Childhood is a time of rapid growth and advances in development, with infancy (birth to 2 years) and puberty providing more velocity of growth than in any other stage of child or adult life.
Growth in children is one of the most important characteristics of wellbeing. Optimal growth signifies adequate nutrition, health and development (Secker and Jeejeebhoy, 2007; Goulet, 2010; National Institute for Health and Care Excellence (NICE), 2017). Growth refers to the height and weight of a child in relation to their chronological age.
When children fail to grow within expected ranges for their age over a period of time this is referred to as faltering growth (Ryan, 2013; NICE, 2017). NICE (2017) stated that for growth to be recognised as faltering from the normal ranges for a child, there needs to have been a failure in growth rate over a period of time that has resulted in a fall of at least two centiles on the World Health Organization (WHO) (2006) growth charts. The only exception is for children above the 90th centile where a fall of three centiles is required before faltering growth is suspected.
Faltering growth is a direct result of lower calorie intake/absorption than calorie expenditure (Great Ormond Street Hospital for Children (GOSH), 2018). Faltering growth in indicated through weight and height deficits over a period of time, usually months, or possibly weeks in infancy.
Any nurse who is presented with a child with growth concerns needs to feel confident in performing detailed assessments and recognising when referral and nutritional support are essential in minimising the risk and progression of faltering growth.
The nurse's role
Suboptimal growth is multifaceted; it may be the only indicator of a pathological disorder (Lee et al, 2018). However, studies across Europe (Joosten and Meyer, 2010; Romano et al, 2015), report that only around 6% of children affected by faltering growth are diagnosed with physiological illness or disease, with the vast majority of cases being non-organic in origin. Regardless of the mechanisms involved, faltering growth is known to induce inadequate nutritional status with a high risk of leading to impairment in brain and motor development, stunted growth, and with an impact on social and emotional stability, as well as increasing parental and child anxiety around feeding (Marino et al, 2001).
Nurses who have contact with children in communities and hospitals are in a prime position to recognise where growth may be deviating from normal ranges, to assess the child and implement strategies to support optimal feeding and nutrition in an attempt to reduce or halt faltering growth (Singer et al, 1990; Lee et al, 2018).
Assessment will include growth measurement, history-taking and an examination of physical and social determinants, alongside feeding diaries in order to ensure a comprehensive approach is performed. Red flags that could indicate organic pathogens need to be eliminated before management and preventive plans can be initiated.
Faltering growth can be a direct result of physiological conditions where a child is unable to feed or obtain full nutrition from their feeds. Diseases and conditions such as dysphagia, odynophagia, choking, recurrent pneumonia, pyloric stenosis, severe gastro-oesophageal reflux, heart and lung abnormalities, cleft palate and neurological conditions can all contribute to a child being unable to feed with efficacy or maintain nutritional components of the feed (Lundeen et al, 2014). Children with such a condition may first present with slow or faltering growth as their primary symptom.
Thorough medical and social history-taking can help establish organic pathologies and ensure that the child is referred to specialist services to support their individual needs.
Non-organic causes of faltering growth are often more difficult to identify. A comprehensive assessment of feeding behaviours, patterns, and family and social environmental factors is essential when striving towards successful management of a child's nutrition (McCann et al, 1994; Lee et al, 2018). Unsuitable feeding behaviour is identified as the cause of faltering growth in 40-50% of non-organic cases (Marino et al, 2001; Joosten and Meyer, 2010; Romano et al, 2015).
Patterns of feeding where a child has not received optimal reciprocity of feeding cues, intrusive feeding due to parental anxiety over feeds, failure to progress feeding at the required times, such as on to solid foods, prolonged or shortened meal times, and abnormal feed patterns, often begin in early infancy and develop into food refusal or aversion. This will cause insufficient calorie intake, therefore restricting growth (McDonald et al, 2008) (Table 1).
| Organic feeding behaviours | Non-organic feeding behaviours |
|---|---|
| Vomiting | Food refusal |
| Choking | Anticipatory gagging |
| Breathlessness, sweating | Food aversion |
| Diarrhoea | Abnormal feed routines |
| Feeding interrupted by crying | Missed feeding cues/responsiveness |
| Skin rashes | Parent/carer initiation of feeds |
Feeding behaviours that result in a child's aversion to certain foods and textures may be representative of autistic spectrum disorders or lack of exposure to certain foods. These behaviours often begin in late toddler stages and early childhood. This may cause alarm to parents as often the behaviours are seen as a regression from normal feeding for the child. Assessments need to identify all areas of the child's development in order to ensure the correct care plan is devised.
Measurement of growth
Poor gain in weight or height is the primary indicator of faltering growth. Measurement of growth in children is a vital skill and must be completed with precision and accuracy in order to ensure efficacy. WHO centile charts are the only approved international tool that accurately records weight, height and head circumference in infants and school-age children. WHO has formulated charts for preterm babies, children under 1 year, children aged 1 to 5 years and those aged 5 to 18 years. The correct centile chart for male or female and age band must be used. WHO established that children from all areas and backgrounds grow at similar rates if they have the same opportunities for nutrition and social environments (Goulet, 2010). Therefore these charts can be used across all cultures and have been commissioned for use in many developed countries.
NICE guidance (2017) advises that babies and infants under 2 years should be weighed naked and their length obtained. Children aged over 2 years should not wear nappies, coats or shoes when having weight and height recorded.
Frequency of weighing should be guided by the clinical concern; however, this should take place no more than weekly (NICE, 2017), with monthly weighings providing the best measure in children more than 1 year old. Length and height measurements are not required more than every 3 months. It is recommended that, in children over 2 years, a calculation of body mass index (BMI) is performed to establish a clear growth pattern. Where children are under the 0.4th centile, nutritional support should be considered at the outset. It can also be beneficial to calculate the mid-parental centile if concerns over short stature are evident. Mid-parental centile calculates the expected height of a child, considering the height of their biological parents.
Assessing feeding
In the assessment process for faltering growth a full detailed feeding history is essential. It is important to establish how the child feeds and what behaviours are present before, during and after each feed/meal (Table 2).
| Child behaviours | Parent/carer behaviours |
|---|---|
| Any crying? When does this happen? | When are feeds offered? |
| Refusing or avoiding foods? Which ones? | Do the family eat together? |
| Does the child self-feed and make a mess? | What are the portion sizes? |
| Is the child fed when hungry? | Who feeds the child? Is the child's behaviour different for different parent/carer? |
| Is the child distracted from the food? | What signs do the parents recognise for their child hunger? |
| Where are they sitting when fed? | Do they encourage eating? Is this more intrusive than normal? |
It is recommended that observation of feeds should be completed alongside comprehensive feeding diaries (Dinsmore et al, 2011; Romano et al, 2015; NICE, 2017; Jarod et al, 2018).
Food diaries allow the professional to establish what is being offered and the sizes of meals offered and consumed. Next, calorie and protein content of the foods consumed can be formulated. This helps in clarifying where any deficits may be present in a child's nutritional status.
Observing feeding behaviours and patterns, preferably in the child's natural environment, can help professionals establish feeding techniques and behaviours that can contribute to the assessment process and guide intervention. It may be advisable to film the child while feeding may be more beneficial in gathering an accurate picture, rather than the child being observed by an unfamiliar professional, which may unsettle the child and enhance any anxiety-provoked behaviours (King and Davis, 2010).
Management
Comprehensive assessments formulate the management strategy that will support the individual child or young person and their family in addressing faltering growth in community settings. In line with NICE (2017) guidance, all cases of non-organic faltering growth should be managed in community settings unless enteral feeding is considered necessary (Table 3).
| Ask parent/carer to keep a food diary for a minimum of 1 week | Educate parents and carers on volume of feeds/portion sizes |
| Calculate actual and ideal protein and calorie intake | Observe feeding |
| Devise food plan to meet calorie/protein requirements for age of child or young person | Ensure non-intrusive feeding through information |
| Stipulate set and consistent feed times | Monitor timings of feeds and meals—not too long or too rushed (20 minutes is a good guide for children over 6 months) |
| Encourage child/young person to self-feed if age appropriate | Measure weight and height |
| Encourage family meal times | Provide behavioural support to family to assist with promotion of positive feeding routines |
| Consider nutritional supplements or fortified formulas for additional requirements | Monitor milk intake. Milk intake may need to be limited to increase the amount of solid food consumed |
Referring on to specialist services
Within community provisions it can sometimes be necessary to consider further assessment and intervention from specialist services such as dietitians for nutritional support, speech and language therapy for any swallowing issues, occupational therapists for mechanical feeding support and paediatricians to ensure there is no delay in treatment of conditions with organic origins. Marino et al (2001) support the role of social workers with cases of non-organic faltering growth, their rationale being that social workers are highly skilled in understanding the social patterns and lifestyle choices that may impact on feeding regimens. Extreme cases may also benefit from intervention from a social worker or paediatric psychologist to address significant feeding behaviours if parenting capacity is questioned (O'Brien, 2004).
NICE (2017) advises that, in all cases, care in the community should be the first-line management. Hospital admission should only be considered when enteral feeding is required, when it is essential to avoid risk of malnutrition or dehydration.
Primary care providers are in a unique position to detect early onset of faltering growth and promote successful feeding behaviours (WHO, 2006), implementing early strategies to minimise malnutrition and its associated mortality.