Previously known as ‘failure to thrive’ (FTT), also known as weight faltering Infant or children whose current weight or rate of weight gain is significantly below that expected of similar children of the same age, sex and ethnicity Can occur in both infants (< 1 year of age) and in children (> 1 year of age)

1. The Journey of the Low
Birth Weight Infant
Presented by
Professor; Khaled Saad

2. Malnutrition is not new!
“The flesh is consumed; the abdomen fills with water.
The shoulders, clavicles, chest, and thighs, melt away.
This illness is fatal.”
Hippocrates (460 BC)

3. Faltering growth is a global issue
~100M
children are
suffering from
faltering growth in
the world
Up to 70% of
children with a
pediatric disease
are at risk of
faltering growth
Only 15%
of children with a
pediatric disease
initiated medical
nutrition
Sanon M. et al. Value in Health 2014;17(3):A23-A24
Walson JL and Berkley JA. Current Opinion June 2018;31(3):231-36
Western Australia Child & Adolescent Health Service, Community Health Manual, Dec 2017
Singhal A. Ann Nutr Metab. 2017;70:236–40.
Peterson et al. JAMA Pediatr. 2014;168:361-70
Mahleet al. Circulation. 2009;120:447-582
Disease-
related
Non-Disease-
related
Appetite
problem, quality
of diet, access to
food, maternal
issues

4. Highly malnourished and normally nourished children suffer
worsening of nutritional status during hospitalization
% of BMI decrease
≥0.25 SD during
hospitalization
in 496 pediatric
patients.
Shaughnessy E. and Kirkland L. Hospital Pediatrics 2016;6:37-41
0
5
10
15
20
25
30
35
< - 2 - 2 / 0 0 / + 2 > + 2
Percentageofpatients
Z-scores on admission
After 72 h
Discharge
*o P< .05
*o
*
o

5. Prevalence of undernutrition in the last 10 years in
European hospitalized children
Huysentruyt et al. JPGN 2016;63:86-91
6.1 to 11.9%

6. Prevalence of malnutrition depends on the
underlying medical condition
Malnutrition
Prevalence
Medical
Condition
~40% Neurologic diseases
~35% Infectious disease
~33% Cystic fibrosis
~29% Cardiovascular disease
~27% Oncology patients
~24% GI diseases
Mehta N. et al. JPEN 2013;37(4)

7. Malnutrition is much more than a deficit in energy
and nutrients
Abnormal cell function due to
energy/nutrient deficits
MALNUTRITION
Prolonged deficits in
energy/nutrients
Clinical
Insult
↑ Requirements
↑ Losses
↑ ↓ Metabolism
↓ Intake
Impact on clinical outcomes
Long-term
consequences
Loss of normal body
function
Medium-term
consequences
Changes in body
size/shape/composition
Short-term
consequences

8. Consequences of malnutrition
VICIOUS CYCLE
OF
MALNUTRITION
Length of Stay
Higher Associated Costs
 Morbidity & Mortality

9. • Prospective multicenter
European study
• 2567 patients (1 month to 18
years)
• Assessed within 24 h after
admission
“Disease-associated
malnutrition in children
correlates with prolonged
hospital stay, increased
complications, and
reduced quality of life”

10. Malnutrition status by BMI
Hecht C. et al Clin Nutr 2015;34:53-9
Children with moderate and severe malnutrition remain
hospitalized longer than those without malnutrition
0 10 20 30 40 50
0.00.20.40.60.81.0
Estimatedfunction
no
moderate
severe
LOS in days

11. Disease-associated malnutrition correlates
with increased complications
Hecht C. et al Clin Nutr 2015;34:53-9

12. Nutritional risk classification correlates with
length of stay
Length of stay increased from medium- to high-risk patients as identified with the use of all 3 tools
Chourdakis et al AJCN 2016;103:1301–10.
PYMS: Paediatric Yorkhill
Malnutrition Score
STAMP: Screening Tool for
the Assessment of
Malnutrition in Paediatrics
STRONGKIDS: Screening Tool
for Risk Of Impaired
Nutritional Status and
Growth
LOS: length of stay

13. Malnutrition is not simply a measurement of
anthropometry
• Anthropometric measurements
• Changes in weight/growth
• Biochemistry
• Clinical examination
• Dietary intake
• Body composition
1 year 2 years 3 years 4 years 5 years

14. Milani S. et al JHND 2013;26:294-7
Acquisition of anthropometric measurements and
assessment of growth in pediatric inpatients remains poor
97
4
11
0
10
20
30
40
50
60
70
80
90
100
%ofn=447admissions
Weight
Height
Growth

15. Serial anthropometric measurements are required
Faltering growth is defined as weight falling across
more than 2 major percentile lines

16. Serum albumin is NOT a marker of malnutrition
• Correlates with
disease activity index
• Expensive, time
consuming, and
requires blood
• Prealbumin and
thyroxin binding
protein are markers of
acute malnutrition
Gerasimidis K. et al JPGN 2013;50-1

17. Types of malnutrition
Non-illness Associated
Malnutrition
(Environmental and
behavioural factors)
Low Birth Weight
Illness-associated
Malnutrition
Small for
gestational
age (SGA)
Preterm

18. The Journey of the Low Birth
Weight Infant

19. Faltering growth (FG) definition
• Previously known as ‘failure to thrive’ (FTT), also known as weight faltering
• Infant or children whose current weight or rate of weight gain is significantly
below that expected of similar children of the same age, sex and ethnicity
• Can occur in both infants (< 1 year of age) and in children (> 1 year of age)
Lower rate of morbidity and mortality if weight is regained during
the first two years of life1:
• The tendency for weight gained in infancy to convert to lean
body mass
• While weight gained in later childhood produces fat mass
Importance of early identification and management of FG
Nutritional management often requires long-term intervention
1. Victoria CG et al, 2008

20. Newborn classification by weight and gestational age
NEWBORN CLASSIFICATION BASED ON GESTATIONAL AGE
Preterm (premature) Born at/before the 37th week of gestation
Term Born between the beginning of week 38 and the end of week 41 of
gestation
Post-term (post-mature) Born at/more than 42 weeks' of gestation
NEWBORN CLASSIFICATION BASED ON BIRTHWEIGHT
Low birth weight (LBW) < 2500 g
Very low birth weight (VLBW) < 1500 g
Extremely low birth weight (ELBW) < 1000 g
NEWBORN CLASSIFICATION BASED ON BIRTHWEIGHT AND GESTATION
Appropriate for gestational age (AGA) Weight appropriate for the gestational age
Small for gestational age (SGA) Smaller than expected, then expected, weight falls below the 5th
percentile for the gestational age
Large for gestational age (LGA) Heavier than expected, birth weight is above the 95th percentile for
the gestational age

21. Low birth weight (LBW) is generally recognized as a
disadvantage for the infant
• May directly or indirectly contribute to 60-80% of all
neonatal deaths
• Single most important predictor of infant mortality,
especially within the first months of life
• ~ 20.6 million LBW infants are born each year  96.5%
of them in developing countries1
1. WHO, 2011 Report
< 2.500kg

22. Prevalence of LBW
1. Malcolm WB. Beyond the NICU: Comprehensive Care of the High-Risk Infant. 1st edition, 2015.
2. Adair LS, Fall CH, Osmond C, et al. 2013.
3. Singhal A. 2017
• Up to 40% of those admitted to hospital for FG are low birth
weight infants1
• Poor growth in infancy  adverse health outcomes in adults2
Prevention of faltering growth and promotion of recovery from a
period of poor growth has always been a high clinical priority3
During infancy and childhood  LBW infants are at higher risk of:
1. Early growth retardation
2. Infectious disease: frequent hospital admission
3. Developmental delays
4. Early death

23. A study of risk factors for weight faltering in infancy
according to age at onset
Olsen EM. et al Paediatr Perinat Epidemiol. 2010 Jul 1;24(4):370-82
OBJECTIVE
Identify risk factors for FTT or weight faltering according to age of onset
METHOD
• Observational longitudinal study
• 6090 children born in year 2000 followed prospectively
• Weight faltering/FTT defined as slow conditional weight gain
• Subtypes according to age of onset:
• Birth to 2 weeks
• 2 weeks to 4 months
• 4 to 8 months

24. Results
Olsen EM. et al Paediatr Perinat Epidemiol. 2010 Jul 1;24(4):370-82
1. Onset of weight faltering within the first weeks of life is strongly
associated with low birth weight and gestational age
2. Onset between 2 weeks and 4 months was associated with congenital
disorders and serious somatic illness
3. Later onset (between 4-8 months) was associated with feeding problems
which develop in otherwise healthy children

25. Impact on growth and health
‘‘While under nutrition kills in early life, it also
leads to a high risk of disease and death later in
life”
United Nations Standing Committee on Nutrition
“Optimal nutrition is one of the fundamental
components for infants to reach their full
growth potential and neurodevelopment“
Tuthill DP, Child Nutrition Panel. Matern Child Nutr.
2007;3(2):120-8

26. Small for Gestational Age
(SGA) Infant

27. Is there an optimal growth trajectory for LBW infants?
OBJECTIVE:
Identify an optimal growth trajectory for term SGA babies from birth to 7 years of age
STUDY DESIGN:
 Data from the Collaborative Perinatal Project (CPP): US multicenter prospective cohort
study
 1957 term SGA babies grouped into 5 weight growth trajectories
 Optimal growth pattern based on the lowest overall risk of childhood diseases
Lei X. et al. J Pediatr 2015;166:54-8

28. Growth pattern results
Lei X. et al. J Pediatr 2015;166:54-8
A : NO catch-up growth
C : SLOW catch-up growth
E: EXCESSIVE catch-up growth
B: REGRESSION after 4 months
D: APPROPRIATE catch-up growth

29. Infants with appropriate catch-up growth did not
have increased risk of adverse outcomes
Risks of adverse outcomes for term SGA in each weight growth trajectory
relative to AGA infants
Lei X. et al. J Pediatr 2015;166:54-8

30. Conclusions on optimal growth trajectory for term
SGA infants
Lei X. et al. J Pediatr 2015;166:54-8
 May be fast catch-up growth that raises weight or weight-to-
length ratio to about the 30th percentile in the first several
months
 Modest catch-up growth thereafter could be around the 50th
percentile by 7 years of age

31. Current evidence
Castanys-Munoz E. et al. Acta Pædiatrica 2017;106:1230–8
Trials Outcomes
2 randomized trials with
enriched infant formulas
 Promoted early growth
 Increased fat mass, lean mass and blood pressure
 No effect on neurocognitive outcomes
31 observational studies Consistent positive association between postnatal
weight gain and growth with:
• Neurocognitive outcomes
• Adiposity, insulin resistance and blood pressure

32. Conclusions for term SGA infants
 Establishing optimal growth patterns to minimize short-term and long-
term risks is crucial
 Future prospective studies should assess the potential contribution of
body composition, rather than total body weight gain on later outcomes
 Potential benefits of postnatal growth on neurocognitive and other
outcomes may be related to gains in lean body mass, whereas gains in
body fat mass, in particular central fat, might predict insulin resistance
and related adverse metabolic and health outcomes
Castanys-Munoz E. et al. Acta Pædiatrica 2017;106:1230–8

33. Regular assessment of growth is important in SGA
infants who are faltering
Frequency of weight monitoring per NICE guidelines
1. Malks-Jjumba L. The University of British Columbia. Learn pediatrics. February 2011.
 Measure different growth parameters
 Assess and monitor growth velocity
patterns
 Feeding interventions support
growth if needed
 Adjust feeding regimes to growth of
infant
Normal median weight gain in children1
Age Frequency
<1 month Daily
1 to 6 months Weekly
6 to 12 months Fortnightly
>12 months Monthly
Age (months)
Media weight gain (gm per
day)
0 to 3 26 to 31
3 to 6 17 to 18
6 to 9 12 to 13
9 to 12 9
12 and older 7 to 9

34. Nutritional recommendations for infants
1. Shaw V, Lawson M. (2007) Clinical Paediatric Dietetics, 3rd edn. Oxford: Blackwell Publishing.
 Protein-to-energy ratio (energy from protein)
should ideally be kept within the range1
 7.5–12% for infants
 5–15% in older children
Age
(months)
Calories required
(Kcal/kg/day)
Average weight gain (gm/day)
0-3 100-120 25-30
3-6 100-120 15-20
6-12 90-100 10-15
> 12 80-90 5-10
 For catch-up growth:
 9% energy from protein
 130-150 kcal/kg/day

35. Breast milk is the gold standard for LBW infants
BM
(regular or
fortified)
Standard
formula
Nutrient-
dense
formula
If BM not possible • Poor weight gain, or
• Intolerance to volume
required to meet needs

36. Nutrition profile of nutrient-dense
vs. standard formula
Nutrients
Standard
Formula/100ml
Nutrient-Dense
Formula/100ml
Energy 66 kcal 100 kcal
Protein (g)
Protein % E
1.5 g
8%
2.6 g
10.4%
Fats 3.5 g 5.4 g
Iron 0.8 mg 1 mg
Benefits of a nutrient-dense vs. standard formula:
1. Contains up to 52% more energy
2. Contains up to 73% more protein and provides 10.4% energy from protein
3. Contains up to 50% more of most micronutrients and vitamins

37. Preterm Infant

38. Preterm birth is on the rise globally
Rising trend
 15M preterm
births/year and
rising
 Leading cause of
death in those <5yrs
 Global prevalence
of 5%-18%
Source: WHO 2015
11 countries with
preterm birth rates
over 15%
1. Malawi
2. Congo
3. Comoros
4. Zimbabwe
5. E. Guinea
6. Mozambique
7. Gabon
8. Pakistan
9. Indonesia
10. Mauritania
11. Botswana

39. Preterm birth is a major health concern in
the Middle East
2014 Global Nutrition Report
Lebanon
7.9% of babies are born preterm
5.9% mortality rate
KSA
8% of babies are born preterm
6% mortality rate
UAE
7.6% of babies are born preterm
2.9% mortality rate
Kuwait
10.6% of babies are born preterm
1.9% mortality rate

40. Major health challenges of preterm infants
Infections
Chronic
lung
disease
Leading to hospitalization and increased costs
BPD, bronchopulmonary dysplasia; NEC, necrotizing enterocolitis
Impaired
renal
function
Immature
digestive
tract
Growth and
developmental
delay
Bone
mineralisation

41. Preterm birth and implications on feeding
Immature peristalsis
Feed volume
intolerance
No sucking reflex at
<34 weeks
Reduced enzyme
activity
Impaired
absorption of
nutrients
CHALLENGE
Need nasogastric/cup
feeding
IMPLICATION

42. Preterm birth and implications on feeding (Continued)
High growth rate
Low body reserves
Increased requirements
for energy and most
nutrients
Immature renal
function at <34 weeks
Increased heat loss due to
increased surface area and
non-cornified skin
Increased fluid
needs
CHALLENGE
Excretion of sodium and
other waste products
poorly controlled
IMPLICATION

43. Short term health challenges highlight the need for
provision of adequate nutrition
Risk of obesity,
diabetes, CVD,
bone density
IMMATURE
GUT
GROWTH FAILURE/
GROWTH RETARDATION
MICROBIOTA
IMMUNE
PHYSIOLOGY
Impaired cognitive
outcome
neurological
disabilities,
behavioral problems
BRAIN
Early life
nutrition
Limited
nutrient reserves
High
nutrient needs
= NUTRIENTS
SHORT TERM IMPACT LONG TERM EFFECT

44. Nutritional requirements of the preterm vs.
term infants
Nutritional needs per gestational age (GA)
An RDA is the average daily dietary intake level sufficient to meet the
nutrient requirements of nearly all (97-98%) healthy individuals in a group
Adapted from Rigo J. J Pediatr 2006;149(5):S80–S88 and Ziegler EE. Ann Nutr Metab 2011;58(1):8–18 Dietary Reference Intake. Office of Disease Prevention and Health Promotion.
https://health.gov/dietaryguidelines/dri/updates.asp
Calorie and protein requirements, RDA
RDA, recommended dietary allowance

45. The nutrition journey of the formula-fed preterm infant
Birth – Preterm formula initiated
Appropriate weight for GA reached – Discharged from
hospital
Post-discharge formula (PDF) initiated
40-52 weeks postconceptional age – Nutrition
assessment and Catch-up formula as needed

46. Various formulas designed to meet the specific needs of
the preterm infant along the journey
Nutrient Human
Milk
Term
Formula
Preterm
Formula
Post-discharge
Formula (F75)
Catch-up
Formula (F100)
Energy (Kcal/100ml) 67 67 81 73 100
Protein (g/100ml) 1 1.4 2.4 2.1(11.5%) 2.6(10.4%)
Fat (g/100ml) 3.5 3.6 4.3 4 5.4
CHO (g/100ml) 7 7.3 8.7 7.6 10.3
Ca (mg/100ml) 28 53 140 83.5 80
P (mg/100ml) 14.7 32 74 47.5 40
Na (mmol/100ml) 0.8 0.8 1.8 1.1 2.5
Fe (mg/100ml) 0.04 1.22 1.46 1.33 1
Zn (mg/100ml) 0.12 0.6 1.22 0.9 0.9
Vit A (mg/100ml) 0.007 0.006 0.3 0.1
Vit D (mg/100ml) 0.05 1 4 1.4 1.7

47. Post-discharge formulas are NOT the same as
preterm formulas
 Preterm formulas were developed for preterm and NOT for term FG/FTT infants.
 Both patient groups have different needs and require a different nutritional
management.
Post-Discharge PhaseNICU Phase
Premature Infant
> 37 weeks
0 month
Term Infant
12 months

48. Post-discharge formulas are designed for preterm
infants up to 12 months gestational age
12
months
Post-discharge Formula
Premature Infant
> 37 weeks
0 month
Term Infant 40 - 52
weeks
(gestational age)

49. Evidence-based Practice

50. ESPGHAN recommendations for nutrient-dense
formula after hospital discharge
Infants with appropriate weight for
postconceptional age at discharge
Breast milk If BM not possible
Infants with subnormal weight for
postconceptional age at discharge
Supplemented BM
Post-discharge formula with high contents of
protein, minerals, trace elements and LCP
At least until 40 weeks, possibly 52 weeks
postconceptional age
If BM not possible
Standard formula
with long-chain
polyunsaturated
fats (LCP)
ESPGHAN Committee on Nutrition J Pediatr Gastroenterol Nutr. 2006 May;42(5):596-603

51. Optimizing nutrition for preterm/LBW infants post-
discharge is essential
• Particularly during critical growth period of about 40-52 weeks PMA when
catch-up growth is optimal
• Nutrient-dense post-discharge formulas are designed specifically to meet
the additional nutritional needs of LBW and early term infants
• A nutrient-dense discharge formula is clinically proven to support
appropriate catch-up growth, resulting in improved weight gain and optimal
lean body mass deposition

52. “Small, preterm infants… may benefit from the use of such
formulas for up to 9 months after hospital discharge”
AAP and ACOG recommendations for nutrient-dense
formula after hospital discharge
When compared with term formulas, post-discharge
formulas result in greater:
linear growth,
weight gain
bone mineralization
AAP, American Academy of Pediatrics
ACOG, American College of Obstetrics and Gynecology

53. WHO feeding guidelines for catch-up growth
According to the WHO Guidelines for treatment of severe malnutrition, an
infant/child enters the rehabilitation phase when their physiological state is stabilized
and appetite returns.
In the rehabilitation phase, a rapid feeding approach is required to achieve rapid
weight gain of > 10g gain/kg/day. This rapid feeding approach must include very high
energy and protein intakes.
Therefore, the F-100 catch-up formula is recommended in this phase to provide high
energy and high protein to encourage a weight gain of > 10g gain/kg/day, i.e. 100
kcal/100 ml and 2.9 protein/100 ml.
The rehabilitation phase may last from 2-3 weeks or longer.
WHO 2003, for several malnourished children
F-100 Feeding Rehabilitation Phase

54. Catch-up growth dilemma
1. Victora CG, et al. 2001 ; 2. Adair LS, et al. 2013. ; 3. Brandt I, et al.
2005.; 4. Pylipow M, et al. 2009.; 5. Longo S, et al. 2013. ; 6. Lei, X, 2015
 Persistent poor postnatal growth is associated with more:
frequent infection1
short stature2,3
Impaired cognitive development4,5
When compensating for earlier growth restriction, LBW and SGA infants are more likely
to have rapid postnatal growth6
 The developmental origins of adult disease hypothesis suggests that rapid postnatal
growth is associated with a number of metabolic disorders later in life including:6
obesity,
hypertension
cardiovascular diseases
metabolic syndrome and endothelial dysfunction

55. Nutritional Management

56. Key features of a nutrient-dense formula
AIM: Support catch-up growth in LBW infants and illness
(e.g. CHD)
• Nutritionally complete with high energy/protein in a
small volume (1 kcal/ml)
• Meets WHO guidelines for F-100 formulation used in
rehabilitation phase

57. Key features of a nutrient-dense formula (continued)
• Lactose – the predominant energy source in breast milk
– supplying energy, promoting a healthy gut flora and
helping calcium uptake
• At least 8.9% of protein energy for adequate ratio of lean
muscle mass:fat tissue weight gain
• Whey-to-casein ratio 60:40 (similar to human milk) which
enhances gastric emptying and reduces emesis

58. Key features of a nutrient-dense formula (continued)
• LCPs with DHA and AA for structural development of
brain, central nervous system and retinal tissue
• Prebiotic mixture of 90% GOS and 10% FOS to support
gut flora and immunity
• Calcium-to-phosphorus ratio 2:1 ratio for optimal bone
growth
• Nucleotides - conditionally essential during periods of
rapid growth

59. Postnatal growth and the preterm infant
“Given that adults born preterm are at greater risk of both
impaired neurodevelopment and CVD, current nutrition policy for
preterm infants is therefore based on a risk–benefit analysis.
On balance, in view of the widely accepted consensus that
supporting optimal neurodevelopment is the highst priority,
current nutrition policy in preterm infants favors a higher protein
intake and faster growth in order to improve later cognitive
function, irrespective of any increase in CVD risk.”
Singhal A. Ann Nutr Metab 2017;70:236–240Singhal A. Ann Nutr Metab 2017;70:236–240

60. Key messages
 Onset of weight faltering within the first weeks of life is strongly associated with low
birth weight and gestational age
 FG related to low birth weight has serious health implications and appropriate catch-
up growth may reduce the risk of adverse outcomes
 When the use of BM is not possible, nutrient-dense formulas are clinically proven to
support appropriate catch-up growth

61. THANK
YOU
Thank you
for caring
for me