Clinical algorithms, practice standards, position papers

Terminology

• Growth Failure, Failure to Thrive, Growth Faltering
• Protein Energy Malnutrition = final common pathway

 

I. Definitions & Characterizing Growth Patterns

Progression of “Simple” Undernutrition:
Weight for age Þ ê Length/height for age Þ ê Head Circumference

Weight faltering (wasting):

• Crossing > 2 major percentile groups (wt for age)
• Rate of weight gain < normal for age
• Weight/length < 5th %ile

Implies ~ acute undernutrition, esp. inadequate energy intake Length/height faltering (stunting):

• Mild: 90-95% of median (50th %ile)
• Moderate: 85-89% of median
• Severe: < 85%

Implies chronic undernutrition
DDX: endocrinopathy, IUGR, constitutional, IBD, chronic illness, etc

  ¯ Head Circumference:

• consider congenital infection
• intrauterine or early post-natal insult
• chronic undernutrition

% Ideal Body Wt (50th %ile wt/len):

• Normal: > 90% of median (50 ^th %ile)
• Mild: 81-90%
• Mod undernutr: 70-80%
• Severe undernutr: <70%

Why characterize the extent of malnutrition?

• Severity of problem – Urgency of intervention
• Type of intervention – Set goals for catch-up

 

II. Evaluation of Growth Problems

History

• Growth
• Nutritional
• Medical

Anthropometry
Physical Exam
Laboratory Evaluation
HISTORY, HISTORY, HISTORY…

History sh/b seeking explanation for

Growth hx: chronicity & pattern poor growth: poor intake, increased requirements, increased losses

Nutrition hx:

• Early feeding – breastfeeding or formula;
• Introduction of solids – good acceptance? Progression in variety?
• Introduction of self-feeding – when, how much?
• Intake – record/recall; types/amounts; amount of formula/milk, juice, water
• Routines – grazing? Eating during the night?

Medical Hx:

• PG/birth, health, development, habits*, meds/supplements, allergies, ROS (DDx for non-organic causes)

* Beware the ” PESTT !!” (Poor Eaters & Sleepers, & Temper Tantrums)
Social hx: (more than pets & tobacco!!)

• Who’s at home
• Employment/finances
• Living conditions
• Stresses & supports

Vulnerable ages and environments, risks associated with each, according to developmental stage:

Age	Psych/ Developmental Stage	Motor Skills	Feeding & Eating Issues	Nutritional Issues
0-2 mo	homeostasis	Suck-swallow, oral motor	Infant determines amount, timing	Rapid growth, Relatively high needs
2-6 mo	attachment; develop trust; positive interaction	“	“	Growth rate slows some
6-16 mo	Separation	¯ sucking; ability to sit; hands/toys/food to mouth pincer grasp	Introduction of solids; cup; finger-feeding new tastes, textures; neophobia	¯ Growth rate; activity ­ ; appetite ¯ ; Iron, zinc
16-36 mo	individuation; autonomy; ­ distractibility	Refining skills	Self-feeding (utensils, cup); food jags routine/structure	POC: offer good choices; structure Child: determines amount

PARENTS “job” to provide good structure, healthful choices, security;
CHILD’s “job” to determine how much to eat
Fine line exists between structure and control …empower parents to learn the difference!
Profiles of causes/environments associated with growth failure:

1. Nutritional Ignorance

• Inadequate amounts or types of food (including inadequate/inappropriate breastfeeding)
• Unusual types of foods/diets (e.g. perceived allergies, delayed introduction of complementary foods, “health food” beliefs)

2. Family Chaos

• Inconsistent feeding (e.g. grazing)
• Changing sites & times of feeding
• Multiple feeders
• Unstable home environment

3. Child/Parent Conflict

• Poor eating behavior
• Meal time disruption (e.g. TV on, no one eats w/ child, eating “on the go”, etc)
• Poor limit setting (meals last an hour, toddler up & down from table, child throws food)

Mother/Child [mis]Matches – Set-ups for problems!
Mother Child

• Adequate Easy going/docile
• Marginally adequate Sometimes difficult
• Inadequate Difficult

ANTHROPOMETRY : (Weight, length/height, OFC – see above)
PHYSICAL EXAM:

• wasting of fat vs muscle mass (consider skinfold measurements)
• developmental level/neurologic deficits;
• oral-motor control, coordination
• evidence of nutritional deficiencies (pallor, rash/lesions, edema, ¯ DTR’s) &/or disease process?

FEEDING OBSERVATION: Child’s motor skills, approach to food, interaction with POC, etc
LABORATORY SCREENING:

• blood (cbc, electrolytes & bicarb, + LFT’s, + TFT’s)
• urine (UA, + Ucx)
• stool (r/o fat, blood)

A few words on micronutrients, esp Iron & Zinc:
Iron deficiency:

• Increasing risk in latter part of first year of life for breastfed infant without dietary source (other than human milk); risk for infant fed standard Fe-fortified formula low;
• Effects : anemia, neuro-cognitive delays, poor growth;
• Good weaning foods: iron-fortified cereal, meats; supplement if deficient

Zinc deficiency:

• Increasing risk by mid way-latter part of first year of life for breastfed infants if no dietary source (besides human milk); risk for formula fed infants low ;
• Effects : slow growth & anorexia; immune deficits, neuro-cognitive delays;
• Good food sources : animal products, esp meats (beef/pork >>chicken/fish);

Rx: 1 mg elemental Zn/kg/day, ideally divided BID
 

III. THERAPY AND MONITORING

• Good Medical Care
• Diet
• How to set goals (esp w/ IBW) to achieve “catch-up” growth
• High calorie foods – (e.g. Carnation Instant Breakfast, added oil/margarine); limit juice: 0-6 oz/d
• Increased intake
• Micronutrient supplements if indicated (see Fe & Zn above)
• Education of family about good child nutrition, reasonable expectations

Behavior/Parenting

• Food/eating habits – 3 meals/2-3 snacks by ~ 1 yr,
• Feeding routines – high chair/table, TV off, simple & familiar foods, eat w/ others; reduce pressure on child
• Limit setting – avoid short order cook routine; meals last ~ 15 min
• Role modeling

Family Support

• Other therapies/services as indicated: OT, social work, day care?
• Support parents – positive approach rather than judgmental

How do we define success?

• Normal development
• Establishment of healthy eating patterns/behaviors
• Interrupt/reverse “faltering” on growth chart; (may not see true “catch-up” or normalization)
• Less parental anxiety

Other issues for discussion:
When to consider tube feedings – NG/GT (severe undernutrition, developmental delays, need for long-term support)
When to consider hospitalization – severe undernutrition &/or need for diagnostics; limited value for “observation” (abnormal situation; not likely to observe usual dynamics)