Approach
The severity of growth deficit should be assessed as a percentage of median weight-for-length of the child.[39] The treatment approach is based on the severity of the condition and the etiology. If an organic cause is identified, appropriate treatment is needed. For example, if the child has a history of protracted vomiting, diarrhea, or fever, the underlying illness should be treated; if there is a history of parental depression, anxiety, or other mental health problems, a referral to a mental health provider may be needed; if there is suspected child neglect, a referral to Child Protective Services must be considered. Referral to a specialized growth and nutrition clinic may be valuable for interdisciplinary evaluation and treatment.
The dichotomy between organic and nonorganic causes of growth faltering has been criticized because optimal practice should consider and address both organic and nonorganic causes of faltering growth. Clinicians should keep in mind, however, that organic problems (e.g., nutrient deficiencies) can result from faltering growth with a nonorganic origin, and parent-child conflicts over mealtime stress can result from faltering growth due to an organic origin. Problems should be addressed stepwise depending on the severity of the condition.
Successful treatment of faltering growth requires more frequent and extended contact than is advised in the traditional primary care schedule. Frequency is dependent on degree of malnutrition, disordered feeding, and other comorbidities.[1] Early referral of multidisciplinary support can reduce the severity of malnutrition, feeding difficulties, and long-term developmental problems.[1] Healthcare professionals should consider involving speech and language pathologists, dietitians, occupational therapists and psychologists or other appropriate professionals. Referral to early intervention, a support program such as Head Start, specialized services in public schools, and social work support may also help in supporting parents and families.[1] Office of Head Start: Head Start Services Opens in new window In general, it is advised to establish a plan involving parents, with specific goals for each child with faltering growth, and involve multidisciplinary support at an early stage.
Nutritional support
Feeding support should be given if there is concern about faltering growth in the first weeks of life. In infants, this begins with a lactation consult for breast-feeding infants and additional formula supplementation when indicated, with the aim of increasing feeding volume and caloric density of formula or breast milk if needed, while still considering free water requirements.[1] In older infants and children, nutritional supplements and fortified foods can be useful when it is not possible to meet needs for one or more nutrients.[23] In older infants this can be through the addition of powdered formula or oil.
In toddlers and children, the focus should be on increasing calories using calorically dense foods such as avocado, heavy cream, and peanut butter, but while avoiding low nutritional value foods such as sweet and fried foods.
The goal of treatment is sustained expected velocity of weight gain for age without the need for prescribed supplements; therefore, children receiving oral nutritional supplementation should be regularly assessed to decide if it should be continued.[1]
Nutritional supplements should be used in conjunction with helping children transition to the family diet and age-appropriate mealtime behavior. Early childhood is the time to help children develop health-promoting nutritional habits. Pediatric dietitian referral may also be appropriate and early referral for multidisciplinary support may help reduce the severity of malnutrition and feeding difficulties.[1]
In an evaluation of 286 children ages 6-36 months referred to an interdisciplinary clinic for weight faltering, weight recovery over 6 months was statistically significant, although modest; weight recovery was greater among children younger than 24 months and among children with multiple child and household risk factors. Findings suggest the importance of helping families with access to healthy food, healthy eating habits, promoting child autonomy, and responsive feeding.[40] Responsive feeding recognizes that feeding is a bidirectional process, driven by the child’s signs of hunger and satiety and the caregiver’s ability to recognize and interpret the signs, to respond promptly and in an age-appropriate and nurturant manner. Responsive feeding also promotes the child’s autonomy and self-regulation by caregivers stepping in to assist and feed when necessary and stepping back, although still attending, to facilitate the child’s learning to self-feed and to determine how much food to consume.
Access to healthy food: families are counseled to provide a healthy and diverse diet and increase calories by adding butter, oil, cheese, or peanut butter. Any nutritional supplements should be given after meals, not as meal replacements.
The American Academy of Pediatrics recommends against offering juice to infants 12 months and under; there is little nutritional benefit and it can predispose to inappropriate weight gain. For children ages 4-6 years, juice consumption should be limited to 6 ounces per day; for those ages 7-18 years, the recommended limit is 8 ounces per day.[41]
Healthy eating habits: consistent routines (in both times and places) are encouraged for family meals and snacks, eliminating grazing, minimizing distractions, and engaging in pleasant conversation.
Appetite and autonomy: children should be actively involved in meal preparation, if possible, and encouraged to touch and pick up food to increase appetite.
Responsive feeding: using a video recording of the child and caregiver during a meal and using motivational interviewing, caregivers are shown how to model positive behaviors and respond to their child’s cues.[40]
Cyproheptadine (an antihistamine with antiserotonergic effects) has been shown to be safe and effective in the short term (not studied long term) for improving oral intake, weight gain, and mealtime behavior. There is some evidence to support cyproheptadine as a pharmacologic tool for weight gain in children.[1][42] In clinical practice, this would usually be considered after nonpharmacologic treatment and on a case-by-case basis.[1]
Enteral tube feeding
Enteral tube feeding should only be considered when there are serious concerns about weight gain and only after an appropriate specialist multidisciplinary assessment has been completed. Additionally the intervention should only be undertaken as a last resort, following the trial of other interventions with no improvement.[35]
Hospital admission
Hospitalization is rarely indicated; however, there are select circumstances in which it is recommended by the American Academy of Family Physicians (AAFP). These include:[36]
Extreme parental impairment or anxiety
Extremely poor parent-child interaction
Need for precise documentation of nutritional intake
Outpatient treatment failure
Psychosocial factors that put the child’s safety at risk
Serious underlying illness or medical problem
Severe malnutrition or dehydration
Additionally, it is also recommended to consider admission in suspected child abuse, a rare cause of faltering growth.[36] See Child Abuse
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