A 1 month 13 day old infant presented with poor weight gain since birth. The infant was born at term via SVD with a birth weight of 3.13kg. Initial weight loss and poor subsequent weight gain was noted. Investigations revealed metabolic acidosis and the infant required intubation. The case discusses evaluating growth patterns in infants, identifying causes of failure to thrive, and obtaining a thorough feeding history to determine the underlying cause of poor nutrition.

1. Approaching
children with
poor weight
gain
DR FADHLY SHARIMAN BIN HJ
YAHAYA
HOSPITAL PORT DICKSON

2. Case base discussions
Approaching children with poor weight gain
Dr Fadhly Shariman
Malaysia - Ireland Training for Family Medicine (MInTFM)
Supervised by
Dr Aina Mariana Binti Manaf
08/05/2023

3. Case Study
(28/02/2023)
NAME :B/O ALINA AMELIA BINTI ABDUL RAHMAN
AGE : 1 months 13 days
DOB : 15/01/2023
Birth hx : Term 39 weeks 5 day , SVD
Birth weight : 3.13kg length 48 cm COH 32 cm
Issues : Poor weight gain

4. Referral from Klinik Kesihatan
Poor weight gain
Birth History:
BW: 3.13kg
Length:48cm
COH: 32cm
Apgar score:9 at 1 min, 10 at 5 min
G6PD: normal
CTSH: 4.873
Born term at 39 weeks 5 days via SVD
ANC
1. Maternal morbid obesity
booking bmi 36
latest bmi 40
ECHO : Normal
2. 1 previous scar with 1 successful VBAC
3. Poor spacing
4. GBS positive
HVS C&S on 30/11/2022
Given stat dose of IV Cpen (less than 10 minutes prior delivery)
No PROM

5. Birth history
Born term SVD at 39 weeks 5 days, vigorous
Antenatally, mother GBS carrier with inadequate antibiotic coverage prior to
delivery
Postnatal
baby was admitted to our SCN in view of infant of GBS mother with
inadequate coverage and was subsequently covered for presumed sepsis in
view of early onset jaundice with high retic count.
However she was prematurely discharged
parents insisted persistently on bringing the baby back home despite advice
on risk and complications to baby.

6. Noted during medical check up in 1 month old at KK
weight only 3.05kg ( 2.5% ) weight loss
repeat weight 3.13kg
mother claim previously on lactogen , 4oz 3 hourly
had loose stools for the past 1/52
tca 2 weeks for weight monitoring at KK
Noted weight 2.85kg ( 8.94% ) weight loss
Refer to hospital for poor weight gain

7. Current weight 3.01kg ( 1 month 13 days )
Rp : Urea 3.0 / sodium 135 / K 2.8 / chloride 107 / Creat 17
FBC : rejected
mother claim diarrhoea for 1/52
frequent changes pampers,
watery stools improving
initially given lactogen Dutch baby and s26
Frequent loose stools
currently similac soya for 5 days
3oz 3 hourly – loose stools improving

8. otherwise
no trauma
no fever
no vomiting
no rapid breathing
no sick contact
no recently travel
o/e sleeping, warm periphery, CRT<2sec
Lung : good breath sound a/e equal
p/a soft no mass palpable
weight gain 5%
weight for age : below 3rd centile
length for age : below 3 centile

9. plan
continue similac soya for now
TCA in 6/52 to review back weight and growth
KIV to expose baby for cow milk if patient weight gain well

10. 13/03/2023
ED HPD
c/o:
fever for 2/7
reduced oral intake and activity for 2/7
rapid breathing x1/7.
There is a history of ill contact with her sibling at home.

11. upon presentation: severe dehydration in hypovolemic shock - lethargic and
limp, poor pulse volume, poor perfusion CRT=3s, sunken eyes, sunken
anterior fontanelle, crying with no tears with poor skin turgor.
Tachypnoeic with acidotic breathing.
HR was 150bpm
BP wide pulse pressure 80/36mmHg
Saturation 97% under RA.
Glucose stat 5.3mmol/l
severe metabolic acidosis on VBG - pH 6.89, pCO219, pO2 34 HCO3 3.6, BE -
29.5, Lac 1.3

12. Patient intubated in view of the severe metabolic acidosis.
Clinically patient sedated, pink, good pulse volume, central and peripheral
perfusion good
Anterior fontanelle normotensive. Eyes still sunken, skin turgor slow
+Acidotic breathing

13. Physical assessment
PO2 97% ventilator PIP 14/6, rate 40, fio2 100%
Lungs : breath sounds good and equal, clear
CVS : DRNM
PA : soft, not distended, hepatomegaly 4cm, no splenomegaly, BS
active
Bilateral femoral pulses palpable
Normal female genitalia
Severe perianal excoriation
Multiple fungal skin lesions seen all over the face, trunk and limbs

14. Investigations
Investigations :
FBC: TWC: 32.2 (Lym: 38.8 Neut: 41.9) Hb 11.9 PLT 811
LFT:T. protein 87 Alb 45 Glo 42 ALT 47 ALP 373 T.bili 17.2
RP: Urea 4.6 Na 120 K 4.2 Cl 110 Creatinine 32
Pre intubation VBG: pH 6.89 HCO3 3.6 Lac 1.5 Glu 5.3 pCO2 19 pO2 34
Post bolus VBG: pH 6.87 HCO3 < 3.0 Glu 8.7 Lac 1.5 pCO2 13 pO2 65
Repeat VBG: pH 6.87 HCO3 3.7 Lac 2.2 pCO2 20 pO2 36
Post intubation ABG: pH 6.80 HCO3 5.8 BE -28.1 pCO2 37 pO2 442 (under
fio2: 100%)

15. Management plan
Plan:
IVD HSD5% full maintenance at 18.8cc/hr
IVD correction 10% NS run at 25cc/hr over 12 hrs(start at 8pm)
IVI morphine 3mg in 50cc D5% run 1ml/hr (20mcg/kg/hr)
IV Cefotaxime 150mg STAT given at 9pm (50 mg/kg)
Transfer out to HTJS for ventilator support and further management

16. Discussions

17. Key points
• Optimal growth assessment requires serial measurements plotted on
appropriate growth charts
• Nutrition is the main driver of growth in children under 2 years of
age. Most cases of slow weight gain are secondary to inadequate
caloric intake
• Slow weight gain is commonly multifactorial in origin, with
psychosocial stressors often a significant contributor
• Small and otherwise healthy babies following a growth percentile line
may not need any investigations

18. IDENTIFY NORMAL
GROWTH PATTERN IN
AN INFANT

19. WEIGHT
• Lose 10-15% of their birth weight in first 7-10 days of life due to:
I. Excretion of excess extravascular fluid
II. Possibly poor intake (intake improves as colostrum is replaced by
higher fat milk, as infant learn to latch on and suck more
efficiently, and as mother become more comfortable with feeding
technique)
• 1st 3months of life, rate of weight gain 25g/day
Babies usually regain their birth weight by 2nd week
• Double birth weight by 5 month age
• Triple birth weight by 1 year of age
• Weight estimation for children
infant (age in months x 0.5 )+4
children 1-10 years (Age in yr +4) x 2

20. © 2010 Royal College of Paediatrics and Child Health
www.growthcharts.rcpch.ac.uk
Measuring and plotting
Measuring Weight
Babies should be weighed without any
clothes or nappy
Children older than two years can be
weighed in vest and pants, but no shoes,
footwear, and dolls or teddies in hand
Only class III clinical electronic scales in
metric setting should be used
Class III
Clinical
Electronic
Scales

21. HEAD CIRCUMFERENCE
• At Birth - 13.5 inches (35 cm)
• rate of growth in preterm infant is 1cm/week but
reduce with age. head growth follow that of term
infant when chronological age reach term
• COH increase 12 cm in 1st year of life (6 cm 1st 3
months, 3cm in second 3 months and 3 cm in last 6
months)
• 5-12 y 0.33cm/year

22. © 2010 Royal College of Paediatrics and Child Health
www.growthcharts.rcpch.ac.uk
Measuring and plotting
Measuring Head Circumference
Head circumference should be
measured using a narrow plastic or
disposable paper tape
Measurement should be taken
where the head circumference is
widest

23. LENGTH
• Preterm infants = average 0.8- 1.0cm/week.
• Term infants = average 0.69- 0.75cm/week.
Age Length
Birth 50cm
6 months 68cm
1 year 75cm
3 years 90cm
4 years Double birth length (100cm)
5 – 12 years 5 cm yearly

24. © 2010 Royal College of Paediatrics and Child Health
www.growthcharts.rcpch.ac.uk
Measuring and plotting
Measuring Length
Measure length before age 2 years if concerned.
Length should be measured without nappy or footwear.
Use proper equipment (length board or mat) as any other
method is too inaccurate. Requires two measurers

25. THE CAUSES OF FAILURE TO
THRIVE IN AN INFANT

26. DEFINITION
Given to malnourished
infants & young children
who fail to meet expected
standards of growth : Fails
to gains weight / length /
head size / development.
Related to organic,
environment and
psychosocial causes.
Nelson, essential of Peadiatrics, 6th edition.

27. DEFINITION
Suboptimal weight gain in infants and toddlers
Inadequate weight gain when plotted on a centile
chart
Mild FTT – Fall across 2 centile lines
Severe FTT – Fall across 3 centile lines
Illustrated textbook of peadiatrics, 4th edition

28. DIAGNOSED BY:
Weight that falls or remains below the third percentile for age
OR
Weight that decreases, crossing two major percentile lines on the
growth chart over time
OR
Weight that is less than 80% of the median weight for the height of the
child
Nelson, essential of Peadiatrics, 6th edition.

29. Failure
to
Thrive
INADEQUATE
INTAKE
INADEQUAT
E
RETENTION
MALABSORPTIO
N
INCREASED
REQUIREMENT
FAILURE
TO UTILISE
NUTRIENT

30. INADEQUATE
INTAKE
ORGANIC
NON-
ORGANIC

31. Organic Causes
Impaired
Suck/Swallow
Oromotor
Dysfunction
Neurological
Dysfunction eg
Cerebral Palsy
Mechanical feeding
difficulty
Cleft Palate/cleft lip
Chronic illness
leading to
anorexia
Crohn’s
Disease
Chronic Renal
Failure
Illnesses that
increase
metabolic
demands
Liver Disease
Organic Causes:
caused by an underlying medical disorder.

32. Non-organic Causes
Inadequate availability of
food
Feeding Problem—Insufficient breast milk
or poor technique or ineffective latching,
incorrect preparation of formula
Insufficient or unsuitable food
offered
Lack of regular feeding
time
Infant difficult to feed
Conflict over feeding, intolerance of
normal feeding behavior- eg
throwing food around or messiness
Problem with budgeting, shopping,
cooking food, famine
Low socioeconomic status
Psychosocial
Deprivation
Poor maternal-
infant interaction
Maternal
depression
Poor maternal
education
Neglect or Child
Abuse
Factitious
illness
Non-organic Causes:
associated with broad spectrum of psychosocial and environmental
deprivation

33. • Vomiting
• Severe Gastro esophageal reflux
INADEQUATE
RETENTION
•IDA
•biliary atresia
•Coeliac Disease
•irritable bowel syndrome
•Cystic Fibrosis
•Cow’s milk protein intolerance
•Short Gut Syndrome
•Post Necrotizing Enterocolitis, NEC
MALABSORPTION
•Chromosomal disorders (eg: Down Syndrome)
•IUGR
•Congenital infection
•Metabolic disorder (congenital hypothyroidism, storage disorders,
amino- and organic acid disorder)
FAILURE TO UTILISE
NUTRIENT
• Thyrotoxicosis
• Cystic fibrosis
• Malignancy
• Chronic infection(HIV, Immune deficiency,TB)
• chronic lung disease
• Congenital heart disease
• Chronic renal failure
INCREASED
REQUIREMENT

34. DEMONSTRATE THE
IMPORTANCE OF A FEEDING
HISTORY

35. The importance of a feeding history
• To know the current nutritional intake
• To provide the better look at correlating the infant’s
development with the types of food offered.
• To assess the adequacy of nutritional intake for
growth.
• To screen for undernutrition or nutritional deficiency.
• To detect the causes of undernutrition and exclude
other causes of FTT
• Planning of management

36. Feeding history
Breastfeeding
Formula feeding
Weaning
Types of
feeding :

37. Breastfeeding history
History Comments
1. Ask if the baby is breast fed
or bottled fed
•Full term newborn babies can obtain all the
nutritional needs from breast milk in their first 4-6
months (only breastmilk can supply the secretory Ig A,
lactoferrin, peroxidase, lysozyme).
2. The duration of exclusive
breastfeeding and mixed
breastfeeding
Exclusive breastfeeding reduces infant mortality due to
common childhood illnesses such as diarrhoea or
pneumonia, and helps for a quicker recovery during
illness.
3. Frequency per day Demand or timed
Well term babies should be given breast feed on
demand. (usually 8-12 times/day)
4. Strength of sucking Good sucking reflex means that the baby is well.
Otherwise baby may be too weak to suck.
5. Any difficulty in
breastfeeding
The common reasons to quit breastfeeding are:
 Low milk production
 Mastitis
 Flat or inverted nipples
 Sore nipples

38. Formula feeding history
History Comments
1. Type of formula Infant, special, soy formula
2. The amount and frequency of milk
intake
 1 oz= 30mls
 The milk requirement
Day 1: 60mls/kg/day
Day 2-3: 90mls/kg/day
Day 4-6: 120mls/kg/day
Day 7 onwards: 150mls/kg/day
3. Preparation of feeds and hygiene Bottle sterilization, water source
4. Who feeds the baby Placement of the infant for feeding

39. Weaning
History Comments
1. Ask about weaning and
when did the weaning start.
 Food is needed after 6 months of age in addition to
milk to satisfy the increasing energy demands of the
infant.
 However, babies should not be started on foods other
than milk before they are 4 months old as their
kidneys and digestive system are not fully developed.
2. The types of solid food
introduced
 Normally cereals are introduced and mix with food
such as stewed fruits, mashed banana and pumpkin.
 Gradually, at around 8 months, an eating pattern of 3
meals a day should emerge. The type and quantity of
food taken for breakfast, lunch and dinner should be
obtained to quantify total calorie intake.
3. Ask about the feeding
pattern (Abnormal feeding
pattern can cause
malnutrition)
 Refusal (selective to mode of feeding or to a specific
parent or selective for some types of food)
 Fixation (willingness to ingest only 1 type of
food/texture of food)

40. DESCRIBE THE
NUTRITIONAL
REQUIREMENTS FOR
CHILDREN

41. INTRODUCTION
1. Nutrient needs determined by:
 Body size
 Growth rate
 Age
2. A child’s requirement is higher than an adult’s.
3. Nutritional deficiency are more commonly seen in
infancy as young children have fewer body reserves
of all nutrients.

43. Source: National Coordinating Committee on Food and Nutrition (2005)

44. Recommended Nutrient Intake (RNI)
1. RNI for children do not differ for boys and girls
except for energy.
2. All RNI values has a margin of safety except for
energy
3. RNI for most nutrients is higher than physiological
needs of most children.
4. If nutrient intake of a child less than RNI, it does not
necessarily mean child has nutritional problem.

45. Nutrient Recommendations
• Based on Malaysian Dietary Guideline (MDG) 2010:
Key message 12:
Practice exclusively breastfeeding from birth until six months and continue to
breastfeed until two years of age.

46. Key recommendations:
• Prepare for breastfeeding during pregnancy
• Initiate breastfeeding within one hour of birth
• Breastfeed frequently and on demand
• Give only breast milk to baby below six months with no
additional fluid or food
• Continues to give babies breast milk even if baby is not with
the mother
• Introduce complementary foods to baby beginning at six
months of age
• Lactating mothers should get plenty of rest, adequate food and
drink to maintain health
• Husbands and family members should provide full support to
lactating mothers

47. Cereal Products and Tubers group

48. Fruits

49. Vegetables

50. Fish, Poultry, Meat and Egg

51. Fish, Poultry, Meat and Egg(2)

52. Milk

53. FORMULATE THE APPROACH
TO MANAGEMENT OF A
CHILD WITH FAILURE TO
THRIVE

54. Calories required for catch-up
• Children with failure to thrive require 150% of
Recommended Daily Requirement of calories
• Schedule: Replacement calories needed per day for
malnourished and catabolic infant
Age 0-6 months:
130-150 KCal/kg/day (high)
150-220 KCal/kg/day (very high)

55. ORGANIC FAILURE TO THRIVE
Treat underlying medical condition
Caloric supplementation
• Depend on severity and underlying medical problems.
• The responds depends on : (Specific diagnosis,
medical management, severity of the failure to
thrive.)
Monitor amount of protein
• In children with renal failure

56. NON ORGANIC FAILURE TO THRIVE
Home visit
- By health visitor
- Assess eating behavior
- Provide support
Direct practical advice
following observation
Paeds dietician
- Assess quantity &
composition of food intake
- Recommend strategies to
increase E intake
Speech & language
therapist
- Feeding disorder therapy
Clinical psychologist &
social services
Nursery placement
- Alleviate stress at home
- Assist feeding

57. Solid food -> liquid
Environmental distraction minimized
Eat with other people
Not force-fed
Rule of 3 : 3 meals, 3 snacks, 3
choices

58. Limit intake of :
• water
• juice
• soda
• low-calorie beverages
Emphasize intake of : high-calorie
foods –
• peanut butter
• whole milk
• cheese
• dried foods
High-calorie
supplementation :
• Duocal
• Polycose
High-calorie liquids :
• Carnation Instant breakfast
with whole milk
• Formulas containing
>20cal/oz – Pediasure,
Ensure, Resource

59. Base on case
Severe Failure to thrive – Fall across 3 centile line
Diagnose
Weight that falls or remains below the third percentile for age

60. Weight
1st 3months of life, rate of weight gain 25g/day
Babies usually regain their birth weight by 2nd week
Double birth weight by 5 month age
Triple birth weight by 1 year of age
Weight estimation for children
infant (age in months x 0.5 )+4
children 1-10 years (Age in yr +4) x 2
----------------------------------------------------------------------------------
Base on case
( 1 month old x 0.5 ) + 4 = 4.5kg
Rate of weight gain 25g/day

61. Failure to thrive
Non Organic
Feeding Problem - Insufficient breast milk or poor technique or
ineffective latching, incorrect preparation of formula
Malabsorption
• Cow’s milk protein intolerance

62. Breastfeeding history
History Comments
1. Ask if the baby is breast fed
or bottled fed
•Full term newborn babies can obtain all the
nutritional needs from breast milk in their first 4-6
months (only breastmilk can supply the secretory Ig A,
lactoferrin, peroxidase, lysozyme).
2. The duration of exclusive
breastfeeding and mixed
breastfeeding
Exclusive breastfeeding reduces infant mortality due to
common childhood illnesses such as diarrhoea or
pneumonia, and helps for a quicker recovery during
illness.
3. Frequency per day Demand or timed
Well term babies should be given breast feed on
demand. (usually 8-12 times/day)
4. Strength of sucking Good sucking reflex means that the baby is well.
Otherwise baby may be too weak to suck.
5. Any difficulty in
breastfeeding
The common reasons to quit breastfeeding are:
 Low milk production
 Mastitis
 Flat or inverted nipples
 Sore nipples

63. Formula feeding history
History Comments
1. Type of formula Infant, special, soy formula
2. The amount and frequency of milk
intake
 1 oz= 30mls
 The milk requirement
Day 1: 60mls/kg/day
Day 2-3: 90mls/kg/day
Day 4-6: 120mls/kg/day
Day 7 onwards: 150mls/kg/day
3. Preparation of feeds and hygiene Bottle sterilization, water source
4. Who feeds the baby Placement of the infant for feeding

64. Reference
The Royal Children Hospital Melbourne, clinical practise guideline
Royal College Paediatrician child and Heath
Nelson Essentials of Pedriatic 6th edition
Illustrated textbook pf pedriatic 4t edition
National Coordinating committee food and nutrition
Malaysia Dietary Guideline
Malaysia Dietary Guideline,national coordinating committee for food
and nutrition

65. THANK YOU