Approach
Introduction
Healthcare professionals should specify the criteria they have used to diagnose faltering growth. Both medical and psychosocial problems may be present and interacting: a comprehensive evaluation is needed.[25] The strength of the evidence is mixed and sometimes tricky to weigh and hence all risk factors should be considered as possible contributors.
A graded diagnostic approach is recommended to tailor treatment to the specific situation. Growth charts should be used. Special growth charts are used for certain circumstances such as children born prematurely, with low birth weight, or with Down and other genetic syndromes.[26][27] If appropriate charts are not used, faltering growth may be erroneously diagnosed. Disease-specific growth charts should be used in conjunction with standard growth charts given the concerns with methodologies and small sample sizes available to create disease-specific charts.
Extensive medical tests are generally not indicated; rather limited screening is appropriate. Additional testing should be guided by the history and exam.[28]
Growth data
The general consensus is that faltering growth should be defined by a decline in anthropometric parameters. However, there is currently no agreed standardized anthropometric criteria.[3]
The American Academy of Pediatrics (AAP) uses faltering growth as a descriptive term for 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]
Accurate measurements of the child are important with plotting on correct age- and sex-specific growth charts. CDC: clinical growth charts Opens in new window CDC: recommendations for WHO growth standards Opens in new window Implications of using the WHO growth charts with children who are experiencing faltering growth have been noted in the US and the UK.[29][30][31]
After careful measurement of weight and length/height, plot the child’s growth, and calculate weight-for-age, length/height-for-age, and BMI-for-age, based on WHO Child Growth Standards (ages <5), WHO Growth References (and ages 5-19), or other appropriate growth standards or references.[32] If there is a substantial deviation from the previous plot, repeat the weight or length/height measure independently to avoid errors and misinterpretation. Interpret:[1][32][33]
Underweight if weight-for-age scores <-2 SD from the median
Stunting if length-for-age or height-for-age scores <-2 SD from the median
Wasting if weight-for-height or BMI scores <-2 SD from the median
Additional considerations:
In children ages <2 years, head circumference-for-weight scores should be used.[34]
Preterm mature infants should have their growth plotted on special charts that account for gestational age, such as Fenton Preterm Growth Charts.[1]
Length should be measured supine in children ages <2 years. Height is measured standing for children ages >2 years.
Two assessments by someone blind to the initial results may be required if there are unexpected findings.
A mid parental height guides height expectations for a child.
Growth trends that appear problematic but do not meet the diagnostic criteria may offer an early warning that faltering growth is developing. A brief assessment and careful monitoring are recommended to help prevent possible faltering growth.
History
Birth history
Problems during pregnancy, particularly poor maternal nutrition, can impede growth in utero, and after birth. It is important to ask about complications during the pregnancy (e.g., infections, toxin and drug exposure), during labor and delivery, and in the neonatal period. Newborns affected by genetic or toxic exposures tend to be symmetrically small, with a poor likelihood of catch-up. In contrast, asymmetry with weight predominantly affected suggests malnutrition (e.g., placental insufficiency) late in the pregnancy; the prognosis is much better.
Birth length and weight should be obtained. Gestational age needs to be factored into future expectations for growth. Low birth weight may reflect intrauterine growth retardation. Premature infants with complications such as bronchopulmonary dysplasia are especially vulnerable to poor later growth.
Development
Although developmental delay is not part of the faltering growth definition, children with faltering growth are at risk and a complete developmental history should be taken.
Feeding patterns
A feeding history should probe oral motor problems such as difficulty with chewing or swallowing.
Information should be obtained on feeding behaviors such as spitting, refusal, or vomiting. The child's communication regarding hunger and satiety signals, preferences regarding self-feeding, mealtime routines, snacking, meals at daycare, and chair/support during meals should be ascertained.
Common methods of gathering information on children's intake are a 24-hour diet recall and food frequency question (e.g., "how many days in a week does your child eat vegetables?").
A history of atopy or multiple food allergies can be a risk factor for eosinophilic esophagitis. Dysphagia could be a symptom of eosinophilic esophagitis or another anatomic cause of poor feeding.
Food neophobia (fear of trying new food) is normal in toddlers and can often be resolved by repeated introductions of the food and modeling. If carried to extremes, food neophobia can negatively impact dietary intake and weight gain.
Pickiness and food refusal often occur in young children, as expressions of autonomy, and can be managed by effective parenting.
Mealtime routines
Information should be gathered on family mealtime routines. Does the child have a consistent, developmentally appropriate place to sit for meals? Are meals provided on a consistent schedule?
The child's likelihood of being hungry at meals should be assessed. Children who have unlimited access to food or juice throughout the day are unlikely to be hungry at mealtime.
Other behavioral problems
Children with poor self-regulation often have difficulty adjusting to sleeping and eating routines. Asking about sleep routines and amount of sleep in comparison with age expectations provides important information.
The child's behavior in other contexts such as responding to household rules and routines, interaction with peers, and separation from caregivers provides important information.
Social history
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.
Health professionals should ask about families' access to food and public assistance programs.[7]
Parental perceptions and possible concerns about the child's size and feeding behavior should be obtained. Particular strategies that the parents (or others) used to encourage feeding may have been successful. An interview with the parents can provide information: how they determine when the child is hungry or full, how they relate to one another and to the child, and their support from (or conflict with) other family members. There may be one parent who eats with or feeds the child, makes decisions regarding the child's food, and has strong beliefs regarding meals, nutrition, and health. Parents' perceptions of mealtimes (pleasant or stressful) are also useful.
Exam
A thorough review of systems and careful exam are important because many chronic medical conditions can impede growth.[8]
Malnutrition is usually first detected via accurately plotted growth. As malnutrition becomes moderate or severe, there may be other signs, such as listlessness and skin folds resulting from lost muscle mass and subcutaneous fat.
There may also be signs related to specific nutrient deficiencies such as pallor from anemia, and rachitic changes due to vitamin D deficiency.
Dehydration is generally associated with acute illness. Faltering growth reflects a more chronic state, although some conditions such as chronic and severe diarrhea may present with both poor growth and dehydration. It is thus important to check for signs of dehydration (e.g., sunken eyes and fontanelles, loss of skin turgor, changed mental status, tachycardia, and hypotension).
A thorough physical exam helps exclude other conditions that may contribute to faltering growth. For example, a cleft palate may compromise feeding. Milk bottle caries, poor hygiene, severe diaper rash, and toxic ingestions suggest neglect.
Investigations
The child's history and exam should guide the careful and appropriate use of lab tests.[7][35] The American Academy of Pediatrics recommends considering the following:[1]
Complete blood cell count with differential count for anemia and other abnormalities including immunodeficiency and malignancy
Iron studies as iron deficiency is common in children with poor growth
Blood lead level to investigate lead poisoning if locally prevalent
Chemistry panel which will enable assessment of renal tubular acidosis, or monitoring of refeeding syndrome, if indicated
Serologic testing for celiac disease including total immunoglobulinA (IgA) and tissue transglutaminase IgA antibodies in children consuming a gluten-containing diet. For young children (around 2 years or below), deamidated gliadin IgA and IgG antibodies should also be included. Prevalence of celiac disease is increasing in prevalence and can present with faltering growth without other symptoms
Urinalysis if indicated (e.g., concern for infection, glycosuria, or renal pathology)
Stool analysis if indicated (e.g., for infection, malabsorption, or depending on symptoms and travel history)
HIV testing or other infectious screen if indicated
Micronutrients other than iron, only if indicated by the history or physical exam
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