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Also known as Failure to Thrive

Child Health Guideline Identifier

Faltering Growth - Failure to thrive

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Definition

Faltering growth describes a growth pattern and is not a diagnosis. Other terms include "Failure to Thrive" and "Poor Growth". The patients of main concern are those whose growth:

  • is much lower than expected (taking into account familial growth pattern etc)
  • has crossed two major centile lines.

The standard growth charts for use in Starship are the NZ-WHO growth charts for pre-school, and the UK-WHO growth standards for older children.

There are additional growth charts for specific conditions such as Down Syndrome.

Expected weight gains

(adjust for premature delivery for first 24 months)

26 to 31 g/day for those 0 to 3 months
17 to 18 g/day for those 3 to 6 months
12 to 13 g/day for those 6 to 9 months
9 to 13 g/day for those 9 to 12 months
7 to 9 g/day for those 1 to 3 years

Etiology

Organic disease or neglect is identified in approximately 5% cases of faltering growth3. In developed countries studies have shown no significant association between faltering growth, low socioeconomic status or maternal educational attainment4,5,6.

Causes to consider:

  1. Inadequate caloric intake. Not enough food offered/poor intake/emesis

  2. Malabsorbtion.  Cystic fibrosis/coeliac disease and other malabsorbtion states
  3. Increased caloric load.  Chronic disease/recurrent infections/syndromic diagnosis
  4. Abuse and neglect.  The role of abuse and neglect in faltering growth has probably been overstated. Population studies3 found that between 5% and 10% of children with faltering growth had been registered for abuse or neglect. However the study of Skuse and colleagues7 found that children with faltering growth were four times more likely to be abused than controls. Therefore, abused or neglected children are probably at increased risk of faltering growth, but this group only comprise a small proportion of all cases.

Evaluation

History

  • Pregnancy, including inutero exposure to illicit drugs, alcohol and medications.
  • Perinatal, including Apgar scores, neonatal history
  • Developmental history - age appropriate developmental milestones
  • Feeding history - breast fed - time, attachment, distraction, supply, frequency. Formula fed - volumes, frequency. Time spent feeding
  • Weaning history - Dietary history - including any excessive volumes of juice or milk, or unusual diets
  • Past medical history including symptoms of chronic disease or recurrent infections, wheeze, cough, respiratory distress or pallor during feeding, vomiting, diarrhoea, frequency of hospital admissions, GP visits, prescriptions
  • Social history - Multiple careers, household makeup. Maternal mental health, Financial constraints, child protection involvement

Examination

General

  • Dysmorphism
  • alertness
  • sub-cutaneous tissue
  • dehydration
  • vital signs

Systemic

  • Respiratory - Chest deformity, RR, Clubbing, wet cough, wheeze/crackles
  • CVS - Pulse rate, murmur, femoral pulses, BP
  • Abdominal - Organomegaly, genitalia
  • CNS- Tone, power, reflexes, inappropriate head lag, abnormal gait

Investigations

  • In children without obvious organic symptoms elicited on history, 92% were ultimately diagnosed with a non-pathological cause of faltering growth8.
  • Screening tests to consider (depending on presenting symptoms):
    • Blood tests - Full blood count, ESR, CRP, liver and renal function, electrolytes including Calcium and Phosphate, Iron studies, Coeliac antibodies if >9 months old on gluten containing diet.
    • Additional blood tests to consider - Thyroid function, B12, folate, Karyotype if female and very short stature
    • Stool tests- Microscopy and culture, Faecal steatocrit, elastase. Faecal calprotectin if concerns about inflammatory bowel disease (note - calprotectin difficult to interpret in < 12 month old)
    • Urine tests- Microscopy and culture, Protein:Creatinine ratio (consider urinary pH and glucose if concerned about tubular dysfunction)

Management

Management depends on how severely growth is affected, presenting symptoms, and other social and psychological factors. For more complex presentations a multi-disciplinary approach is needed. The following may be required:

  • Lactation consultant if a breast feeding problem
  • Dietician - for formal nutritional assessment, parental support, specific advice e.g allergy/intolerance.
  • Feeding supplements may be required (usually guided by a dietitian)
  • Social work support
  • Consult liaison psychiatric team support
  • Admission is indicated for:
    • Severe malnutrition/dehydration
    • Observation of feeding/maternal and infant interaction
    • Severe social problems/maternal anxiety & mental health issues

Prognosis

Children who are non-dysmorphic, with normal development and no stigmata of chronic disease, with normal screening investigations have an excellent prognosis.

Additional educational resources

  • UK-WHO growth chart resources (http://www.rcpch.ac.uk/improving-child-health/public-health/uk-who-growth-charts/uk-who-growth-charts-0-18-years)
  • CDC growth charts (http://www.cdc.gov/growthcharts/)

References

  1. Wright CM, Garcia A. 2012. Child under-nutrition in affluent societies: what are we talking about? Proc Nutrition Soc 2012 Nov;71(4):545-55. doi: 10.1017/S0029665112000687. Epub 2012 Sep 7.
  2. www.cdc.gov/nccdphp/dnpa/growthcharts/training/modules/module2/text/module2print.pdf
  3. Wright C, Birks E. Risk factors for failure to thrive: a population-based survey. Child Care Health Dev2000;26:5-16
  4. Emond A, Drewett R, Blair P, Emmett P. Postnatal factors associated with failure to thrive in term infants in the Avon Longitudinal Study of Parents and Children. Arch Dis Child2007;92:115-9.
  5. Wright CM, Waterston A, Aynsley-Green A. 1994b. The effect of deprivation on weight gain in infancy. Acta Paediatrica1994;83:357-9
  6. Wright CM, Parkinson KN, Drewett RF. The influence of maternal socioeconomic and emotional factors on infant weight gain and weight faltering (failure to thrive): data from a prospective birth cohort. Arch Dis Child2006;91:312-7.
  7. Skuse D, Gill D: (1995) Failure to thrive and the risk of child abuse: a prospective population study. J Med Screen 2:145-149
  8. Panetta F, Magazz├╣ D, Sferlazzas C, Lombardo M, Magazz├╣ G, Lucanto MC. Diagnosis on a positive fashion of nonorganic failure to thrive. Acta Paediatr. 2008;97(9):1281-1284

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Document Control

  • Date last published: 17 February 2017
  • Document type: Clinical Guideline
  • Services responsible: General Paediatrics
  • Author(s): John Milledge, Greg Williams
  • Owner: John Milledge
  • Editor: Greg Williams
  • Review frequency: 2 years

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