Tables of trace elements and  vitamins.

Background

Concerns about nutrition and growth are common in refugee-background children, although there are no Australian population data for this group. Specific issues include low weight and/or height for age, vitamin deficiencies, iron deficiency and anaemia. Low B12 has been a common issue in Afghan arrivals from 2021. Increasingly, clinicians are noting overweight/obesity as a health issue in the years after settlement,¹ and there are anecdotal reports of dyslipaemia in the Afghani community and diabetes in the Karen community. The early settlement period represents a window for health promotion around nutrition.

Post-natal growth is most rapid during early infancy; then slows by the primary school years picking up again at puberty. Linear growth is similar in children aged <5 years worldwide,² although growth must be considered in the context of parent height, ethnicity (Australian growth charts are based on American data)³ and pubertal status. Children may have different growth parameters to their Australian born peers and still have normal growth, they may appear thinner than Australian born peers, considering 25% of Australian children are overweight/obese (2017-18 data).⁴

Most common causes of poor growth in refugee children are elicited with a careful history and examination.

Key points in assessment of nutritional status/growth

• Clarify the correct age/birthdate 
• Chart growth parameters on percentile charts (weight, height or length, BMI, head circumference) and check pubertal status
• Measure parent height and weight where possible and consider family patterns of growth/puberty, remembering parents may have also been malnourished
• Assess nutrition during pregnancy and early childhood - an early severe/prolonged nutritional insult or chronic disease during infancy will affect long-term growth and may affect final height (‘stunting’). This history is usually easily elicited.
  • Birthweight may not be available, but parents will usually recall if their child was >2 kg or >3 kg.
  • Clarify duration of breastfeeding, age solids introduced.
  • Clarify food access overseas, including both quantity/quality of food.
  • Weight at 2 years may be available, ask about malnutrition and oedema.
  • Management for malnutrition overseas (e.g. admission to camp feeding centre) indicates significant nutritional compromise.
• Clarify chronic disease during childhood, including chronic diarrhoea or infections/infestations.
• Take a good dietary history and assess food insecurity after resettlement – this is well reported in refugee communities, including in Australia.^5,6
  • Ask about a typical day – meals, snacks, drinks, any behavioural issues around mealtimes.
  • Fussy eating (+/- growth issues) is often due to high caloric intake in the form of drinks/juices at the expense of solids/mealtimes. 
  • There may be a mismatch between the food the child is used to, and food offered at childcare/school.
  • Families may be accustomed to eating 1 or 2 main meals a day, and children may skip meals, or not take school lunches.
• Assess family functioning, mental health and settlement related stressors, including financial and housing stress. These issues are common, and increasingly an issue, particularly for asylum seekers.
• Consider organic disease early in refugee children with poor growth or reduced appetite. A useful framework is to consider causes:
  • Poor intake – dental caries, tonsillar hypertrophy (if severe), Helicobacter pylori gastritis causing pain. Iron deficiency may affect appetite and compound poor intake. Mental health issues may also be a cause of poor intake/growth.
  • Increased losses – upper or lower gastrointestinal losses or renal losses, any cause of vomiting, diarrhoea, or malabsorption, e.g. infections ( Giardia duodenalis, other parasites), or gut inflammation. Lactose intolerance is common in most of Australia's humanitarian source countries, coeliac disease is rare in Asian populations, but is prevalent in sub-Saharan Africa. Allergic disease appears to be uncommon in recently arrived populations.
  • Increased requirements – any chronic disease including renal, cardiac, respiratory, endocrine disease, hyperthyroidism, chronic infection (including tuberculosis and HIV).
  • Poor utilisation - genetic or metabolic conditions, disorders of protein, fat or carbohydrate metabolism (including diabetes). Micronutrient deficiencies (from any cause, including rickets due to low vitamin D) may contribute to poor utilisation of intake. 

Examination

• Assess for macronutrient deficiency (fat/protein/carbohydrate) by checking growth (as above), oedema, muscle bulk, subcutaneous fat stores and mid upper arm circumference (MUAC). Length is used up to 2 years, and standing height beyond this. Severely malnourished children should have anthropometry performed by a dietitian. See percentile charts.
• Assess for micronutrient deficiency (vitamin/trace element/mineral) by checking pallor, xerophthalmia, cheilitis, glossitis, gum disease, goitre, rash, rickets, neuropathy, hair and nail changes. See tables of  trace elements and  vitamins.

Investigations

• Initial refugee health screening investigations include FBE and film, ferritin, Vitamin D, Ca, PO4, and ALP (all), and serum active B12 and folate in people with risk factors.
  • Vitamin B12 (serum active B12) and red cell folate screening should be completed in people from Afghanistan and Gaza, and exclusively breastfed babies where there has been poor maternal food access, or where deficiency is suspected clinically.B12/folate screening should be considered in people from Bhutan, Iran, Iraq and Horn of Africa (especially where there has been poor food access).
• In children with malnutrition, consider additional investigations (this list includes initial tests only to avoid confusion when ordering blood tests):
  • Vitamin deficiency - Vitamins A, D, E, C, serum active B12, red cell folate, coagulation (vitamin K), lipid profile (E:lipid ratio).
  • Trace element deficiency - ferritin, Zinc, Selenium, Copper, TFT (iodine). 
  • Mineral status – Ca, PO4, Mg.
  • Protein, acid base, fluid, sugar (carbohydrate) lipid and electrolyte status – BSL, VBG, LFT (total protein, albumin), UEC, lipid profile and consider carnitine
  • Causes/contributors – TFT, full ward test urine (protein loss), faecal MCS, OCP (fixed specimen, may need more than one specimen), pH, total sugars, reducing sugars, consider Helicobacter pylori screening if symptoms, elastase if steatorrhea, electrolytes if chronic diarrhoea, urine organic acid screen if sprue is suspected, others as clinically indicated.

Management

Once the initial screen has been completed and treatment initiated as necessary, a period of monitoring growth is often appropriate. 

• Manage any organic medical contributors. Consider on spec treatment for Giardia in children with symptoms, even if parasite microscopy is negative. 
• Treat micronutrient deficiencies – see trace elements and vitamins.
• Dietitian referral – see directory of accredited practising dietitians, or check community health services.
• The principles of healthy eating are universal and should be discussed with families.
  • Breastfeeding should be promoted. 
  • Encourage introduction of solids at 4-6 months of age, introduction of meat before 12 months and an appropriate diet containing vegetables, legumes, fruit, cereals, meat and dairy. Limit juice, cordial, fizzy drinks and highly processed foods, including instant noodles.
  • Encourage 3 meals and 2 snacks daily.
  • Milk should be limited to <500 ml daily after 12 months; in children with lactose intolerance, regular yoghurt and cheese are appropriate sources of calcium. Adequate calcium intake is essential for all children but has additional implications in groups at risk for low vitamin D. 
  • Home cooked food and maintaining families’ cultural food preferences is usually healthier and more economical.

Resources

• Pictorial resources from ISIS Wyndham, developed for the Karen community
  • Breakfast,  food refusal,  oral health,  cooking methods,  general healthy eating,  packed lunches,  infant weaning
• Raising children - picture based resources, including nutrition related
• RCH nutrition resources (no translated versions, some picture based information) 
  
• Diabetes Australia translated resources
• Get Up & Grow: Healthy Eating and Physical Activity for Early Childhood (Australian Government Department of Health and Ageing) - campaign for health eating and lifestyle   
  

References

• References

_{Immigrant health clinic protocols. Author: Georgie Paxton, initial January 2014, most recent update Feb 2024. Contact georgia.paxton@rch.org.au}