetic potential

Question 3

What are some causes of faltering growth?

Answer 3

1. Nutritional factors (Wt before Ht)
2. Environmental problems
3. Endocrinopathy (Ht>Wt)
4. Adjustment towards genetic potential (Ht=Wt)
5. Systemic disease (Wt before Ht)

Question 4

How to evaluate a child falling off the growth curve?

Answer 4

1. Obtain accurate growth parameters and plot them on the WHO growth curves
2. Calculate mid-parental height
3. Complete nutritional history with caloric intake calculated from 72h food diary
4. Complete history and physical examination
5. Basic workup (step 1): CBC, ESR, CRP, lytes, gas, glucose, BUN, Cr, protein, Alb, iron studies, Ca, PO4, ALP, AST, ALT, GGT, serum Ig, TTG, TSH, urine
6. Basic workup (step 2): sweat chloride, vitamin levels, fetal elastase, bone age
7. Refer to specialist

Question 5

How do you calculate mid-parental height?

Answer 5

Boys (father’s height + mother’s height)/2 + 6.5cm +/- 8.5cm

Girls (father’s height + mother’s height)/2 - 6.5cm +/- 8.5cm

Question 6

What are the leading causes of growth failure?

Answer 6

1. Inadequate nutritional/caloric intake
   a) Poor eating
   b) Anorexia due to chronic disease
   c) Eating and/or oral skills lacking
2. Increased energy losses due to:
   a) emesis
   b) malabsorption due to
   i/ pancreatic disease (CF, Shwachman-Diamond)
   ii/ cholestatic liver disease
   iii/ intestinal disease (i.e. celiac, Crohn)
3. Increased energy needs due to:
   a) underlying chronic condition
   b) chronic or recurrent infections
4. An endocrine problem:
   a) hypothyroidism
   b) growth hormone deficiency
5. Rare causes:
   a) diencephalic tumor
   b) renal tubular acidosis

Question 7

If no underlying disease is detected what interventions should occur?

Answer 7

1. Ensure dietician sees to add additional calories to diet
2. Consider cyproheptadine (antihistamine increases appetite)
3. Do not administer cannabioid derivatives and megestrol acetate to healthy children
4. Tube feeding only in the last resort in otherwise healthy children
5. Reduce parental anxiety
6. Return control of feeding to child
7. Make mealtimes more enjoyable and positive family experience
8. Consider involving a psychologist, OT, and SLP

Question 8

How do you calculate caloric needs?

Answer 8

Caloric needs (cal/kg/day) = caloric need for weight age (cal/kg/day) x ideal weight for height (kg)/actual weight (kg)

Question 9

What are the CPS recommendations regarding a child who is not growing appropriately?

Answer 9

1. Verify the accuracy of anthropometric measurements.
2. Plot the child’s weight and length or height on the growth chart.
3. Calculate mid-parental height to estimate the child’s growth potential.
4. Obtain a complete history and perform a physical examination.
5. Assess caloric intake using a food diary analysed by a trained nutritionist.
6. Evaluate the child’s feeding history and mealtime behaviours and explore family dynamics.
7. Perform a basic workup.
8. Optimize oral caloric intake when it is found to be inadequate.
9. When behavioural issues interfere with nutrition, consult a psychologist, or an occupational or speech therapist, as appropriate.
10. Consider appetite stimulants only in refractory cases, and only after evaluation by an expert in this area.
11. Tube feedings are a last resort if the child has no underlying disease