Faltering growth in children

Faltering growth occurs across all socio-economic groups
Faltering growth occurs because children receive insufficient calories
Dividing faltering growth into two categories – non-organic and organic is misleading.
They are not mutually exclusive
Most cases of faltering growth do not have organic causes
Many children have a range of intrusive and inappropriate medical tests to eliminate
organic causes
Only a tiny minority of children fail to grow because of neglect or abuse
Emotional deprivation is not a major reason for faltering growth
Difficulties with feeding is the most commonly cited factor involved in faltering growth

Growth has a long tradition of being used as a measure of young children’s health and well-being. Weighing begins early at the ante-natal clinic with the expectant mother being anxious to put on just the right amount of weight for optimum health for her baby. Scans measure babies’ growth and parents are reassured if the gestational size appears right. Subsequently parents are frequently asked after their baby is born ‘how much does s/he weigh?’ and visits to the clinic can often convey success or failure to parents in relation to whether the baby has gained weight. Stern (1995) has described a strong biological need within most mothers to ensure that their baby survives – if a mother feels unable to feed her infant successfully she may well experience intense anxiety and depression and a feeling of failure.

Faltering growth is a common occurrence and health visitors can play a key role in taking the failure out of faltering growth. Most children with faltering growth will be detected by the primary health care team and supported within the community. Supportive, empowering home visiting not only helps families to overcome this problem, it may well prevent children developing a worrying weight loss in the first place.

Historical context -exploding the myths

At the turn of the century the term ‘failure to thrive’ was commonly used to describe children, often brought up in foundling homes, who were thought to receive adequate food but still grew poorly. Gradually it became assumed that these children failed to grow because they lacked stimulation and love from their carers. Failure to thrive was divided into two separate categories:

an organic cause for the failure to gain weight, such as cystic fibrosis or a heart defect
no organic cause found and therefore the loss was probably due to emotional deprivation, maternal deprivation and/or neglect.

The two types of failure to thrive were thought to be completely separate although later research clearly shows that these sharp divisions are not helpful, as the two categories are not mutually exclusive. Also, they usually have the same cause in that the child is receiving too few calories. In fact evidence suggests that only about 50/o of young children with inexplicable poor growth are found to have a previously undiagnosed illness and only a very small minority have faltering growth because of abuse or neglect (Boddy and Skuse,1 994; Wright and Talbot, 1994).

Faltering growth is present in all socio-economic groups yet research indicates that health visitors showed certain misconceptions. Batchelor and Kerslake’s (1990) study showed that babies who were well cared for and had no signs of physical illness were just considered small and others, who were weighed regularly, passed unrecognised. Yet children from poorer families were often considered to be neglected if their growth was faltering.

In faltering growth most of the research up until the 1980s tended to focus on the distorted mother/child relationship which was thought to lead to mothers offering their child too few calories. Current research (cited Batchelor 1999) has shown that the majority of mother-child relationships in families where a child has faltering growth are no poorer than in the families where children are growing normally. Current research has become more sophisticated and moved away from the simple ’cause and effect’ model. Studies now highlight an interactional perspective in which a multiplicity of factors may result in faltering growth (Batchelor, 1999).

Why is faltering growth important?

Faltering growth is not a ‘syndrome’ or a specific disease, but simply an observation that a child is growing exceptionally slowly. This growth can sometimes reflect serious underlying problems and, if unresolved, may result in stunted growth and delayed development. Thus it is important that all children with slow growth are identified and given support.

Health visitors must recognise that:

most children with faltering growth look well and live in loving families
if poor growth continues it may affect the parent-child relationship and lead on to long-term problems including possible developmental delay.

Prevalence

As many as 50/o of children under 5 years of age will experience an episode of growth faltering at some stage (Batchelor and Kerslake, 1990).

What causes children’s growth to falter?

Growth requires a combination of a child’s genetic potential and the food energy needed to achieve this. Children grow extremely fast in the first two years of life and consequently need large amounts of food to fuel this growth.

Energy needs in the first year

At birth babies need 3-4 times adult requirement per kilogram bodyweight
At one year babies need 2-3 times adult requirement per kilogram bodyweight.
In the first year of life there is:
- 300% increase in weight
- 50% increase in length.
Proportionally speaking, babies increase more in weight than height in the first year so an average-weight one-year-old would look squat and round!

It is hardly surprising that many different sorts of circumstances may interrupt feeding and result in growth faltering.

How do children become undernourished?

This may occur because of decreased appetite due perhaps to illness, feeding difficulties, dietary misconceptions, late weaning or inappropriately restricted diets. There may be associated organic conditions such as asthma, chronic infection, cerebral palsy or congenital heart disease, which may lead to decreased dietary intake or increased calorie needs. In a few cases under-feeding may be a result of major social or emotional problems in the family. Inappropriately applying adults’ ‘healthy eating’ patterns, such as high fibre, low fat diets to children may also cause growth to falter. Children’s energy requirements may also vary greatly as a result of individual metabolic rates or differing levels of activity. Faltering growth only rarely results from an inability to absorb or utilise energy intake as a result of conditions such as coeliac disease, cystic fibrosis, cow’s milk protein intolerance or upper gastro-intestinal obstruction.

The food to growth chain

The following ‘food to growth’ chain is useful in showing the basic necessary steps for nutrition and to help health visitors identify the areas where problems may occur.

Requirements	Influencing factors

Purchase	Budgeting, shopping, storage
Preparation	Cooking facilities and skills
Giving	Meals offered when, where, how
Taking	Eating behaviours and skills
Using	Absorption, metabolism, growth

Effects of faltering growth

The long-term effects of faltering growth are not clear. Some research shows that there may be an effect on cognitive development, while other studies indicate that these effects may not be long lasting.

Research by Skuse et al (1992, p66) suggests that the earlier growth falters, the poorer the outcome. ‘It seems likely that there is a “cumulative deficit” in terms of intellectual skills, with deteriorating performance between infancy and four years of age’.
A study in 1991 by Grantham-McGregor et al found that children with faltering growth who had food supplements grew more and performed better in 10 tests if they also had stimulation from nursery nurses.
Later work by Drewett et al (1999) showed that 10 differences between failure to thrive children and controls were not significant, indicating that the effects of under-nutrition on intellectual development are washed out’ over time.

Clearly there is a need for more rigorous studies to determine any long-term effects of faltering growth.

Are professionals effective at identifying faltering growth?

Batchelor and Kerslake (1990) found a wide disparity in the ability of health professionals to identify faltering growth from the routine measurements.

Batchelor and Kerslake suggested several possible reasons why HVs failed to identify faltering growth:

Health visitors may have incorrectly considered faltering growth to be less likely in areas with families from social class one and two, when a child under the 0.4th centile is likely to be considered ‘small’
Health visitors were less likely to diagnose faltering growth in children who are well cared for and have no obvious signs of physical neglect but with low weight
Faltering growth is less likely to be diagnosed when growth charts are not used regularly or kept up to date
Faltering growth is less likely to be diagnosed when there are few facilities for treatment.

The following guidelines are intended to aid health visitors to detect children at risk of faltering growth.

Diagnosing faltering growth

Protocols for weighing children need to be followed carefully so that measurements are accurate and consistent. The following basic guidelines should be followed at every clinic so that they become routine for parents.

Weighing

Babies should be weighed regularly without clothes so that an accurate growth curve can be plotted. Weighing too frequently may cause anxiety.

Age Range	No more than once every:	No less than once every:
1 -3 months	Fortnight	Month
3-12 months	Month	3 months
1-2 years	3 months	6 months
Over 2 years	6 months	At 2 1/2 years and school entry

Environment and equipment

Babies should always be weighed naked
A warm room with space for parents to undress the baby should be available
Provide a nappy disposal bin and spare disposable nappies in case parents are not equipped
Calibrated metric scales should be available
Ensure use of contemporary centile charts
Ensure accurate recording, adjusting for gestational age, if appropriate, according to guidance on the chart.

Which weight charts?

Contemporary centile chartsare based on the 1994 growth standards and are suitable for all ethnic groups (Wright et al 1998 a).
Weight monitoring chartsfor children with slow growth provide guidance on the lower limits of expected weight gain whatever their initial centile position. Health staff in Newcastle developed these charts after studying the weight gain of 3500 children and applying this to the 1994 UK national standards (Wright et al 1998).

The following sections are intended to help health visitors identify children whose weight is either faltering or at risk of faltering. Patterns of growth vary from one individual child to another and health visitors will benefit from frequent discussions with colleagues about their concerns. It is recommended that staff have time allocated to discuss and share concerns. A home visit arranged to coincide with a mealtime offers invaluable insights into possible areas of difficulty.

Identifying faltering growth -when does slow growth become faltering growth?

Many people in the past have identified children as failing to thrive if their weight falls below the 0.4th centile. This is not a helpful definition as it will include some constitutionally small children and fails to identify naturally large children who have not yet fallen as far as the bottom centile. Good practice suggests using a definition for faltering growth that requires a child’s weight to have shown a downward movement on the centile chart. Using the charts for children with slower growth allows a more precise measure of deterioration or improvement in growth than the simple use of centile charts.

Abdul’s weight crossed completely through two inter centile spaces from a baseline position taken at eight weeks, ie. from the 75th centile at two months, to the 25th centile at five months. This would be described as moderate growth faltering with approximately 5% of children’s weight falling this far.

Naomi’s weight fell rather more and crossed four centile spaces between two months and six months and this weight loss would be considered severe.

Why is it so difficult to offer effective support?

Social assessment findings in Newcastle suggest three key reasons why support to parents with a child with faltering growth was ineffective.

Professional message was not clear
Professionals may not have engaged successfully with parents, due to the difficulty in ‘breaking bad news’, lack of professional understanding of problem or cultural or language difficulties.
Parents unable to receive message
Parents may have difficulty in accepting that the growth is poor or that the diet and care may be causing poor growth.
Parents unable to respond to the message
Parents may be overwhelmed by life stresses, relationship difficulties, financial crises or lack of support. They may have experienced emotional trauma which impairs their coping abilities and parenting relationships.

Faltering growth may show in a variety of patterns on the centile chart

Normal growth is usually defined in relative terms and, in general, growth is a continuous process. Gentile charts allow a child’s growth to be viewed in relation to the normal growth of a population.

Hobbs et al (1993) classified a number of different growth patterns which health visitors may identify. These growth patterns may be less easily identified than those of a child whose weight falls clearly and continuously down across centiles. The centile charts that describe children with slower growth should enable health visitors to detect patterns, such as the following, more easily.

Poor parallel centiles – many children with faltering growth appear to go through a phase during which their centile position falls but they continue to grow parallel to the 0.4 centile for weight and height. This occurs when children adapt to the abnormal situation of poor nutrition and the situation becomes chronic.
Height and weight centiles markedly discrepant -faltering growth should be suspected where discrepancies in the centile ranking occur between height and weight. Most children will have weight centile no more than 1 -2 centile spaces below their height.
Family pattern discrepant – children whose growth falters frequently show marked discrepancies from the parents and other family members attained height centiles.
Retrospective rise – improvement in the child’s centile position may occur if nutrition is improved. This often occurs following recovery from severe illness or malnutrition.
Saw tooth – this is also referred to as dipping. Weight goes up and down, crossing and recrossing centile positions. Hobbs et al (1993) state that this may be caused by undercurrent illness, but commonly reflects family stress around life events. This can also be seen if children are weighed too frequently (see guidelines for weighing).

These patterns are not always obvious, so it is good practice to discuss children’s growth patterns with colleagues and time needs to be allocated for this.

Interventions for children with faltering growth

Interventions must be supportive and provided in a non-stigmatising mariner that is acceptable to the cultural norms of the family.

Parents often feel an acute sense of failure if they are not able to ensure adequate nutrition for their child. Those who have been told by medical staff that there is nothing wrong and to get calories into their child often report ‘trying everything’ including, games, feeding on the move, giving constant sweet snacks and force feeding. Support must reflect the family’s lifestyle and must aim to raise parents’ confidence.

Faltering growth should be identified early and interventions provided speedily to avoid adverse effects such as cognitive delay, feeding and behaviour problems and low maternal self-esteem.

Research suggests that the earlier malnutrition begins and the more severe it is the greater the effect on growth and development. Many families who have fraught mealtimes would benefit from supportive advice as a preventative measure even when children’s growth is not faltering.

An inter-disciplinary approach is most effective
Often health visitors have been the only family supporters if there is no apparent organic cause found for growth faltering. Health visitors have been shown to offer positive advice about mealtimes but this has frequently been difficult for parents to follow through in the home. For many families more intensive home visiting with an individual structured approach is needed and a few families may also require therapeutic interventions.
Parents and carers need support to resolve the feeding difficulties and maintain the changes
Changing patterns of feeding behaviour takes time and commitment from both parents and staff. There are no ‘quick fixes’. Parents need to be supported to gain insights into what is causing the feeding difficulties and then helped to change and maintain behaviours by facilitative, non~ judgmental workers who can promote parents’ confidence. The process of family interactions which may perpetuate the feeding problems can be seen below.

Cycle of interactions compounding feeding difficulties

Case Study

Nasrat, the third child of Sikh parents, was born at 35 weeks gestation weighing 830 grams, indicating a degree of intra-uterine growth retardation. Following discharge from hospital Nasrat was monitored for a short time by the neo-natal service. At ten months Nasrat was admitted as an emergency to hospital with uncontrolled eczema and poor weight gain. She had extensive investigations for failure to thrive – all results were normal. Nasrat was put on a milk-free diet because of the eczema and was then monitored as an outpatient. The eczema was well controlled, but Nasrat was referred to the hospital dietician as she was taking only Wysoy and very little solid food. Liquid food supplements were prescribed, and she was then lost to the hospital follow-up service.

At two years Nasrat was weighed at the clinic and found to be well below the 0.4th centile. The health visitor did a home visit and discovered that Nasrat was very well cared for, although mealtimes were chaotic with Nasrat relying mainly on bottled Wysoy for nutrients. The parents felt that the hospital had not given sufficient feeding information. They had specific cultural beliefs about illness, such as the single hospitalisation would cure their child. This failure discouraged the parents from seeking further advice.

In desperation, the parents had been attempting to force-feed Nasrat, creating a good deal of tension in the family. Both parents were working long hours which made it difficult for them to institute appropriate routines. The health visitor found difficulties at every level of the ‘food to growth’ chain and felt that it was vital that she was present at mealtimes. The parents had been considered to have adequate English, yet it was only when a Punjabi support worker was involved that progress was made.

A whole range of factors contributed to Nasrat’s faltering growth and, importantly, the parents were feeling under-confident in their role. An individual, structured, home-based support programme with the health visitor as key worker, and a Punjabi interpreter, worked with the family over a period of six months. During this time the difficulties with feeding decreased, Nasrat’s weight increased and the parents began to feel much more confident.

Intervention Models

The Children’s Society has developed a programme called Feeding Matters which has proved effective in helping families to resolve the factors which are perpetuating their child’s feeding difficulties and contributing to their faltering growth and development (Hampton, 1996). The programme is based on social learning theory and the belief that every child has the right to a ‘good start’ in life. There is recognition that there are no easy answers to faltering growth or the parents would have already discovered solutions.

The following points are key:

The parents are the experts in relation to their child so their concerns need to be listened to carefully and their views and wishes must be followed about how they would like mealtimes to be different
A detailed observation and assessment process is undertaken to establish a base line – prior to offering any advice or suggestions
A video camera is used to film mealtimes and use of a behavioural framework is used to analyse parent/child interactions and change unhelpful patterns of feeding and mealtime behaviour
The programme of work is negotiated to take account of each child and family’s unique characteristics and culture
Clear aims and targets are identified with the family and recorded
The family is supported to make the changes that they have identified
Regular review of agreed targets and original base lines indicating what has changed and what still needs to take place
The parents are asked to evaluate the work.

The Newcastle Growth and Nutrition Team have developed a community-based service for management of children with failure to thrive which has evolved from evidence-based research of the Parkin Project. This service supports health visitors, acting as key workers, following identification of faltering growth of children in their own caseloads. The health visitors diagnose faltering growth and provide the intervention. This is carried out through an enhanced home visiting programme.

The aim of this service is to:

provide an easily accessed supportive package in working with growth faltering children
limit investigation to those children who fail to respond to social and nutritional approaches
obviate the need for hospitalisation.

The family health visitor acts as the primary worker and is supported by the multi-disciplinary team comprising:

a specialist health visitor
a community paediatric dietician
a community paediatrician.

This intervention has been evaluated by a randomised controlled trial and has shown that health visitor intervention with limited specialist support can significantly improve growth compared to conventional management (Wright et al 1998 b).

Child growth
Interpreting child growth centiles

References

Batchelor, J. (1 999) Failure to Thrive in Young Children. Research and Practice Evaluated. The Children’s Society London.
Batchelor, J. and Kerslake, A. (1990) Failure to Find Failure to Thrive: The Case for Improved Screening, Prevention and Treatment in Primary Care. London: Whiting and Birch.
Boddy, J. and Skuse, 0. (1 994) Annotation: the process of parenting in failure to thrive. Journal of Child Psychology and Psychiatry, 35 131, p401 -24.
Drewett, R. Corbett, S. and Wright, C. (1999) Cognitive and Educational Attainments at School Age of Children Who Failed to Thrive in Infancy: A Population Based Study. Journal of Child Psychology and Psychiatry. Vol. 40 No 4 p 551-561.
Grantham-McGregor, S. Powell, C. Walker, S. and Haines, J. (1991) Nutritional Supplementation, Psychosocial Stimulation and Mental Development of Stunted Children: The Jamaican Study, Lancet, 338, 1-5.
Hampton, 0. (1996) Resolving the feeding difficulties associated with non-organic failure to thrive’ Child Care, Health and Development, 22 (4), p 261 -71.
Hobbs, C. Hanks, H. and Wynne, J, (1 993) Child Abuse and Neglect: A Cliniician’s Handbook. Edinburgh: Livingstone.
Stern, D. (1995) The Motherhood Constellation. Basic Books Incorporated. New York.
Wright, C. and Talbot, 6. (1996) ‘Screening for Failure to Thrive-what are we looking for?’ Child Care Health and Development, 22 (4) p223-34.
Wright, C. Avery, A. Epstein, M. Birks and Croft. (1996 a) A new chart to evaluate weight faltering. Archives of Disease in Childhood 76. 40-43.
Wright, C. Callum, J. Birks, E and Jarnis, S. (1998) Effects of community based management in failure to thrive: randomised control trial. British Medical Journal Vol. 31 7. p 571 -574.
Skuse D. Reilly, S. and Wolke. (1992) ‘Failure to Thrive: Clinical and developmental aspects.’ In H. Remschmidt and M. Schmidt (eds) Child and Youth Psychiatry: European Perspectives, pp. 46~71. Gostinger: Hogrefe and Huber.

Source: The Children’s Society and the Community Practitioners and Health Visitors Association