History and exam
Key diagnostic factors
common
presence of risk factors
Key risk factors include small for gestational age; poverty; gastrointestinal problems (reflux, coeliac disease); poor carer knowledge; poor carer-child interaction.
faltering growth
Used to describe children with below-expected weight-for-age, weight-for-length, or BMI-for-age, and to describe a depressed rate of growth-for-age, after having previously achieved a stable growth pattern.[1]
signs of malnutrition
Malnutrition is usually first detected via accurately plotted growth.
Listlessness, and skin folds resulting from lost muscle mass, in moderate to severe faltering growth.
Specific nutrient deficiencies such as pallor (anaemia), rachitic changes (vitamin D deficiency), and unusual fungal infections (HIV infection).
poor social history
Social conditions may directly or indirectly contribute to a child's poor growth. Families who are experiencing housing, food, or energy insecurity are likely to be experiencing stress, anxiety, and/or depression that may impair their ability to adequately care for their child and provide healthy meals as part of a consistent routine. Possible neglect, such as inadequate health care, emotional support, and clothing, may be associated with inadequate food and/or feeding.
poor quantity or quality of food or fluid intake
Diminished quantity of food intake may be due to parental misunderstanding of what is adequate, child's poor appetite, or lack of food availability.
Infants require more energy per pound of body weight than at any other time across the lifespan. Children with excessive intake of juices and water or overly diluted formula may not be receiving enough food/nutrients.
Diminished quality of food intake may reflect low intake of vitamins and minerals, often due to reliance on low-nutrient-dense foods (e.g., unfortified noodles, 'junk' foods).
lack of clarity in communication between parent and child
Parents may have difficulty interpreting a child's signals of hunger and satiety.
Children with health or developmental problems may lack the skills to communicate clearly.
abnormal feeding/eating behaviour
Difficulties in parent-child interaction especially at toddler stage when parents may wish to control how much a child eats. Pickiness and food refusal often occur in young children as expressions of autonomy, and can be managed by effective parenting.
Abnormal mealtime behaviour and routines with parental coercion or excessive control.
Parents may be unaware of a child’s nutritional needs and the low nutrient value of foods high in fat and sugar and low in nutrients (e.g., junk food) perceived food allergies, and their own mealtime patterns.
Poor swallowing in cerebral palsy or other neuromuscular disorders.
A history of atopy or multiple food allergies can be a risk factor for eosinophilic oesophagitis.
Food neophobia (fear of trying new food) is normal in toddlers and can often be resolved by repeated introductions of the food and modelling. If carried to extremes, food neophobia can negatively impact dietary intake and weight gain.
Autism spectrum disorder and sensory feeding challenges.
perinatal complications
Problems during pregnancy (e.g., infections, toxin and drug exposure) can impede growth in utero and after birth.
A low birth measurement (taking into account gestational age) reflects in utero conditions and may indicate occult problems, such as toxoplasmosis, although there are typically other signs and symptoms too.
Gestational age needs to be factored into the interpretation of growth patterns.
Other diagnostic factors
uncommon
family history of faltering growth
Abnormal growth pattern of parents and siblings.
Other family members may have also experienced faltering growth.
increased caloric loss
Faltering growth may be associated with protracted vomiting, diarrhoea, and fever.
gastrointestinal symptoms
Dysphagia, vomiting, abdominal pain, and diarrhoea may point towards a GI cause. Dysphagia could be a symptom of eosinophilic oesophagitis or another anatomic cause of poor feeding.
comorbid medical history
Congenital heart disease may be associated with poor feeding such as when associated with dyspnoea and recurrent pulmonary infections.
Malignancies may result in poor intake and an increased caloric demand.
Uncontrolled diabetes mellitus and hyperthyroidism may cause faltering growth.
Most chronic illnesses result in a poor intake and poor utilisation of calories.
recurrent ear infections
Results in fever and pain, which may increase caloric demand and/or reduce intake.
recent surgery/burns
Prolonged recovery from major surgical illnesses/burns results in increased demand for calories, often compounded by a poor intake.
dehydration
Often associated with acute illness.
Sunken eyes and fontanelles, loss of skin turgor, changed mental status, tachycardia, and hypotension.
cleft lip and/or palate
A cleft palate may compromise feeding.
Risk factors
strong
small for gestational age (SGA)
If the newborn is SGA with symmetric deficits (low weight, length, and head circumference), this points to a problem early in the pregnancy, such as exposure to a toxin (e.g., alcohol) or infection (e.g., toxoplasmosis), and potential for catch-up growth is limited. In contrast, when primarily weight is affected, this points to a problem late in the pregnancy such as placental insufficiency, and prospects for catch-up growth are good.
gastrointestinal problems (reflux, coeliac disease)
Coeliac disease for example often presents with malabsorption and diarrhoea.
poor carer knowledge
May lack knowledge about child's changing nutritional and developmental needs regarding feeding behaviour.
poor carer-child interaction
Child may attract more attention from carer by not eating. For example, carer may ignore a child who is eating and provide attention (albeit negative) to a child who is not eating.[23] Meals may be described as stressful with frequent conflicts between carers and child.
cerebral palsy
Difficulty chewing or swallowing.
prematurity
May be associated with poor feeding as well as increased caloric demands.
poverty
Poverty and associated stressors may impede caregiving and limit attention to feeding and healthy nutrition. Carers may have difficulty accessing healthy food and rely on low-nutrient-dense food and snacks.
Faltering growth can also occur in middle- and high-income families.
lack of family mealtime routine
May skip meals or allow child to graze, filling up on low-nutrient-dense food throughout the day. Family may not have regular meals at roughly the same time each day.
autism
May be associated with gastrointestinal problems or may experience aversions to specific types of foods or textures.
chronic medical problems
Several chronic medical conditions can jeopardise growth including chronic infections, coeliac disease, cystic fibrosis, inflammatory bowel disease, severe asthma, congenital heart disease, obstructive sleep apnoea, malignancies, diabetes mellitus, hyperthyroidism, renal failure, systemic inflammatory disorders such as lupus erythematosus, and inborn errors of metabolism. See section on Aetiology.
allergies
May experience discomfort with certain foods. Child's repertoire of food may be limited.
swallowing disorder or history of choking
May have difficulty swallowing or with choking history or aspiration. Some parents/carers may therefore not advance textured food, resulting in a diet that is boring for the child. This may present as food refusal and swallowing studies may be warranted.
weak
carer depression
May lack consistency in providing meals or in following recommendations.
Use of this content is subject to our disclaimer