Poor growth


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network


  • This is a guide for the initial management of a child with poor growth who presents to the emergency department.

    See also:

    Background

    • Failure to thrive is an older term often used to describe inadequate weight gain in infants and children.  The term itself can be misleading and often causes distress to parents.  “Poor growth” is a more accurate and less emotive term and will be used in this guideline.
    • Poor growth generally describes a child whose current weight, or rate of weight gain, is significantly below that expected of similar children of the same age and sex.  Adequacy of growth is best evaluated by plotting serial measurements on a centile weight chart.   A child who is tracking downwards on the charts may have poor growth and needs a proper evaluation for nutritional or other causes.  Children less than the 3rd centile for age may also appear to have poor growth, but many may still be within normal limits of growth and are just small healthy babies.
    • Nutrition is the main driver for a child’s growth and this should be the main focus of the initial assessment, although a thorough history and examination for other potential causes is also important, as is evaluation for psychosocial vulnerabilities.

    In a small number of cases, inadequate nutrition could be due to caregiver neglect or child abuse.  This should be carefully considered, especially in the presence of a Red Flag (see below).

    • While apparent poor growth should be an important trigger for assessment for nutritional, medical, and psychosocial problems, not all children who are tracking downwards on the charts have something wrong. 
    • It is common for there to be no specific cause found for a child’s apparent poor weight gain.  A well looking child with normal neurodevelopmental progress, who shows apparent isolated poor weight gain, with no specific cause evident from history, examination and possibly some simple investigations, will have an excellent prognosis for future health, wellbeing and development.  These children should be monitored over time to ensure that no specific causes of poor growth become evident.

    Red flags

    In a small number of cases identified by having one or more of the following red flags, involvement of a multidisciplinary team is essential. Admission to hospital should also be considered if any red flag is present.

    • Signs of abuse or neglect
    • Poor carer understanding e.g. non-English speaking, intellectual disability
    • Signs of family vulnerability e.g. drug and alcohol abuse, domestic violence, social isolation, no family support
    • Signs of poor attachment
    • Parental mental health issues
    • Already/previously case managed by child protection services
    • Did not attend or cancelled previous appointment/s
    • Signs of dehydration
    • Signs of malnutrition or significant illness

    Multidisciplinary team

    • Multidisciplinary team management is important for the treatment of both inpatients and outpatients who have been shown to have poor growth. 
    • Consider referral to relevant health professionals which may include a maternal child health nurse (MCHN), general practitioner (GP), paediatrician, dietitian, lactation consultant, speech pathologist, occupational therapist, psychologist, social worker, infant mental health clinician or child protection worker.

    Causes of poor growth to consider:

    Inadequate caloric intake/retention

    Psychosocial factors

    Inadequate absorption

    Excessive caloric utilization

    Other Medical Causes

    • Inadequate nutrition (breastmilk, formula and/or food)
    • Breast feeding difficulties
    • Restricted diet (e.g. low fat, vegan)
    • Structural causes of poor feeding eg. cleft palate
    • Persistent vomiting
    • Anorexia of chronic disease
    • Error in infant formula dilution
    • Early (before 4 months) or delayed introduction of solids

     

    • Parental depression, anxiety or other mood disorders
    • Substance abuse of one or both parents
    • Attachment difficulties
    • Disability or chronic illness of one or both parents
    • Coercive feeding (including feeding child whilst asleep)
    • Difficulties at meal times
    • Poverty
    • Behavioural disorders
    • Poor social support
    • Poor carer understanding
    • Exposure to traumatic incident/family violence
    • Neglect of this infant or siblings
    • Current or past Child Protection involvement
    • Coeliac disease
    • Chronic liver disease
    • Pancreatic insufficiency eg. Cystic fibrosis
    • Chronic diarrhoea
    • Cow milk protein intolerance

     

    • Chronic illness
    • Urinary tract infection
    • Chronic Respiratory disease eg. Cystic Fibrosis
    • Congenital heart disease
    • Diabetes Mellitus
    • Hyperthyroidism

     

    • Genetic syndromes
    • Inborn Errors of Metabolism

     

     

    • Although a single cause for poor growth is possible, there is frequently more than one condition involved.  These conditions may interact with each other.
    • Historically, there has been an arbitrary division into "organic" or "non-organic" failure to thrive; this has not been found to be useful and there is significant overlap in these categories.

    Growth charts

    • It is recommended that WHO growth standards be used for children under 2 years of age and CDC growth charts for children over 2 years of age.
    • Serial measurements are needed to assess a child’s growth.  One-off measurements show a child’s size but not their growth. 
    • Many healthy children grow on centile lines at the top or bottom of the growth chart and many healthy children have small “dips” above or below a particular centile line or growth curve.
    • Birth weight is not necessarily representative of the genetic potential for future growth.  Eg.  there is no cause for concern if a baby is healthy and gaining weight but tracking along a lower centile than that of the birth weight.
    • Remember to correct for prematurity (<37 weeks) until 24 months of age. 
    • Length and head circumference should also be plotted on growth charts and it is important to take these into account in the overall assessment of a child with poor growth.
    • There are growth charts available for specific conditions including Down syndrome, Turner syndrome and Williams syndrome and these should be used.

    Growth charts for Down syndrome and Turner syndrome are available at: http://www.rch.org.au/genmed/clinical_resources/Growth_Resources/

    More information on how to interpret child growth can be found at: www.rch.org.au/childgrowth/

    Assessment

    Features on history

    Feeding History – this is the most important aspect to elicit.
    Infants:

    • Breastfeeding
      • Breast feeding difficulties, timing of feeds and the presence or absence of vomiting. 
      • Is the infant “settled” with breast feeds?
      • Mother’s perception of breast milk supply/difficulties.
      • Previous experience of breast feeding.
    • Formula feeding
      • Volumes, changes to formula, dilutions (check scoops to volume of water), vomiting, or diarrhoea.
    • Timing of the introduction of solids and the types of foods offered. 
      • The parent infant interaction during feeding eg. Force feeding.
      • Are mealtimes pleasant or unpleasant?
      • Does the infant accept solids readily?

    Toddlers:

    • Mealtime battles, coercive feeding, food refusal.
    • Milk volume over 24 hrs.
    • Assess parental attitude towards foods and mess.

    Other important points on history:

    • Antenatal complications and maternal health.
    • Birth weight, length and head circumference.
    • Significant intercurrent illnesses coinciding with onset of poor growth.
    • Vomiting and diarrhoea.
    • Developmental delay, regression or syndromal causes of poor growth.
    • Mid-parental height and the family history of childhood weight gain.
    • Lack of financial resources for food requirements.
    • Lack of suitable housing.
    • Lack of family/community supports.
    • Refugee or recent immigrant background.
    • Parental mental health problems.
    • Community Services History – particularly failure to engage with MCH Services and local GP.
    • Failure to attend hospital or community services appointments.
    • Previous history of child protection involvement.

    Features on examination

    Does the child appear sick, scrawny, irritable or lethargic?
    Evidence of loss of muscle bulk and subcutaneous fat stores; especially upper arm, buttocks and thighs.
    Conduct a thorough examination with particular attention to potential underlying diagnoses.
    Look for signs of child abuse and neglect. 

    Observe the child-parent interaction and communication (cues from infant)

    In younger infants, consider observing a feed.

    Investigations

    For an otherwise healthy and normally developing child with no suggestive features on history or examination, no investigations are necessary at first.
    If a particular diagnosis is suggested by the history or examination, investigate according to the features you have elicited.
    Simple first line investigations for a child where there is significant concern but no specific pointers to a medical cause:

      • FBE, ESR
      • UEC, LFT
      • Iron studies
      • Calcium, phosphate
      • Thyroid function
      • Blood glucose
      • Urine for microscopy and culture
      • Coeliac screen if on solid feeds containing gluten
      • Stool microscopy and culture
      • Stool for fat globules and fatty acid crystals

    Management

    When to admit and/or consult local paediatric team

    • Consider admission for a child with signs of significant illness or dehydration.
    • When there are signs of child abuse, neglect, poor parental understanding or psychosocial concerns (ie when parents have failed to follow advice or attend follow up appointments), discuss with a senior doctor and consider admission. (See child abuse CPG )
    • Children who continue to have persistent poor growth despite adequate intervention.
    • If you are concerned that a child is not being adequately cared for by their caregiver, a report should be made to Child Protection Services.

    If admitted to hospital

    • One clinician should take responsibility for overall management and coordinating inpatient care; this clinician is responsible for ensuring that recommended treatments are followed, follow up appointments are attended and that handover to an appropriately trained community clinician is achieved.
    • Discharge from hospital requires a professionals case conference and case management plan to be developed.  This should include those in the community or primary health team who will be involved with the family.

    Follow up

    • A clear follow up plan should be documented.
    • The frequency of follow up depends on the child’s weight, age and psychosocial circumstances.  Younger infants need more frequent follow up.
    • Any child with poor growth MUST be referred back to the MCHN and/or GP.  Referral to a paediatrician should be considered.
    • One clinician should take responsibility for follow up and ensure that follow up appointments are attended. . This can often be a MCHN, especially through the Enhanced MCH service, which provides additional support for identified vulnerable children and families.
    • If follow up appointments are not attended, immediate action should be taken to ascertain health status of the child. Refer to Child Protection if considered to be at risk.

    When to weigh?

    • Infants less than 3 months of age may require weekly weight monitoring.
    • Avoid weighing a child too frequently. Do not weigh more than once a week.   There are normal fluctuations in weight velocity and excessive weighing can cause unnecessary anxiety.

    Average growth

    Although the use of a growth chart is the most accurate indication of overall growth the use of average weekly weight gain for children who are followed up at frequent intervals may be required.

    The rate of weight gain per week is variable.

    The table below is a guide to the expected average weight gain per week (it is not the minimally acceptable weight gain).  


    0 to 3 months

    150 -200g/week

    3 to 6 months

    100 - 150g/week

    6 to 12 months

    70-90g/week