Failure to thrive: the prevalence and concurrence of anthropometric criteria in a general infant population

Undernutrition and Intestinal Infections in Children: A Narrative Review

Undernutrition affects thousands of children under five years old worldwide, and various factors are related to its onset, among which we highlight enteric infections and gastrointestinal barrier dysfunction. The cycle of intestinal infections and undernutrition has long-term consequences, such as cognitive deficits, poor growth, and metabolic diseases in adulthood. This review explores factors linked to childhood undernutrition, focusing on intestinal infections and markers of intestinal permeability that affect child development. This narrative review was conducted using Medline/PubMed, Web of Science, and Scopus, from July 2024 to March 2025. Studies involving children under five years old and addressing undernutrition, intestinal infections, or intestinal permeability markers were included. Exclusion criteria comprised studies without therapeutic focus, and books, case reports, or academic theses. No language restrictions were applied, and registration on global platforms was not required. Overall, the studies reported a close relationship between enteric pathogens, diarrheal and non-diarrheal stools, and undernutrition. Among the pathogens most frequently found in the feces of malnourished children were Shigella, enterotoxigenic Escherichia coli, enteroaggregative E. coli (EAEC), and Cryptosporidium. The studies also showed the relationship between gastrointestinal barrier function and undernutrition, with the deterioration of nutrient absorption and, consequently, repercussions on development, linear growth, and weight in children. Although the studies analyzed had different designs and heterogeneity in the age range of the studied children, it was possible to observe the relationship between the infection/undernutrition cycle. Future studies should optimize personalized nutrient-based therapies, assess long-term effects on gut health and growth, and explore the gut microbiome's role in enteric infection susceptibility and undernutrition.

Risk factors for failure to thrive among infants at a hospital in North India: a case-control study

Failure to thrive (FTT) is a commonly used term in pediatric clinical practice, referring to a significant deviation from normal growth patterns. It can have multiple adverse effects on a child, including developmental delays, intellectual deficits, and insecure attachment. Inadequate nutritional intake is the most frequent underlying cause. This study aims to identify the risk factors contributing to FTT in infants in a rural North Indian setting. A case-control study was conducted on infants aged 2-12 months admitted to the pediatric ward of Uttar Pradesh University of Medical Sciences, Saifai, Etawah, India. Detailed histories, clinical examinations, and relevant laboratory investigations were performed for all enrolled patients. Among the 456 study participants, 152 infants (33.33%) were diagnosed with FTT. The majority of cases (92.1%) were from rural areas. Multivariate regression analysis identified key independent risk factors for FTT, including rural residence, incomplete or lack of immunization, absence of exclusive breastfeeding, and lack of timely complementary feeding. This study underscores the significant role of rural residency, inadequate immunization, absence of exclusive breastfeeding, and delayed complementary feeding in increasing the risk of FTT among infants aged 2-12 months in rural North India. Early identification of these risk factors, timely diagnosis, and appropriate interventions are crucial for improving child health outcomes. It will also help in the efficient allocation of healthcare resources.

An Update on the Diagnosis and Management of Faltering Growth and Catch-Up Growth in Young Children

BACKGROUND

The term "faltering growth" (FG) is widely used to refer to a slower rate of weight gain in childhood than expected for age and gender. The prevalence varies depending on the definition and the studied population. Early recognition is important when considering the short- and long-term consequences, which include reduced cognitive development and increased risk of morbidity and mortality.

SUMMARY

The causes of FG are traditionally classified into being either illness- or non-illness-related. However, such a rigid classification does not acknowledge the fact that poor growth may be multifactorial. While many definitions for FG exist, a recent consensus document suggested that a drop of weight-for-height of 1 z-score warrants the consideration for FG. The nutritional assessment supports the calculation of energy and protein requirements, which should be tailored to the underlying cause.

Nap polysomnography in infants with laryngomalacia as a tool to predict treatment strategy

PURPOSE

This study aimed to investigate the role of nap polysomnography (NPSG) in predicting treatment strategies for infants with moderate to severe laryngomalacia and to explore the association between obstructive sleep apnea (OSA) severity, weight gain, and laryngomalacia severity.

METHODS

A retrospective analysis was conducted on infants diagnosed with moderate to severe laryngomalacia who underwent NPSG between January 2019 and June 2023. Clinical variables, NPSG parameters, and treatment decisions were collected. Weight gain rate and its correlation with NPSG indices were assessed. Logistic regression analyses were performed to predict treatment strategies based on NPSG findings.

RESULTS

Of the 39 infants included (median age: 3.3 months), 77% exhibited OSA, with 69% having moderate to severe OSA [apnea-hypopnea index (AHI) > 5/h]. Weight gain rate correlated negatively with indices of OSA severity, including the hypopnea index (HI) and the AHI. In a multiple logistic regression analysis incorporating the severity of OSA (AHI), weight gain rate, and laryngomalacia severity, only AHI predicted the decision for surgical or non-invasive ventilation treatment (OR = 2.1, CI95 [1.6; 2.8], p ≤ 10-4). The weight gain rate was predicted (r2 = 0.28) by the AHI and the presence of retractions of auxiliary inspiratory muscles.

CONCLUSION

This study underscores the importance of NPSG in assessing infants with moderate to severe laryngomalacia. The AHI from NPSG emerged as a potential predictor for treatment decisions and weight gain rate, emphasizing its clinical relevance. These findings advocate incorporating NPSG into the diagnostic and management process for infants with laryngomalacia.

Study on Nocturnal Infant Crying Evaluation (NICE) and Reflux Disease (RED)

BACKGROUND

Nocturnal infant crying is often empirically treated with acid suppressants. The aim of this study was to evaluate the prevalence and characteristics of gastroesophageal reflux (GER) in infants with unexplained persistent crying.

METHODS

We enrolled all infants (0-12 months) referred for suspected GER disease who underwent esophageal impedance-pH monitoring (MII-pH) for unexplained persistent crying not improved by parental reassurance, dietary modification or alginate. Gastrointestinal malformation/surgery, neurological impairment and infections were exclusion criteria. Demographic and anthropometric parameters, GER symptoms and questionnaires (I-GERQ-R) and MII-pH data were recorded and analyzed. Normal MII-pH was defined when acid exposure was <3%, symptom index was <50% and symptom association probability was <95%. Acid exposure >5% and >10% was also considered. Statistical analysis was performed using Chi-Square and univariate and multivariable regression analysis.

RESULTS

We included 50 infants (median age 3.5 months) who fulfilled the study criteria: 30 (60%) had normal MII-pH. I-GERQ-R score was abnormal in 33 (66%) infants, and 21/33 (64%) had normal MII-pH (p = 0.47). In the 26 (52%) infants with nocturnal crying, MII-pH was normal in 16 (54%) (p = 0.82). Associated regurgitation (>3 or >10 episodes/die) did not predict abnormal MII-pH (p = 0.74, p = 0.82, respectively). Univariate and multivariable regression analysis did not identify any clinical variable significantly associated with abnormal MII-pH.

CONCLUSIONS

Infants with persistent unexplained and nocturnal crying should not be empirically treated with acid inhibitors.

Comparison of Characteristics of Children with Severe Acute and Chronic Malnutrition Hospitalized with Diarrhea

Children with malnutrition present with aberrant laboratory parameters. This study aimed to identify high-risk diarrheal children with varied nutritional status. The data were obtained from the electronic database of Dhaka Hospital, International Centre for Diarrhoeal Disease Research, Bangladesh from 2019 to 2021. Among 1,068 children under 5 years of age with diarrhea, 177 (14%) had severe acute malnutrition (SAM; weight-for-length/height Z score < -3), 239 children (17%) had severe stunting (SS; length/height-for-age Z score < -3), and 652 did not have malnutrition (weight-for-length/height and weight-for-age and length/height-for-age Z score > -2). We independently assessed the relationship of nutritional profiles with each clinical and laboratory parameter. After adjustment for age and sex in the multiple regression model, hyponatremia (adjusted odds ratio [aOR] = 2.37 [95% CI: 1.52-3.68]; P < 0.001) and dehydration (aOR = 2.42 [95% CI: 1.67-3.52]; P < 0.001) were independently associated with SAM compared with children without malnutrition. In comparison to non-malnutrition, SS was less likely to be associated with acute watery diarrhea (aOR = 0.66 [95% CI: 0.47-0.92]; P = 0.014) but was significantly associated with anemia (aOR = 2.18 [95% CI: 1.57-3.02]; P < 0.001) and thrombocytosis (aOR = 2.43 [95% CI: 1.78-3.32]; P < 0.001). The presence of hypernatremia was substantially lower in children with SAM (aOR = 0.38 [95% CI: 0.22-0.65]; P < 0.001) or SS (aOR = 0.56 [95% CI: 0.35-0.88]; P = 0.012) than in children without malnutrition. Severe stunting was less likely to be associated with dehydration (aOR = 0.44 [95% CI: 0.29-0.67]; P < 0.001) in contrast to SAM. Therefore, children hospitalized with diarrhea may have different clinical and laboratory manifestations depending on their nutritional status and may require differential treatment.

The Incidence, Prevalence and Clinical Characteristics of Failure to Thrive in Children at King Abdullah Specialized Children Hospital, Riyadh, Saudi Arabia

Introduction Failure to thrive (FTT) in children involves insufficient weight or height gain, affecting general and hospitalized populations which leads to cognitive and behavioral changes. Causes include inadequate caloric intake and underlying diseases (organic - OFTT) or psychosocial factors (non-organic - NOFTT). Our study in King Abdullah Specialized Children Hospital (KASCH) aims to assess FTT incidence, prevalence, and clinical characteristics, and also, to distinguish between different causes. Methodology It is a retrospective cohort study, conducted at KASCH, Riyadh, Saudi Arabia. This study includes children under three years old with documented FTT from 2017 to 2019. Data was collected from the hospital's electronic system and it was analyzed by the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 29.0, Armonk, NY). Results Our study, including 214 FTT patients, revealed a balanced gender distribution of 109 males (50.9%), and 105 females (49.1%), with a majority of Saudi nationality 208 (97.2%). In most cases, 120 (56.1%) are in the 0-12 months age group. The prevalence of FTT was 26.75% (267 cases per 1000). Antenatal/post-natal features showed diverse delivery modes and NICU admissions. Chronic diseases like gastrointestinal diseases 62 (29.1%), cardiac 50 (23.4%), and pulmonary 50 (23.4%) conditions were prevalent. Associations were found between NICU admission and pre-term births, birth weight status, and congenital anomalies, highlighting significant clinical correlations. Conclusion Our study concluded the significant burden of FTT at KASCH. Chronic diseases were playing a major role as a cause of FTT. Thus, emphasizing the causes and knowing the importance of addressing the prevalence and incidence is effective for appropriate intervention.

Sociodemographic Differences of Hospitalization and Associations of Resource Utilization for Failure to Thrive

OBJECTIVES

This study examines the sociodemographic differences between elective and nonelective admissions for failure to thrive (FTT). We investigate associations between admission type and hospital resource utilization, including length of stay and feeding tube placement.

METHODS

We included children <2 years old with FTT in the nationwide Kids' Inpatient Database. We described differences between elective and nonelective admissions using Fisher exact and t tests. To assess associations of admission type and hospital resource utilization, we used negative binomial and logistic regression for length of stay and feeding tube placement, respectively.

RESULTS

In this study of 45,920 admissions (37,224 nonelective vs 8696 elective), we found differences by race and ethnicity, income, and insurance type, among other factors. Compared to elective admissions, nonelective admissions had higher proportions of infants who were Black, Hispanic, and of lower-income. Nonelective admissions were associated with longer lengths of stay (incidence rate ratio 1.46; 95% CI: 1.37-1.55), independent of child age, sex, neighborhood income, insurance, admission day, chronic conditions, and location. Nonelective admissions were associated with lower odds of feeding tube placement compared to elective admissions (adjusted odds ratio 0.62; 0.56-0.68). In the stratified analyses, children of racial and ethnic minority groups admitted nonelectively versus electively had relatively higher odds of feeding tube placement, while White children had relatively lower odds of feeding tube placement.

CONCLUSION

There are various sociodemographic differences between elective and nonelective FTT admissions. Future research is warranted to elucidate drivers of these differences, particularly those related to racial and ethnic disparities and structural racism.

Infancy weight faltering and childhood neurodevelopmental disorders: a general population birth-cohort study

While it is known that intrauterine growth restriction is associated with later mental disorders, it is still unclear whether similar associations exists for postnatal weight faltering, also known as 'failure to thrive' in infancy. This study examined the potential connection between infancy weight faltering and mental disorders diagnosed in childhood focusing specifically on neurodevelopmental disorders. The Copenhagen Child Cohort (CCC2000) was used to explore weight gain in infancy assessed by community health nurses. Data from the Danish national registries were used to quantify ICD-10 mental disorders diagnosed between birth and 12 years of age, as well as potential child and family confounders. Of 4.476 children with sufficient weight data, 339 (7.3%) children were diagnosed with a mental disorder in childhood. Both any (weight gain < -1SD) and severe infancy weight faltering (weight gain < -2SD) were associated with psychomotor delays, while severe infancy weight faltering was also associated with intellectual impairments. Notably, no significant associations were found between weight faltering and autism spectrum disorders or attention deficit hyperactivity disorders. Weight faltering in infancy may be an early marker of neurodevelopmental delays. This possibility should be considered when assessing infants with slow weight gain, to early identification and treatment of co-occurring neurodevelopmental disorders.

Growth failure of very low birth weight infants during the first 3 years: A Korean neonatal network

We aimed to evaluate risk factors for growth failure in very low birth weight (VLBW) infants at 18-24 months of corrected age (follow-up1, FU1) and at 36 months of age (follow-up2, FU2). In this prospective cohort study, a total of 2,943 VLBW infants from the Korean Neonatal Network between 2013 and 2015 finished follow-up at FU1. Growth failure was defined as a z-score below -1.28. Multiple logistic regression was used to analyze risk factors for growth failure after dividing the infants into small for gestational age (SGA) and appropriate for gestational age (AGA) groups. Overall, 18.7% of infants were SGA at birth. Growth failure was present in 60.0% at discharge, 20.3% at FU1, and 35.2% at FU2. Among AGA infants, male sex, growth failure at discharge, periventricular leukomalacia, treatment of retinopathy of prematurity, ventriculoperitoneal shunt status and treatment of rehabilitation after discharge were independent risk factors for growth failure at FU1. Among SGA infants, lower birth weight, pregnancy-induced hypertension, and treatment of rehabilitation after discharge were independent risk factors for growth failure at FU1. Mean weight z-score graphs from birth to 36 month of age revealed significant differences between SGA and non-SGA and between VLBW infants and extremely low birth weight infants. Growth failure remains an issue, and VLBW infants with risk factors should be closely checked for growth and nutrition.

Canadian Nationwide Survey on Pediatric Malnutrition Management in Tertiary Hospitals

Background: Disease-associated malnutrition (DAM) is common in hospitalized children. This survey aimed to assess current in-hospital practices for clinical care of pediatric DAM in Canada. Methods: An electronic survey was sent to all 15 tertiary pediatric hospitals in Canada and addressed all pillars of malnutrition care: screening, assessment, treatment, monitoring and follow-up. Results: Responses of 120 health care professionals were used from all 15 hospitals; 57.5% were medical doctors (MDs), 26.7% registered dietitians (RDs) and 15.8% nurses (RNs). An overarching protocol for prevention, detection and intervention of pediatric malnutrition was present or “a work in progress”, according to 9.6% of respondents. Routine nutritional screening on admission was sometimes or always performed, according to 58.8%, although the modality differed among hospitals and profession. For children with poor nutritional status, lack of nutritional follow-up after discharge was reported by 48.5%. Conclusions: The presence of a standardized protocol for the clinical assessment and management of DAM is uncommon in pediatric tertiary care hospitals in Canada. Routine nutritional screening upon admission has not been widely adopted. Moreover, ongoing nutritional care of malnourished children after discharge seems cumbersome. These findings call for the adoption and implementation of a uniform clinical care pathway for malnutrition among pediatric hospitals.

Acute Malnutrition in Children: Pathophysiology, Clinical Effects and Treatment

Acute malnutrition is a nutritional deficiency resulting from either inadequate energy or protein intake. Children with primary acute malnutrition are common in developing countries as a result of inadequate food supply caused by social, economic, and environmental factors. Secondary acute malnutrition is usually due to an underlying disease causing abnormal nutrient loss, increased energy expenditure, or decreased food intake. Acute malnutrition leads to biochemical changes based on metabolic, hormonal, and glucoregulatory mechanisms. Most children with primary acute malnutrition can be managed at home with nutrition-specific interventions (i.e., counseling of parents, ensuring household food security, etc.). In case of severe acute malnutrition and complications, inpatient treatment is recommended. Secondary acute malnutrition should be managed by treating the underlying cause.

Failure to Thrive in the Outpatient Clinic: A New Insight

Failure to thrive (FTT) is an abnormal growth pattern determined by inadequate nutrition. It is a common problem in children, representing 5% to 10% of patients seen in an outpatient setting. Many definitions have been proposed based on anthropometric deterioration; however, they show poor concordance. No single definition is sufficiently sensitive in identifying faltering growth whilst a combination of multiple criteria seems more accurate. In light of the recent redefinition of pediatric malnutrition as a disequilibrium between requirements and intakes of energy, and macro- and micronutrients, a wider conception of FTT as an unsatisfactory nutritional status related to poor growth and health is useful. Although the most severe problems of micronutrient malnutrition are found in developing countries, people of all regions of the world can be affected by micronutrient deficiencies (MNDs), a form of undernutrition with relevant effects on growth and health. Changes in diets and lifestyle, elimination diets, food insecurity, and food intake disorders create the conditions at risk of faltering growth and MNDs. This new insight integrates the "classical" anthropometric criteria for definition and treatment, in the aim of warranting both a regular increase in size and an overall adequate development and health status.

Effect of nutritional supplement formula on catch-up growth in young children with nonorganic faltering growth: a prospective multicenter study

BACKGROUND/OBJECTIVES

Inadequate nutrition in infants and young children affects physical growth and neurocognitive development. Therefore, early nutritional intervention is important to promote catch-up growth in young children with faltering growth. The aim of this study was to evaluate the effect of nutritional supplementation with a pediatric concentrated and balanced nutritional supplement formula on promoting growth and improving nutritional status in children with nonorganic faltering growth.

SUBJECTS/METHODS

Children aged 12-36 months whose body weight-for-age was < 5th percentile on the Korean Growth Charts were enrolled. Children born premature or having organic diseases were excluded. Children were instructed to consume 400 mL of formula per day in addition to their regular diet for 6 months. Pediatricians and dietitians educated the parents and examined the subjects every 2 months. Anthropometric parameters were measured at baseline and at 2, 4, and 6 months, and laboratory tests were done at baseline and 6 months. The good consumption group included children who consumed ≥ 60% of the recommended dose of formula.

RESULTS

Total 82 children completed the 6-month intervention. At baseline, there were no significant differences in all variables between the good consumption and poor consumption groups. Weight and weight z-scores were significantly improved in the good consumption group compared to the poor consumption group at the end of the intervention (P = 0.009, respectively). The good consumption group showed a significant trend for gaining weight (P < 0.05) and weight z-score (P < 0.05) compared to the poor consumption group during 6 months of formula intake. The concentration of blood urea nitrogen was significantly increased in the good consumption group (P = 0.001).

CONCLUSIONS

Nutritional supplementation with a concentrated and balanced pediatric nutritional formula along with dietary education might be an effective approach to promote catch-up growth in children with nonorganic faltering growth.

May Failure to Thrive in Infants Be a Clinical Marker for the Early Diagnosis of Cow's Milk Allergy?

Objectives—Failure to thrive (FTT) in infants is characterized by growth failure. Although, cow’s milk allergy (CMA) may have an impact on growth and leads to FTT, data are still limited. We focused on FTT as a possible clinical marker for an early diagnosis of CMA. The aim of the present study was to evaluate the implications of cow’s milk hypersensitivity in infants with FTT and the growth catch-up after a cow’s milk-free diet (CMFD). Methods—A cross-sectional study of all consecutive infants evaluated at the Pediatric Nutrition and Allergy Unit of the University Hospital of Bari (Italy) from January 2016 to April 2018 with a medical-driven diagnosis of FTT. Eligible infants were investigated for possible IgE mediated or non-IgE mediated CMA. Results—43 infants were included, mean age 5.7 months. 33/43 (77%) FTT presented a CMA related disease: 3/43 (7%) were diagnosed as presenting an IgE mediated CMA, 30 (93%) had a non IgE-mediated CMA, confirmed by the elimination diet for diagnostic purposes, that led to a significant improvement of symptoms and recrudescence after milk reintroduction. A total of 29 out of 30 patients (one patient was lost at follow-up) moved up to their original growth percentile after dietary changes. Growth z-scores were computed based on WHO anthropometric data. In 10 out of 43 patients (23%) were diagnosed with gastro-esophageal reflux disease (GERD). Conclusions—when evaluating an infant with FTT, physicians should include in their evaluation an extensive search for IgE mediated and non IgE mediated CMA. When in vivo and in vitro analysis are not conclusive, a 4- to 8-weeks trial of CMFD and a consecutive re-introduction of milk proteins may be helpful in less common diagnoses.

Maternal anemia and offspring failure to thrive - results from a large population-based cohort

Objective: To evaluate whether an association exists between maternal anemia and offspring failure to thrive (FTT) during childhood.Methods: A population-based cohort analysis was performed, comparing the risk for FTT among children (up to 18 years old) based on maternal hemoglobin (Hb) levels, upon postpartum discharge. Maternal Hb levels were categorized into 3 levels: <9.0 (moderate-severe anemia), 9.0-11.0 (mild anemia), and ≥11.0 g/dL (no anemia). FTT diagnosis was based on hospital records. All singletons born between 1991 and 2014 and discharged alive without congenital malformations were included. A survival curve was constructed to compare the cumulative FTT incidence, and a Weibull parametric survival analysis to assess the independent association between maternal anemia and offspring FTT while controlling for confounders.Results: Of the 214,305 included deliveries, 22,071 parturients (10.3%) were discharged with Hb <9.00; 83,932 (39.2%) with Hb between 9.0-11.0; and 108,302 (50.5%) with Hb ≥11.0 g/dL. FTT rates were 1.3% (n = 287), 1.2% (n = 967), and 1.1% (n = 1141) in the same groups, respectively (p = .003). The survival curve demonstrated a significantly higher cumulative incidence of FTT diagnosis in the moderate-severe maternal anemia group (p < .001). In the Weibull analysis, constructed for newborns with appropriate birthweight, both groups of maternal anemia were found to be independently associated with FTT related hospitalizations (mild anemia aHR, 1.1; 95%CI 1.002-1.219; p = .045, moderate-severe anemia aHR, 1.321; 95%CI, 1.141-1.529; p < .001).Conclusion: Maternal anemia is independently associated with long-term FTT in offspring, with increasing FTT rates proportional to anemia severity.

Examining Mid-Upper Arm Circumference Malnutrition z-Score Thresholds

BACKGROUND

Anthropometric z-scores used commonly for diagnosis and determining degree of malnutrition, specifically body mass index (BMIz), weight-for-length (WLz), and mid-upper arm circumference (MUACz), are not wholly concordant, yet the proposed thresholds for classification are identical. This study was designed to critically examine MUACz thresholds and their ability to correctly classify nutrition status.

METHODS

This was a 2-year, prospective single-center study of children ≤18 years seen by registered dietitians within a large pediatric institution. The sensitivity, specificity, and predictive performance of the malnutrition classification thresholds were estimated against clinician-based classification.

RESULTS

Sixty-one dietitians enrolled 10,401 patients with distributions of z-scores for weight (-0.5 ± 1.9), length (-0.8 ± 1.6), BMI or WL (-0.1 ± 1.8), and MUAC (-0.4 ± 1.5), suggesting participants were smaller and shorter than the reference U.S.

POPULATION

Distributions of MUACz were broad and overlapped between nutrition classification groups, an observation that extended to BMIz and WLz as well. Consequently, existing thresholds do not accurately classify 100% of children. Misclassification rates increase, with increasing severity ranging from 8% in children with no malnutrition to 71% in children with severe malnutrition. Algorithm- and manually-based refinement of thresholds result in mixed improvements and can be explored by the reader with the associated supplement.

CONCLUSION

The sensitivity of proposed MUACz thresholds systematically decreases with increasing severity of malnutrition and will require optimization if we aim to limit the number of children at risk of misclassification. Indicators for overnutrition remain to be addressed but are explored herein.

Malnutrition in Children With Chronic Disease

Malnutrition occurs when nutrient intake does not meet the needs for normal body functions and as a consequence leads to alterations of growth and development in children. Chronic illness puts children at risk for developing malnutrition. Because of children's rapid periods of growth and development, early diagnosis, prevention, and management of malnutrition are paramount. The reasons for malnutrition in children with chronic disease are multifactorial and are related to the underlying disease and non-illness-associated factors. This review addresses the causes, evaluation, and management of malnutrition in pediatric congenital heart disease, chronic kidney disease, liver disease, and cystic fibrosis.

Defining Pediatric Failure to Thrive in the Developed World: Validation of a Semi-Objective Diagnosis Tool

There is no concordance between current diagnostic criteria for failure to thrive (FTT). We analyzed validity of the Semi-Objective Failure to Thrive (SOFTT) diagnosis tool, which uses a combination of subjective and objective components to make the diagnosis of FTT. The tool was used to diagnose FTT in 94 patients who met 1 of 7 accepted criteria for FTT. Concurrent and predictive validity were demonstrated using anthropometric z-scores and change in anthropometric z-scores, respectively. SOFTT results correlated with differences in anthropometric z-scores for length ( P = .011), weight, weight-for-length, body mass index, mid-upper arm circumference, and triceps skinfold thickness ( P < .0001) between those diagnosed as normal and those with FTT. At follow-up, children with FTT compared with children rated as normal had significantly higher change in weight ( P ≤ .001) and body mass index ( P = .026) z-scores. The SOFTT tool leads to the accurate diagnosis of FTT demonstrated by concurrent and predictive validity.

Risk of metabolic consequences of rapid weight gain and catch-up growth in the first two years of life: a systematic review protocol

REVIEW QUESTION

The specific review question to be addressed in this review is: what is the risk of metabolic outcomes for individuals who experience rapid weight gain or catch-up growth during the first two years of life?

Nutritional disorders resulting from food allergy in children

The elimination of food allergens that contribute essential nutrients in paediatrics may lead to the development of nutritional disorders. The most common nutritional disorders include poor growth, micronutrient deficiencies and feeding difficulties. Of the aforementioned, growth faltering has been well studied and is seen as a common presenting factor in paediatric food allergy. However, the use of different criteria and cut-off values makes it difficult to establish the overall effect. The impact of number and type of foods eliminated and comorbidities has yielded varying results, although there seems to be a trend towards worsening growth with atopic dermatitis and the avoidance of cow's milk. Low micronutrient intake is common in paediatric food allergy; however, a low intake does not necessarily translate into a deficiency as measured by biomarkers. Vitamin D and calcium have been well studied, and a long-lasting impact on bone mineral density has been found. However, other micronutrient deficiencies have also been found and should also be considered. Feeding difficulties is a common complaint in clinical practice, but limited data have been published in food allergy. Poor growth and reflux/vomiting have been shown to be associated with feeding difficulties, in particular in non-IgE-mediated food allergies. There seems to be a long-lasting effect on feeding, in particular in cow's milk allergy, which needs to be taken into account with dietary input. The interplay between growth, feeding difficulties and micronutrient deficiencies has been implied in some studies, but cause and effect is not well established and requires further research.

Limitations of Weight Velocity Analysis by Commercial Computer Program Growth Analyser Viewer Edition

Commercial software package “Growth Analyser Viewer Edition” (“GAVE”) aims to document, monitor and analyze growth and development in children and adolescents. Although its clinical and scientific use is widespread, there are no published studies that describe the method and its validation. We were informed that GAVE calculates the weight velocity (kg/year) at age t from the weight difference between t and 448 days earlier or at birth, divided by the time difference. We recently discussed a case of false child abuse diagnosis (Pediatric Condition Falsification), resulting in the separation of the child from its parents, in which GAVE played a negative contributing role. To prevent such inappropriate diagnoses, we analyzed GAVE from a schematic representation of the measured clinical weight curve, with precisely defined weight velocities. In conclusion, the 448 days included for weight velocity predictions by GAVE caused the erroneous outcomes. Until the necessary changes to the software are implemented and validated, we advise against the use of GAVE in infants younger than 1.5 years, if multiple weight changes occur within 448 days, and following a long-lasting weight velocity change. Our analysis suggests to discard all medical software packages that lack public description and proof of validation.

Pediatric Condition Falsification Misdiagnosed by Misjudged Weight Growth from the Curve of Measured Weights

Patient: Male, 0–2

Final Diagnosis: Cow milk allergy

Symptoms: Obstipation • airway infections

Medication: —

Clinical Procedure: Elementary feeding

Specialty: Pediatrics

Gastrointestinal symptoms in children: Primary care and specialist interface

AIMS

Gastrointestinal symptoms and diseases represent one of the major reasons for paediatricians' requests for specialist consultations and hospital admissions. One fourth of annual medical consultations for children younger than 6 years can be attributed to gastrointestinal symptoms. High-quality guidelines have been validated worldwide to provide clinical recommendations and support healthcare providers' practice. Nevertheless, overall compliance to standards of care is unsatisfactory, and children with gastrointestinal symptoms frequently undergo expensive, useless specialist consultations and laboratory evaluations. The aim of this study is to review the main epidemiological and clinical aspects, together with management strategies, of the most common gastrointestinal symptoms in children, pointing out pitfalls and practical tips in primary care management, and providing correct indications for specialist consultations.

METHODS

For this review, articles published in English from 2000 to January 2018 were identified from the PubMed/Medline (http://www.ncbi.nlm.nih.gov/pubmed/) database and selected on the basis of quality, relevance to the illness and importance in illustrating current management pathways. The search used the following keywords: gastrointestinal symptoms, functional gastrointestinal symptoms, children, primary care, specialist consultations and management. Particular emphasis was placed on evidence-based guidelines and high-quality studies.

RESULTS

Functional gastrointestinal symptoms have a high impact on the quality of life of children and families and on healthcare costs. A complete medical history and clinical examination are often sufficient to guide the primary care provider in the diagnosis, further workup or referral to a paediatric gastroenterologist.

CONCLUSION

Paediatric gastroenterology outpatients' clinics are among the most crowded specialists, and functional gastrointestinal symptoms and disorders are the most frequent reason for counselling. The number of specialist consultations could be reduced if guidelines were applied in primary care settings.

Targeting of epigenetic regulators in neuroblastoma

Approximately 15,000 new cases of pediatric cancer are diagnosed yearly in Europe, with 8–10% corresponding to neuroblastoma, a rare disease with an incidence of 8–9 cases per million children <15 years of age. Although the survival rate for low-risk and intermediate-risk patients is excellent, half of children with high-risk, refractory, or relapsed tumors will be cured, and two-thirds of the other half will suffer major side effects and life-long disabilities. Epigenetic therapies aimed at reversing the oncogenic alterations in chromatin structure and function are an emerging alternative against aggressive tumors that are or will become resistant to conventional treatments. This approach proposes targeting epigenetic regulators, which are proteins that are involved in the creation, detection, and interpretation of epigenetic signals, such as methylation or histone post-translational modifications. In this review, we focused on the most promising epigenetic regulators for targeting and current drugs that have already reached clinical trials.

Treatments that target chromatin, the combination of DNA and proteins, are emerging as alternative ways to treat aggressive neuroblastomas, cancers of neural tissue. Altering the structure and function of chromatin is a form of “epigenetic therapy”, treatment that affects inheritable molecular signals controlling the activity of genes, rather than targeting the genes directly. Researchers in Spain led by Miguel Segura at the Vall d’Hebron Research Institute in Barcelona review progress in developing epigenetic therapies for neuroblastomas. A growing body of fundamental research and evidence from clinical trials suggest this approach could open promising new avenues to treating aggressive and drug-resistant cancers. The authors recommend an increased effort to identify and explore the activities of small molecules that could form the basis of effective epigenetic therapies for various cancers.

Faltering growth in the critically ill child: prevalence, risk factors, and impaired outcome

Low body mass index (BMI) z score is commonly used to define undernutrition, but faltering growth allows for a complementary dynamic assessment of nutritional status. We studied the prevalence of undernutrition and faltering growth at admission in the pediatric intensive care (PICU) setting and their impacts on outcome. All (685) consecutive children (aged 0 to 18 years old) admitted in a single-center PICU over a 1-year period were prospectively enrolled. Nutritional status assessment was based on anthropometric measurements performed at admission and collected from medical files. Undernutrition was considered when z score BMI for age was < - 2SD. Faltering growth was considered when the weight for age curve presented a deceleration of > - 1 z score in the previous 3 months. Undernutrition was diagnosed in 13% of children enrolled, and faltering growth in 13.7% mostly in children with a normal BMI. Faltering growth was significantly associated with a history of underlying chronic disease, and independently with extended length of PICU stay in a multivariate analysis.

CONCLUSION

Assessment of nutritional status in critically ill children should include both undernutrition and faltering growth. This study highlights that faltering growth is independently associated with suboptimal outcome in PICU. What is Known: • Malnutrition, defined according to BMI-for-age z score, is correlated with poor outcome in the critically ill child. • In this setting, nutritional assessment should consist not only of a static assessment based on BMI-for-age z score but also of a dynamic assessment to identify recent faltering growth. What is New: • Critically ill children frequently present with faltering growth at admission. • Faltering growth is a newly identified independent associated factor of suboptimal outcome in this setting (extended length of stay).

Hospitalization for Failure to Thrive: A Prospective Descriptive Report

Failure to thrive (FTT) is a common symptom leading to hospitalization of children. Most literature describing this population is from 30 years ago. Since that time the hospitalized population has become more medically complex. We aimed to describe children hospitalized for FTT in a tertiary care pediatric hospital. We prospectively collected demographic, anthropometric, evaluation, and outcome data for 92 consecutive children admitted with FTT. The majority of children grew with behavioral interventions alone (primary nonorganic FTT) and had negative evaluation (n = 63). Children with primary organic FTT had longer hospital stays (7 vs 4 days; P < .001) and lower daily weight gain (35 vs 58 g/d; P < .001). Laboratory, radiological, and endoscopic evaluation rarely led to a diagnostic etiology of FTT in hospitalized children. We conclude that children hospitalized with FTT should be observed for weight gain prior to pursuing diagnostic investigation.

Diencephalic Syndrome as Presentation of Giant Childhood Craniopharyngioma: Management Review

Diencephalic syndrome (DES) is an extremely uncommon occurrence, and approximately 100 cases have been reported. It presents as a failure to thrive in infants and children but rarely occurs in adult population. The characteristic clinical features of DES include severely emaciated body, normal linear growth and normal or precocious intellectual development, hyperalertness, hyperkinesis, and euphoria usually associated with intracranial sellar–suprasellar mass lesion, usually optico-chiasmatic glioma or hypothalamic mass. DES as a presentation of craniopharyngioma is extremely uncommon but can also occur with brain stem mass. Detailed PubMed and MEDLINE search for craniopharyngioma associated with DES yielded only six cases in children below 6 years of age. Thus, we reviewed a total of seven cases including previously published six cases and added additional our own case. Overall, the mean age at diagnosis was 4.15 years with male:female ratio of 4:3, the mean time interval between symptom of DES appearance and final diagnosis was 6.6 months. The most commonly observed symptom of DES was weight loss (85%). The clinical feature, imaging, and management of such rare syndrome along with pertinent literature are briefly reviewed.

Weight Gain After Vertical Expandable Prosthetic Titanium Rib Surgery May Be From Nutritional Optimization Rather Than Improvement in Pulmonary Function

STUDY DESIGN

Prospective comparative study.

OBJECTIVE

To evaluate whether weight percentile (WP) increases after vertical expandable prosthetic titanium rib (VEPTR) insertion, and whether WP correlates with nutrition laboratories and pulmonary function.

SUMMARY OF BACKGROUND DATA

Children with thoracic insufficiency syndrome often have "failure to thrive" (WP ≤5). Previous authors have reported an increase in WP after VEPTR surgery. Weight gain was hypothesized to be secondary to improved pulmonary function. The presence of a correlation between WP and nutrition laboratories and pulmonary function tests (PFT) after VEPTR insertion has not been studied.

METHODS

Demographic, nutrition, radiographic, and PFT data were collected on 35 VEPTR patients with a minimum follow-up of 2 years. The relationship between WP and nutrition laboratories and pulmonary function was analyzed.

RESULTS

Preoperative WP was ≤5 (PREOP≤5) in 13 patients (37%) and >5 (PREOP>5) in 22 patients (63%). Although all children gained weight, the PREOP≤5 group was more likely to have an increase in WP (P = 0.014). Sixty-eight percent of the PREOP>5 group had a decrease in WP and 32% of the PREOP>5 patients met the criteria for failure to thrive at final follow-up. Overall, there was no change in the number of children with a WP ≤5 (13 vs. 15). Forty-two percent of the children who maintained or increased their WP had a gastrostomy tube, compared to 19% of those who decreased their WP. Seventy-three percent of the patients with failure to thrive at final follow-up did not have a gastrostomy tube. No significant correlations were found between WP and nutrition laboratories, radiographic measures, or PFTs.

CONCLUSION

We did not find an overall change in WP after VEPTR insertion. We did not find any correlation between WP and nutrition laboratories or pulmonary function. Weight gain after VEPTR surgery may be secondary to nutritional optimization in high-risk patients. Children who do not have failure to thrive at presentation also require attention.

LEVEL OF EVIDENCE

2.

Race and Sex Differences of Long-Term Blood Pressure Profiles From Childhood and Adult Hypertension: The Bogalusa Heart Study

This study aims to characterize longitudinal blood pressure (BP) trajectories from childhood in black-white and sex groups and examine the association between childhood level-independent trajectories of BP and adult hypertension. The longitudinal cohort consisted of 2732 adults who had body mass index and BP measured 4 to 15 times from childhood (4-19 years) to adulthood (20-51 years). Model-estimated levels and linear slopes of BP and body mass index at childhood age points were calculated at 1-year intervals using the growth curve parameters and their first derivatives, respectively. Linear and nonlinear curve parameters differed significantly between race-sex groups; BP levels showed race and sex differences 15 years of age onward. Hypertensives had higher long-term BP levels than normotensives in race-sex groups. Although linear and nonlinear slope parameters of BP were race and sex specific, they differed consistently, significantly between hypertension and normotension groups. BP trajectories during young adulthood (20-35 years) were significantly greater in hypertensives than in normotensives; however, the trajectories during middle-aged adulthood (36-51 years) were significantly smaller in hypertensives than in normotensives. Level-independent linear slopes of systolic BP showed significantly negative associations (odds ratio=0.50≈0.76; P<0.001) during prepuberty period (4-11 years) but significantly positive associations (odd ratio=1.44≈2.80, P<0.001) during the puberty period (13-19 years) with adult hypertension, adjusting for covariates. These associations were consistent across race-sex groups. These observations indicate that adult hypertension originates in childhood, with different longitudinal BP trajectory profiles during young and middle-aged adulthood in black-white and sex groups. Puberty is a crucial period for the development of hypertension in later life.

Failure to thrive in babies and toddlers

Failure to thrive in a child is defined as 'lack of expected normal physical growth' or 'failure to gain weight'. Diagnosis requires repeated growth measurements over time using local, age-appropriate growth centile charts. Premature babies with appropriate growth velocity and children with 'catch-down' growth, constitutional growth delay or familial short stature show normal growth variants, and usually do not require further evaluation. In Singapore, the most common cause of failure to thrive in children is malnutrition secondary to psychosocial and caregiver factors. 'Picky eating' is common in the local setting and best managed with an authoritative feeding style from caregivers. Other causes are malabsorption and existing congenital or chronic medical conditions. Child neglect or abuse should always be ruled out. Iron deficiency is the most common complication. The family doctor plays a pivotal role in early detection, timely treatment, appropriate referrals and close monitoring of 'catch-up' growth in these children.

Outcome of nutritional screening in the acute paediatric setting

INTRODUCTION

Multiple nutritional risk assessment tools are available, but there are limited data on their application in the acute setting. We explored the validity of two tools in a tertiary Children's Hospital's acute unit and the cohort's nutritional status using WHO definitions.

METHODS

Prospective study n=300 (median 38 months; 44.6% female; 25.7% ≤12 months). Participants had standard anthropometry measured, all were screened using the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP), the Paediatric Malnutrition Screening Tool (PMST) (modified STAMP) and 125 were additionally screened using the Paediatric Yorkhill Malnutrition Screening (PYMS) tool.

RESULTS

The percentages with medium/high nutritional risk were as follows: STAMP 73.1%, PMST 79.3% and PYMS 30%. Height/weight were normally distributed with: 3.4% stunted (height-for-age z-score <-2); aged ≤ 5 years, 6.8% wasted (weight-for-height z-score (WHZ) <-2), 17.9% overweight (WHZ 1-2) and 6.2% obese (WHZ >2); aged >5 years, 5.8% thin (body mass index (BMI)-z-score (BAZ) <-2), 17.3% overweight (BAZ 1-2) and 5.8% obese (BAZ >2). The tools showed poor specificity and variable sensitivities when compared with WHO malnutrition criteria, with positive predictive values of <50%. κ-Analysis also showed poor agreement between the tools and the WHO cut-offs.

CONCLUSION

These results suggest that nutritional screening tools have poor sensitivity and are difficult to interpret in the acute setting. It may be more effective to include the assessment of weight and height and nutritional intake in the context of the acute presentation as part of routine clinical assessment rather than relying on screening tools to identify those at risk.

Does Persistent Inflammatory Catabolic Syndrome Exist in Critically Ill Neonates?

BACKGROUND

Persistent inflammatory catabolic syndrome (PICS) has not been described in the infant population. This study proposes a definition of PICS in critically ill infants.

METHODS

A published adult criterion of PICS was modified using anthropometric and biochemical reference ranges for infants. A prospective chart review of admissions to a tertiary surgical neonatal intensive care unit (NICU) was performed over 65 days. Demographic, anthropometric, biochemical, and other clinical variables such as length of stay and medication use were collected daily throughout admission. Infants were categorized as having or not having PICS.

RESULTS

Twenty percent of admitted infants (n = 15) developed PICS using the proposed criteria. Infants with PICS were more likely to be classified as failure to thrive (53%), meeting only 75% of their anticipated weight gain. Significantly more infants with PICS had undergone surgery (100%; P = .01), received inotropic medication (40%; P = .05), and had longer NICU and total hospital length of stay ( P < .001 and P < .001). Infants with PICS had higher peak glucose levels (11.8 ± 7.3 mmol/L) and elevated urea concentrations (7.9 ± 4.6 mmol/L).

CONCLUSIONS

PICS does exist in a critically ill neonatal population and may be identified using the definition proposed in this study. Infants with PICS displayed metabolic dysregulation, impaired expected growth velocity, and longer length of stay despite no differences in severity scores or diagnosis between the groups. Validation of this work is required, and research into timely identification of infants with PICS is needed to inform whether these infants would benefit from earlier and novel nutrition intervention.

Development and Application of the Remote Food Photography Method to Measure Food Intake in Exclusively Milk Fed Infants: A Laboratory-Based Study

Background

Accurate methods of assessing food intake in infants are needed to assess the relationship between infant feeding practices and risk of childhood obesity. Current methods are either subjective or have limited ability for use beyond clinical research settings.

Objective

To assess the accuracy of the RFPM to evaluate simulated milk intake including energy, macronutrient, and micronutrient intake compared to direct weighing within a controlled study.

Methods

Individuals were recruited to prepare three 2 fl oz, 4 fl oz, 6 fl oz, and 8 fl oz servings of infant formula and to capture photographs at different stages of preparation (dry powdered formula, prepared formula, and liquid waste) using the SmartIntake^® application. Gram weights of the bottles were obtained by the RFPM and direct weighing. Using the United States Department of Agriculture National Nutrient Database for Standard Reference, energy, macronutrient, and micronutrient values were generated from gram weights.

Results

Intake of formula prepared from powder measured by the RFPM was equivalent to weighed intake within 7.5% equivalence bounds among all servings and each serving size. The mean difference between methods varied among servings sizes with the RFPM underestimating intake by 1.6 ± 0.4 kcals in 2 fl oz servings, 4.8 ± 0.6 kcals in 4 fl oz servings, and 6.2 ± 1.0 kcals in 6 fl oz servings, and overestimating intake by 0.1 ± 1.2 kcals in 8 fl oz servings. Bland-Altman analysis showed that the RFPM overestimated intake at lower levels food intake and underestimated intake at higher levels. Considering photographs of only the prepared formula bottle and the bottle with formula waste to simulate ready-to-feed formula and human breast milk, intake estimated by the RFPM was equivalent to the directly weighed intake within 7.5% for all servings.

Conclusions

The RFPM has higher accuracy than subjective methods and similar accuracy as compared to the objective methods in estimating simulated intake of milk and formula with lower burden to caregivers. The RFPM is a viable method for measuring intake in exclusively milk fed infants by caregivers in a controlled environment with potential for widespread use in research and clinical practice.

Failure to Thrive Hospitalizations and Risk Factors for Readmission to Children's Hospitals

OBJECTIVES

Risk factors for failure to thrive (FTT) readmissions, including medical complexity, have not been described. We sought to characterize children hospitalized for FTT and identify risk factors associated with FTT-specific readmissions during the current era of increasing medical complexity among hospitalized children.

METHODS

This retrospective cohort study used the Pediatric Health Information System database of 43 freestanding children's hospitals across the United States. The cohort included children <2 years of age with index hospitalizations for FTT between 2006 and 2010. The main outcome was FTT-specific readmission within 3 years. Using Cox proportional hazards models, we assessed the association of demographic, clinical, diagnostic, and treatment characteristics with FTT-specific readmission.

RESULTS

There were 10 499 FTT hospitalizations, with 14.1% being readmitted for FTT within 3 years and 4.8% within 30 days. Median time to readmission was 66 days (interquartile range, 19-194 days). Nearly one-half of children (40.8%) had at least 1 complex chronic condition (CCC), with 16.4% having ≥2 CCCs. After multivariable modeling, increasing age at admission, median household income in the lowest quartile (adjusted hazard ratio, 1.23 [95% confidence interval, 1.05-1.44]), and prematurity-related CCC (adjusted hazard ratio, 1.46 [95% confidence interval, 1.16-1.86]) remained significantly associated with readmission.

CONCLUSIONS

Nearly one-half of children hospitalized for FTT had a CCC, and a majority of FTT-specific readmissions occurred after the traditional 30-day window. Children with prematurity-related conditions and low median household income represent unique populations at risk for FTT readmissions.

Failure to Thrive: A Prospective Study in a Pediatric Gastroenterology Clinic

OBJECTIVES

We aimed to describe the clinical characteristics, diagnostic work-up, interventions, and outcomes of children referred to a pediatric gastroenterology clinic with the diagnosis of failure to thrive (FTT).

METHODS

We prospectively enrolled 110 children seen for the first time in our pediatric gastroenterology clinic for FTT. Standard demographic information, history, and anthropometric data were collected at initial and follow-up visits. We also obtained data about diagnostic workup, therapeutic interventions, and growth outcomes.

RESULTS

Seventy patients (63.6%) were boys with a median age of 0.79 years (interquartile range 0.36-1.98). Of the 91 children with follow-up data, 81 (89%) were found to have nonorganic etiologies of their FTT. The majority of children (56.4%) underwent laboratory evaluation. Imaging and endoscopic evaluations were performed in fewer patients (29.6 and 10.2%, respectively). Endoscopic intervention yielded a diagnosis in 16.7% of patients while the positive result rates for laboratory testing and imaging were 3.2% and 3.1%, respectively. The most common therapeutic interventions included increasing calories (71.8%), avoiding grazing (71.8%), and structuring meals and snacks (67.3%). Compared with nonadherent children, children who were adherent with standard behavioral and nutritional interventions showed a higher positive change in z scores for weight (0.36 vs -0.01, P = 0.001) and body mass index (0.58 vs -0.18, P = 0.031).

CONCLUSIONS

The majority of children in a pediatric gastroenterology clinic with FTT have nonorganic etiologies of their failure to thrive. Laboratory, imaging, and endoscopic evaluation are rarely positive and should be judiciously performed. Adherence to standardized interventions leads to improved growth.

Early Predictors of Childhood Restrictive Eating: A Population-Based Study

OBJECTIVE

Childhood eating problems, in particular restrictive eating, are common. Knowledge and understanding of risk mechanisms is still scarce. We aimed to investigate prospective early risk factors for restrictive eating across child, maternal, obstetric, and sociodemographic domains in a population-based sample of Danish 5 to 7 year olds.

METHOD

Data on restrictive eating patterns (picky eating, slow/poor eating, and emotional undereating) collected on 1327 children from the Copenhagen Child Cohort 2000 were linked with registered and routinely collected health nurse data (during the first year of life). Prospective risk factors were investigated in univariable and multivariable regression models.

RESULTS

Feeding problems in infancy were prospectively associated with childhood picky eating (odds ratio [OR] = 2.02, 95% confidence interval [CI], 1.20-3.40) and emotional undereating (OR = 1.49, 95% CI, 1.05-2.11). A high thriving index in infancy was inversely associated with both picky and slow/poor eating. Having 2 non-Danish-born parents predicted slow/poor eating (OR = 5.29, 95% CI, 1.16-24.09) in multivariable analyses, as did maternal diagnosis of a psychiatric disorder before child age 5 years in univariable analyses (OR = 6.08, 95% CI, 1.70-21.72).

CONCLUSIONS

Feeding problems and poor growth in the first year of life show high continuity into childhood restrictive eating. Maternal psychopathology is an important and modifiable risk factor. These findings confirm that early signs of poor eating and growth are persistent and might be useful in predicting eating problems in mid-childhood.

A cross-sectional audit of the prevalence of stunting in children attending a regional paediatric cardiology service

CHD is associated with poor growth, delayed motor and language skills development, and increased length of hospital stay; 28.2% of infants were stunted, with z-scores<-2. The severity of surgery score was not associated with an increased length of stay, suggesting that a low weight-for-age z-score at the time of surgery may impact on length of stay.

ESPEN-ESPGHAN-ECFS guidelines on nutrition care for infants, children, and adults with cystic fibrosis

BACKGROUND

Malnutrition is both a frequent feature and a comorbidity of cystic fibrosis (CF), with nutritional status strongly associated with pulmonary function and survival. Nutritional management is therefore standard of care in CF patients. ESPEN, ESPGHAN and ECFS recommended guidelines to cover nutritional management of patients with CF.

METHODS

The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for determining grades of evidence and strength of recommendation. Statements were discussed, submitted to Delphi rounds, reviewed by ESPGHAN and ECFS and accepted in an online survey among ESPEN members.

RESULTS

The Working Group recommends that initiation of nutritional management should begin as early as possible after diagnosis, with subsequent regular follow up and patient/family education. Exclusive breast feeding is recommended but if not possible a regular formula is to be used. Energy intake should be adapted to achieve normal weight and height for age. When indicated, pancreatic enzyme and fat soluble vitamin treatment should be introduced early and monitored regularly. Pancreatic sufficient patients should have an annual assessment including fecal pancreatic elastase measurement. Sodium supplementation is recommended and a urinary sodium:creatinine ratio should be measured, corresponding to the fractional excretion of sodium. If iron deficiency is suspected, the underlying inflammation should be addressed. Glucose tolerance testing should be introduced at 10 years of age. Bone mineral density examination should be performed from age 8-10 years. Oral nutritional supplements followed by polymeric enteral tube feeding are recommended when growth or nutritional status is impaired. Zinc supplementation may be considered according to the clinical situation. Further studies are required before essential fatty acids, anti-osteoporotic agents, growth hormone, appetite stimulants and probiotics can be recommended.

CONCLUSION

Nutritional care and support should be an integral part of management of CF. Obtaining a normal growth pattern in children and maintaining an adequate nutritional status in adults are major goals of multidisciplinary cystic fibrosis centers.

Clinical Review of Failure to Thrive in Pediatric Patients

Failure to thrive (FTT) is a common problem that occurs when caloric intake is insufficient to maintain growth. For the majority of children it can be reversed with behavioral modifications and increased caloric provisions. In a minority of cases, FTT is the symptom of underlying organic disease. Routine evaluation with laboratory tests, imagining studies, and endoscopy results in an etiology of FTT in <1.4% of cases, and when investigations are positive the organic etiology is most often suspected based on history and/or physical examination. Therefore, these evaluations should be limited to those children with clear symptoms of organic disease and those who fail to grow with behavioral and nutritional interventions.

Diencephalic syndrome: a frequently neglected cause of failure to thrive in infants

Purpose

Diencephalic syndrome is an uncommon cause of failure to thrive in early childhood that is associated with central nervous system neoplasms in the hypothalamic-optic chiasmatic region. It is characterized by complex signs and symptoms related to hypothalamic dysfunction; such nonspecific clinical features may delay diagnosis of the brain tumor. In this study, we analyzed a series of cases in order to define characteristic features of diencephalic syndrome.

Methods

We performed a retrospective study of 8 patients with diencephalic syndrome (age, 5-38 months). All cases had presented to Seoul National University Children's Hospital between 1995 and 2013, with the chief complaint of poor weight gain.

Results

Diencephalic syndrome with central nervous system (CNS) neoplasm was identified in 8 patients. The mean age at which symptoms were noted was 18±10.5 months, and diagnosis after symptom onset was made at the mean age of 11±9.7 months. The mean z score was -3.15±1.14 for weight, -0.12±1.05 for height, 1.01±1.58 for head circumference, and -1.76±1.97 for weight-for-height. Clinical features included failure to thrive (n=8), hydrocephalus (n=5), recurrent vomiting (n=5), strabismus (n=2), developmental delay (n=2), hyperactivity (n=1), nystagmus (n=1), and diarrhea (n=1). On follow-up evaluation, 3 patients showed improvement and remained in stable remission, 2 patients were still receiving chemotherapy, and 3 patients were discharged for palliative care.

Conclusion

Diencephalic syndrome is a rare cause of failure to thrive, and diagnosis is frequently delayed. Thus, it is important to consider the possibility of a CNS neoplasm as a cause of failure to thrive and to ensure early diagnosis.