Growth problems

• 

  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.

  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.

  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.

  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.

  Investigations

  Measurement:

  • Length and height should always be measured with correct device, not tape measure.
  • Remove shoes and ideally nappies when weighing.

  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."

  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 neglect.

  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.

• Short stature

  Definition

  Height <2nd centile.

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