Growth problems Faltering growth Aka failure to thrive. Definition ↓Growth in infancy, falling across 2 centile lines and manifest in poor weight gain. May also have proportionally small height and head circumference, though more acute causes tend to affect weight only. If height also low, may suggest constitutionally small child, so check parental heights. Initial loss of up to 10% in first 3-4 days is normal (likely fluid loss), but this should be regained by 3 weeks. Thereafter, there should be an average weekly gain of 150-200 g in normal children, with weight doubling by 4 months and tripling by 12 months. Faltering growth is both an indicator of underlying disease and can itself can cause long-term problems of ↓growth and ↓IQ.

1. GROWTH
PROBLEMS
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2. FALTERING GROWTH
Aka failure to thrive.
Definition
↓Growth in infancy, falling across 2 centile lines and
manifest in poor weight gain.
May also have proportionally small height and head
circumference, though more acute causes tend to
affect weight only. If height also low, may suggest
constitutionally small child, so check parental
heights.

3. DEFINITION
Initial loss of up to 10% in first 3-4 days is normal
(likely fluid loss), but this should be regained by 3
weeks. Thereafter, there should be an average weekly
gain of 150-200 g in normal children, with weight
doubling by 4 months and tripling by 12 months.
Faltering growth is both an indicator of underlying
disease and can itself can cause long-term problems
of ↓growth and ↓IQ.

4. CAUSES
Non-organic/environmental (>90%).
Inadequate intake due to:
Feeding problems (common): unskilled feeding (breast
or bottle), insufficient breast milk, infant difficult to
feed (e.g. low appetite, weak suck).
Maternal problems: neglect, postnatal depression.

5. ORGANIC:
GI: IBD, coeliac disease, cow milk protein
allergy, GORD.
Swallowing problems: cleft palate, cerebral
palsy.
Chronic disease: kidney, liver, or heart
failure.
Multi-system: Down's, CF, hypothyroidism.
Chronic infection.

6. SIGNS AND SYMPTOMS

7. SIGNS AND SYMPTOMS
May be minimal if non-organic, or at least non-specific e.g.
unhappy.
Signs likely if organic e.g. thin buttocks in coeliac, respiratory
problems in CF.
Differential diagnosis
Constitutionally small babies:
Small but otherwise normal i.e. happy, alert, and responsive.
These are not likely to be crossing centile lines, but just be
always small.

8. INVESTIGATIONS
Measurement:
Length and height should always be
measured with correct device, not tape
measure.
Remove shoes and ideally nappies when
weighing.

9. INVESTIGATIONS
Using and interpreting the growth chart:
Mark point on chart with dot.
When between two centile lines, say "They are between the Xth
and Xth centile" i.e. don't try and estimate it.
If they are close to a centile line, just say they're at that centile.
If they are below the bottom centile line, say they are "Below
the 0.4th centile".
To describe changes, say "They have dropped X centile lines."

10. INVESTIGATIONS
If faltering growth found, do clinical and developmental exam
(doctor), then a detailed dietary history (health visitor):
Ask about: milk feeding, weaning, range of food, mealtime
routines.
Have family complete 3 day diary.
Management
Non-organic causes:
Provide guidance and support on correct feeding.
Initially done by health visitor, then refer to dietician if
unsuccessful.
Social work referral is only indicated if there are other signs of

11. INVESTIGATE ORGANIC
CAUSES
Investigate organic causes if other symptoms indicate
it or there is persistent faltering growth despite
dietary interventions:
Basic: FBC (anaemia, leukaemia), ferritin (↓iron), U&E (kidney
disease), TFT, MSU, coeliac bloods.
Further: sweat test (CF), vitamin D (rickets), CXR (cardiac
anomalies, CF), chromosomal analysis in girls (Turner's).
Admitting for observation with correct feeding can be tried,
though is generally not advised as hospital is not a natural
environment to assess parent-child interaction.

12. SHORT STATURE

13. DEFINITION
Height
Causes
Familial short stature (80%) i.e. small parents. Predicted
height can be calculated in a gender-specific formula using
mid-parental height.
Constitutional delay in growth and puberty. Benign and
needs no investigation. Bone age is matched with height
age (with both below average for chronological age),
differentiating it from serious pathology where bone age is
severely delayed.

14. CAUSES
IUGR
Psychosocial: neglect, poverty.
Genetic: Down's, Turner's, CF, dwarfism.
GI: Coeliac, IBD.
Endocrine: steroid treatments,
hypothyroidism, growth hormone deficiency.

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