Growth Faltering in Newborns and Infants

Definitions and Diagnostic Criteria

Severe acute malnutrition— weight-for-height (or length) that is <–3 SD from the mean or a mid-upper arm circumference between 11.5 cm and 12.5 cm
Moderate acute malnutrition—weight-for-height (or length) that is between –2 SD and –3 SD from the mean or a mid-upper arm circumference <11.5 cm
Underweight—a weight-for-height z-score (WHZ) that is < –2 SD. Also called wasting.
Stunting – height-for-age z-score (HAZ) more than –2 SD from the mean.
Short stature—height-for-age <–2 SD; if occurring without wasting is not growth faltering.

Statistics derived from NHANES (2004 to 2014) show that growth faltering is common in the United States:

• The rate of mild to moderate growth faltering in females is 20.3% (in males = 21.7%);
• The rate of severe growth faltering in males and females is 4.1% to 4.2%
• Growth faltering was found across all race/ethnicity and income categories
• A considerable proportion of children meet the criterion of growth faltering up through age 13 years
  
  

Evaluation

Growth faltering can result from increased energy needs, inadequate supply of energy, or a combination of these:

• Any infant with growth faltering should be promptly evaluated.
• A thorough history and physical examination will direct further evaluation. Keep in mind conditions that require increased energy and those that result in a deficient energy supply, see below.

Conditions requiring increased energy utilization:

• Chronic heart disease (congenital or acquired)
•  Chronic lung disease
•  Chronic anemia
•  Chronic infection
• Endocrine abnormalities
• Malignancy
• Chronic renal disease
• Hepatic insufficiency
• Metabolic disease
  • disorders of amino acid or carbohydrate metabolism
  • idiopathic hypercalcemia of infancy
• Hormonal disturbances
• Genetic conditions
  • Down syndrome
  • de Lange syndrome
  • cri du chat syndrome
  • Smith-Lemli-Optiz syndrome
  • familial dysautonomia
• Micronutrient deficiencies
  • Iron
  • Zinc
  • Carnitine

Conditions that result in deficient energy supply:

• Calories withheld
• In utero conditions
• Formula preparation mistakes
• Breastfeeding difficulties
• Parent-child psychosocial dysfunction
• Maternal depression
• Intentional abuse or neglect
• Poverty
• Unsound parental beliefs regarding nutrition
• Feeding difficulties
• Calories not properly ingested or digested
• Oral pain
• Anorexia
  • reflux esophagitis
  •  emotional deprivation
  • chronic infection
  • dysphagia
• Structural abnormalities of the oropharynx or nasopharynx
  • cleft palate
  • choanal atresia
  • Treacher Collins syndrome
  • Pierre Robin syndrome
  • laryngeal web
• Structural abnormalities of the GI tract
  • stenosis or atresia

In addition to a thorough history and physical examination, observing a feeding can be informative.

In the absence of evidence of an organic condition that may lead to growth faltering, the yield of a laboratory investigation is low. If the cause of growth faltering remains uncertain after careful history and physical examination, then a limited number of screening studies might be considered including:

• a complete blood count,
• a blood pH,
• serum electrolytes,
• blood urea nitrogen and creatinine,
• a urinalysis and urine culture, and
• an examination of the stool for reducing substances, pH, occult blood, and ova and parasites.

More extensive testing for malabsorption, endocrine disorders, occult infection, malignancy, and cardiac, pulmonary, or renal abnormalities should be done only in the presence of historical or physical examination evidence of these diagnoses.

Treatment

An algorithm for addressing malnutrition guides its treatment:

Treating Moderate Acute Growth Faltering

• Focus on nutritional rehabilitation, parental education, and behavioral intervention.
• Avoid overfeeding malnourished infants at the outset of therapy because refeeding that is too vigorous may induce malabsorption and diarrhea
• The refeeding regimen should be calculated to provide about 10% to 15% of calories from protein, 50% to 60% from carbohydrate, and 30% to 40% from fat.

Refeeding occurs in phases:

Phase 1 - Provide 100% of daily age-adjusted energy and protein requirements based on the child’s weight on day 1. Equally important is engaging the parents in an educational program that focuses on family interactions, psychological vulnerabilities, and social needs. Emphasis should be on appropriate nutritional information.

Phase 2 - If phase 1 is well tolerated, increase intake to provide adequate nutrition to achieve catch-up growth. Multiplying the age-adjusted energy requirements (kcal/kg/day) by the ratio of the child’s ideal body weight for height divided by the child’s actual body weight at presentation generates a reasonable estimate [create link to box below for example] Usually the energy and protein requirements can be accomplished with the use of a routine infant formula modified to increase its caloric density.

• For example, mix 13 oz of concentrated formula with 10 oz of water rather than 13 oz of water to create a formula that is 24 cal/oz.
• Alternatively, use carbohydrates (glucose polymers) or fat (medium-chain triglycerides) to add calories while avoiding the complications of overhydration.

Phase 3 – offer nutrition ad libitum as the child gradually approaches ideal body weight. Multivitamin and iron supplementation should be part of every refeeding regimen for undernourished children.

Sample Rehabilitation Schedule for growth faltering

Scenario: A 6-month-old boy with poor weight gain is referred for nutritional rehabilitation. He currently weighs 5.5 kg and is 67 cm in length. The 50th percentile weight for this length is 7.7 kg, putting the infant at 71% of the ideal body weight for height.

Normal adjustment catch-up requirements include the following:

Adding a multivitamin with iron to this child's regimen is advisable.