Growth faltering

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Growth faltering is defined as a pattern of slow growth in children when compared to the predicted values for their age and sex. It is seen in up to 10% of children in the United States and often occurs secondary to malnutrition, which can be due to a complex interplay between biological and psychosocial factors. The primary mechanisms that contribute to growth faltering and malnutrition are inadequate nutritional intake, inadequate absorption, and increased metabolic requirements. Clinical features may include signs of malnutrition such as muscle mass wasting, minimal adiposity, hair loss, developmental delay, and recurrent infections. Growth faltering is confirmed using standardized growth charts (e.g., weight-for-age < 5^th percentile). Clinicians should perform a holistic approach to history and examination to identify risk factors and the underlying etiology. Diagnostic testing is reserved for children with no response to initial management or severe clinical features and can include urinalysis, stool tests, or specific tests depending on the suspected etiology (e.g., HIV test). Management consists of treatment of the underlying cause and nutritional modifications. Most patients can be successfully managed as outpatients. Close follow-up is indicated to prevent relapses or excessive weight gain.

• Growth faltering
  • A pattern of slow growth in children compared to the predicted values for their age and sex
  • Commonly used criteria include: ^[2][3]
    • Weight-for-age, length-for-age; , BMI-for-age, or weight-for-length < 5^th percentile ^[2][3]
    • A decrease across 2 major percentile lines from an already established growth velocity ^[2][3]
• Childhood wasting
  • Low body weight as a result of acute malnutrition, rapid weight loss, or insufficient weight gain
  • Characterized by a z score below 2 standard deviations in BMI-for-age charts or weight-for-length charts
• Growth stunting
  • Reduced height as a result of chronic malnutrition
  • Characterized by a z score below 2 standard deviations in height-for-age charts; weight may be proportional for height

• Seen in up to 10% of children in the United States ^[2]
• Most commonly occurs in children aged 6–18 months of age ^[4]

Epidemiological data refers to the US, unless otherwise specified.

Growth faltering occurs secondary to malnutrition, often due to a complex interplay between biological and psychosocial factors. ^[2][3][5]

Risk factors ^[2][3]

• Biological ^[3]
  • Prematurity and low birth weight
  • Intrauterine growth restriction ^[2]
  • Congenital anomalies
  • Developmental delay
  • Autism spectrum disorder ^[2]
  • Gastroesophageal reflux
  • Dental caries
• Psychosocial (see also “Social determinants of health”) ^[3][5]
  • Low socioeconomic status ^[2]
  • In the caregiver: stress, social isolation, inexperience, or untreated mental illness ^[2][3][5]
  • Restrictive diets ^[6]

Growth faltering is more common in children with multiple risk factors. ^[3]

Mechanisms

Growth faltering is a manifestation of malnutrition and may be accompanied by features of other underlying conditions. ^[2][3]

Features of malnutrition ^[2]

• Failure to gain weight
• Clinical features of protein-energy malnutrition, e.g.,
  • Wasted muscle mass
  • Minimal adiposity
  • Growth stunting
  • Dermatologic signs
    • Thin, weak hair
    • Pale, dry skin
• Features of micronutrient deficiencies, such as: ^[8]
  • Acral dermatitis or change to hair color/texture in zinc deficiency
  • Pallor in iron deficiency anemia
• Developmental delay
• Recurrent infections

Persistent severe malnutrition affects growth parameters sequentially; the first affected is weight, then length, and finally head circumference. ^[3]

Features of underlying conditions ^[3]

Features depend on the cause, examples include:

• Suspicious contusions or fractures; abnormal language, social, or psychological development in children who experience abuse
• Recurrent vomiting and diarrhea in gastrointestinal diseases
• Atopic dermatitis in food allergies
• Heart murmur in congenital cardiac disease
• Dysmorphic features in genetic abnormalities
• Edema in renal or liver failure

Approach ^[2][3]

• Obtain growth measurements and plot them on growth charts appropriate to age and any underlying conditions. ^[2][3]
• Confirm growth faltering by identifying either:
  • Single point measurements in low percentiles
  • OR significant delays in linear growth
• Perform a comprehensive clinical assessment to identify the etiology of growth faltering.
• Consider diagnostic studies in patients with: ^[2][3]
  • Suspected micronutrient deficiencies
  • Severe clinical features (e.g., weight gain velocity < 25% of expected)
  • No response to initial management
• Concurrently assess for abnormal pediatric development. ^[3]

Diagnostics studies are not required unless there are concerning features in the history or physical examination. ^[2]

Clinical assessment ^[2][3]

• Comprehensive pediatric history and physical examination including family history and prenatal/birth history
• Feeding and nutrition history
  • Number and frequency of feeds
  • Food refusal
  • Observation of a feed ^[9]
• Social history: identify risk factors such as food insecurity, lower socioeconomic status
• Identify features suggestive of an underlying etiology (see “Clinical features of growth faltering”).

Because growth faltering is commonly multifactorial, a thorough clinical assessment is necessary to address the interplay of contributing biological and psychosocial factors. ^[5][10]

Diagnostic studies

Common studies ^[2][3]

There is no standard set of blood tests to order; common studies include: ^[2][3]

• CBC with differential for anemia, immunodeficiency, or malignancy ^[2][3]
• CMP for electrolyte disturbances and renal tubular acidosis ^[2][3]
• Thyroid function tests: Hypothyroidism can cause short stature. ^[2][3]
• Urinalysis for glycosuria, infection, or renal pathology ^[2]
• Stool microscopy and culture for infection or malabsorption ^[2]
• Diagnostic studies for celiac disease ^[2]
• Lead and iron levels

Further studies ^[2][3]

Consider additional studies guided by clinical suspicion, for example: ^[2]

• Aspiration: modified barium swallow
• Gastrointestinal conditions
  • Esophagogastroduodenoscopy with biopsies
  • Upper gastrointestinal series with small bowel follow-through
  • Fecal calprotectin
• Cholestatic jaundice (e.g., biliary atresia): liver chemistries and imaging
• Food allergies: IgE skin prick test
• Congenital heart disease: echocardiogram
• Cystic fibrosis: sweat test, CFTR genetic testing
• Infections: tuberculosis screening
• Immunodeficiency: immunoglobulin levels for congenital immunodeficiency disorders, HIV screening

Approach

• Determine malnutrition severity and whether inpatient management is required.
  • Severe malnutrition or other admission criteria for growth faltering: inpatient management
  • Mild or moderate malnutrition: Trial outpatient management.
• Educate parents on behavioral modifications for mealtimes.
• Refer families with food insecurity to social work or community resources.
• Calculate additional calories required for catch-up growth and start nutritional modifications for growth faltering.
• Replete micronutrient deficiencies, if present.
• Treat any underlying etiology and address modifiable risk factors.
• Ensure immunizations are up to date.
• Arrange regular follow-ups to ensure adequate growth. ^[2][3]

Appetite stimulants are not routinely recommended but may be considered in select cases, e.g., children undergoing cancer treatment. ^[3]

Malnutrition severity

Ensure children are measured correctly, e.g., by a trained professional using a calibrated scale with infants unclothed and older children in undergarments or lightweight clothing. ^[2][11]

Serial measurements allow for dynamic assessment of growth faltering. ^[2]

Inpatient management of growth faltering

Inpatient management allows subspecialist workup of underlying causes, structured feeding evaluations, and intensive provision of nutritional support and caregiver education (see “Outpatient management of growth faltering”).

Admission criteria for growth faltering

• Severe malnutrition or dehydration
• Serious underlying medical issues
• Extreme psychosocial factors that do not allow for successful outpatient management
• Need for precise and specific documentation of nutrition
• Unsuccessful outpatient management

Inpatient management of severe malnutrition

• Start the 10 steps of recovery for severely undernourished children.
• Monitor for refeeding syndrome.
• Involve multidisciplinary teams in the assessment and management of the child.
• See also “Treatment of protein-energy malnutrition.”

Outpatient management of growth faltering

The majority of children with growth faltering can be managed as outpatients.

Caregiver education on feeding ^[2][12]

• Provide a balanced diet with a variety of foods to try.
• Avoid snacking (and drinks other than water) between meals.
• Schedule regular mealtimes where everyone eats together.
• Limit mealtimes to 20–30 minutes.
• Allow children to self-feed; avoid force-feeding.
• Provide positive reinforcement.

Nutritional modifications for growth faltering ^[2]

• Determine caloric intake required to reach ideal weight-for-height. ^[2][3]
  • The dietary reference intake for young children is:
    • 0–6 months of age: 108 Kcal/kg/day
    • 6–12 months of age: 98 Kcal/kg/day
    • 1–3 years of age: 102 Kcal/kg/day
  • Catch-up caloric requirement (in Kcal/kg/day) = dietary reference intake (in Kcal/kg/day) × ideal weight-for-height ^[3]
• Infants
  • If breastfeeding: Refer to a lactation consultant.
  • Increase the volume of breast milk or formula during feeds (as tolerated).
  • Consider increasing the caloric density of feeds.
• Children ^[2]
  • Preferred: increasing calorie-dense foods
  • Alternative: supplemental high-calorie drinks

Follow-up ^[2][3]

• Schedule regular appointments.
  • Weekly appointments may be appropriate initially, moving to monthly or every few months.
  • Infants may require more intensive follow-up.
• Weigh children every few days to one week.
• Initially, catch-up growth should occur.
  • Rapid growth at up to 2–3 times the normal rate
  • Growth should continue until an acceptable weight-for-length or BMI-for-age z score is attained (usually 4–9 months). ^[3]
• Monitor children long-term to ensure appropriate weight gain velocity.
  • Relapse may occur if underlying etiology is inadequately addressed.
  • Excessive weight gain may also occur and should be avoided.

Measure weight every few days on a calibrated scale, at the same time of day with the same clothing on. ^[3]

• Increased susceptibility to infections
• Developmental delay
• Persistent short stature
• Increased risk of cardiovascular disease and metabolic syndrome in adulthood
• See also “Complications of protein-energy malnutrition.”

We list the most important complications. The selection is not exhaustive.