Failure to Thrive or Growth Faltering: Medical, Developmental/Behavioral, Nutritional, and Social Dimensions

Head Circumference Versus Length and Weight Deficits up to 2 Years of Age in Bangladesh

Infant undernutrition, defined by length- and weight-based indices, is common in low- and middle-income countries (LMICs), but corresponding deficits in head size have received less attention. In a cohort of term newborns in Dhaka, Bangladesh, we compared the severity of deficits (vs. World Health Organization Growth Standards) in head circumference (HC), length and weight at birth and every 3 months until 2 years of age (n range across timepoints: 843-920). We estimated the mean and 25th, 50th and 75th percentiles of HC-, length- and weight-for-age z-scores (HCZ, LAZ and WAZ, respectively). Differences between HCZ and LAZ (or WAZ) were analyzed using paired t tests and quantile regression. We also derived HCZ using height-age instead of chronological age at 3-24 months. Mean HCZ was significantly higher than mean LAZ and WAZ at birth, but HCZ was significantly lower than LAZ at 6, 9 and 12 months and the HCZ and LAZ deficits were similar from 15 to 24 months. Mean HCZ was lower than WAZ at all ages beyond birth. Patterns were broadly consistent at the 25th, 50th and 75th percentiles. The HCZ deficit remained evident when HC was standardized using height-age at all ages beyond birth, indicating HC was reduced relative to body size. In conclusion, among term-born children in Dhaka, HCs were smaller than international standards at all ages up to 2 years, and there was no evidence of postnatal head sparing. Consideration should be given to routine measurement of HC in population health surveys in LMICs.

Prevalence of Malnutrition and Associated Factors Among the Elderly With Type 2 Diabetes Using MNA Form

Objective: This study has been conducted to identify the frequency of malnutrition and different factors associated with it among elderly people with Type 2 diabetes. Methods: This cross-sectional study was conducted in the National Institute of Diabetes and Endocrinology (NIDE), DUHS, Karachi, between January 2023 and October 2023. A total of 325 elderly participants aged ≥ 60 years with Type 2 diabetes were included. Mini Nutritional Assessment (MNA) was used for data collection. Results: Nutritional assessment of older diabetic patients according to the MNA revealed that 226 (69.5%) patients were at risk of malnutrition whereas 53 (16.3%) were malnourished. A total of 325 Type 2 diabetic patients were included in the study with a mean age of 65.7 ± 5.5 years, where 135 (41.5%) were male and 190 (58.5%) were female. Older patients (mean age: 65 years) were significantly more malnourished compared to those with normal nutrition (mean age: 62 years; p=0.021). Employed patients were less likely to have the risk of malnutrition as compared to housewives (p=0.005). Patients who had low family income were eight times more likely to be malnourished as compared to those who had better family income (p=0.003). It was also found that patients with low BMI and calf circumference will be more prone to be malnourished as compared to those with high levels of BMI (p=0.003) and calf circumference (p=0.013). Conclusion: The majority of study participants were at risk of malnourishment, with associated factors such as rapid weight loss, poor health status, decline in physical activity, and food intake. Therefore, these findings highlight the importance of tailored interventions for at-risk individuals, including regular screening and nutritional support.

Utilize administrative data to assess impact of individual-level and neighborhood-level socioeconomic status on childhood health in a longitudinal study

OBJECTIVES

Our study aims to 1) propose an approach to standardize individual-level and neighborhood-level socioeconomic status (SES) measures from administrative records across three decades, 2) determine the degree of agreement between individual-level and neighborhood-level SES measures, and 3) compare the associations of individual-level and neighborhood-level SES measures and childhood health.

STUDY DESIGN

Retrospective observational study.

METHODS

Our cohort included children born in Utah during 1978-2008. Parental SES indicators including education, occupation, and area household income corresponding to maternal addresses were collected from birth certificates. Spearman rank correlation tests were used to determine the correlation between SES measures. Cox regression models and causal mediation analyses were used to assess the association between three childhood health outcomes-mortality, failure-to-thrive, and asthma- and three SES measures: highest education level and occupational status score of parent(s) and area household income.

RESULTS

819,108 children were included in the final analysis. We observed moderate agreement (r ranges 0.43-0.49) between individual-level SES measures (education and occupation) and weak agreement (r ranges 0.19-0.25) between these measures and neighborhood-level SES measures. Parental education had the strongest association with childhood health. The associations of parental occupation and area household income with childhood health, and their mediating effects on parental education, varied by the severity of health outcomes.

CONCLUSIONS

We introduced an approach to standardize SES measures from administrative records for longitudinal analyses. We confirmed that individual-level and neighborhood-level SES measures are distinct indicators of social standing and validated the importance of the choice of SES measures when analyzing childhood health.

Food insecurity in a diverse community pediatric gastroenterology clinic: Screening strategies and insights

OBJECTIVES

We aimed to evaluate the prevalence of food insecurity (FI) in the community pediatric gastroenterology (GI) subspecialty clinic at Texas Children's Hospital (TCH) West Campus and to assess the utilization of services through our partnership with a local food bank.

METHODS

From July 1, 2023, to February 29, 2024, all patients seen in the pediatric GI clinic at TCH West Campus were screened for FI using the validated Hunger Vital Sign tool and given the opportunity to consult with a local food bank representative. A retrospective chart review was then performed on patients who completed the implemented FI screening process.

RESULTS

13.4% of the total patients screened positive for FI. Hispanic patients (p < 0.0001), patients with the preferred language of Spanish (p < 0.0001), those enrolled in Medicaid or Children's Health Insurance Program (p < 0.0001), and patients with obesity (body mass index ≥ 30.0, p = 0.0003) were more likely to screen positive for FI. Poor weight gain/failure to thrive and steatotic liver disease were significantly more common in those with FI (p < 0.0001 and p = 0.0003, respectively), while celiac disease, abdominal pain, and blood in stool were more common in those without FI (p = 0.0003, 0.0475, and 0.0404, respectively). As a result of our implemented FI screening process, 68.4% of those screening positive opted for resource referral, with 50.7% successfully receiving assistance in combating FI.

CONCLUSIONS

Identifying the potential impact of FI in common pediatric GI conditions calls for proactive screening and more holistic, patient-centered approaches in clinical practice.

Food Insecurity and Weight Faltering: US Multisite Analysis of Young Children's Weight Trajectory

BACKGROUND

Food insecurity is associated with poor health and development among young children, with inconsistent findings related to longitudinal growth.

OBJECTIVE

The aim of this study was to investigate associations between household and child food insecurity and young children's weight trajectory during ages 0 to 2 years.

DESIGN

Longitudinal survey data were analyzed for years 2009 to 2018.

PARTICIPANTS/SETTING

Racially diverse mothers of 814 children ≤24 months interviewed twice (interval >6 months, mean 11 months) in emergency departments of 4 US cities. Children were included if born at term, with birth weight within 2500 to 4500 g, and weight-for-age z score within ±2 SD at first interview.

MAIN OUTCOME MEASURES

Weight-for-age z score difference between 2 visits was defined as "expected weight gain" (within ±1.34 SD), "slow weight gain" (< -1.34 SD), or "rapid weight gain" (> +1.34 SD).

STATISTICAL ANALYSES PERFORMED

Multinomial logistic regression was conducted to examine adjusted associations between household or child food insecurity and weight-for-age z score differences.

RESULTS

Of 814 children, 83.5% had expected weight gain, 7% had slow weight gain, and 9.5% had rapid weight gain, with mean ± SD of 11 ± 4 months between visits. Child food insecurity, but not household food insecurity, was associated with slow weight gain (adjusted relative risk ratio 2.44; 95% CI 1.16 to 5.13 and adjusted relative risk ratio 1.30; 95% CI 0.69 to 2.51, respectively). Neither exposure was associated with rapid weight gain.

CONCLUSIONS

The association between child food insecurity and slow weight gain during the first 2 years of life raises clinical concern. Tracking child food insecurity in addition to household food insecurity can be an effective strategy to prevent weight faltering and to support optimal child growth.

Prevalence and determinants of failure to thrive in children with vesico-ureteral reflux

AIM

To assess the prevalence and determinants of failure to thrive (FTT) among patients with vesico-ureteral reflux (VUR) and evaluating the effects of supplementation on growth in patients with urinary solute losses.

METHODS

We retrospectively enrolled 1277 patients with VUR (mean age at diagnosis = 6.5 months). Patients with FTT were screened for renal tubular function impairment (TFI). If fractional excretion of sodium (FENa) >2% or blood bicarbonate <20 mmol/L, supplementation was provided.

RESULTS

Among 1277 patients, 56 (4.4%) had FTT. Of these, 42 (75%) presented extrarenal causes of FTT, 3 (5.4%) had chronic kidney disease (CKD), 9 (16.1%) had TFI, and 2 (3.5%) had CKD and TFI. FTT occurred in 8/208 patients (3.8%) with and in 48/1069 patients (4.5%) without (p = 0.68) recurrent urinary tract infections (UTIs). At multiple logistic regression, birthweight <10th percentile, preterm birth, TFI, identified or suspected syndromes and other diseases were predictors of FTT. Eleven (19.6%) patients with FTT had TFI; five with increased FENa and/or acidosis received supplementation and showed catch-up growth. The remaining six patients exhibited spontaneous catch-up growth.

CONCLUSION

FTT was found in <5% of children with VUR. It was not determined by recurrent UTIs and was mainly associated with extrarenal causes. Supplementation with sodium and bicarbonates could be useful in selected cases.

Pediatric Crohn's Disease With Avoidant and Restrictive Food Intake Disorder (ARFID) Resulting in Failure to Thrive: A Case Report

Failure to thrive (FTT) refers to a condition where a child does not gain weight or grow at the expected rate for their age and gender. An accepted definition includes a weight less than the lowest acceptable range on standardized growth charts. FTT is often a diagnostic challenge for providers treating children with mixed etiologies. This report discusses the case of an 11-year-old female with a diagnosis of Crohn's disease and avoidant and restrictive food intake disorder (ARFID). Management by an interprofessional healthcare team has been difficult, given the multifactorial nature of the patient's weight loss. This report suggests that behavioral and psychological aspects, such as aversion to eating and reluctance to experiment with different foods, may align with symptoms of Crohn's disease in children. It also emphasizes the importance of timely diagnosis and appropriate interventions, as they can mitigate psychological and developmental setbacks.

Comparative Analysis of Nutritional Advice and a Combined Approach for Addressing Impending Stunting in Infants: A Clinical Trial

Weight faltering (WF) has been associated with stunting and with long-term adverse consequences for health and development. Nutritional care for managing WF may consist of giving nutritional advice (NA) and/or provision of oral nutrition supplements (ONSs). In this study, we aimed to evaluate practical management options in the community for infants with WF aged 6-12 months. This nonrandomized clinical trial was conducted in the community of Makassar, South Sulawesi, from March 2022 to March 2023. A total of 1013 infants were enrolled for screening. Anthropometric measures were performed in 913 infants, of which 170 showed WF below the 15th percentile of the WHO weight increment table without stunting. Infants with a weight increment below P5th were assigned to receive NA plus ONS, while infants between P5th and below P15th were assigned to receive only NA. At the second and third months, ONSs were administered to WF infants who were below P15th. One month after the intervention, 87/105 infants in the NA-plus-ONS group (82.8%) and 52/65 infants in the NA-only group (80%) were no longer WF. After 3 months, infants in the NA-plus-ONS group achieved greater weight gain than infants in the NA group (264.1 g vs. 137.4 g, p < 0.001) as well as greater length gain (2.35 cm vs. 2.14 cm, p < 0.001). WF management should be started at below P15th to achieve a better result. Infants with greater nutritional deficits should be assigned to receive the combination of NA plus ONSs to achieve a higher rate of resolution of growth.

Progressive Thrombocytopenia, Splenomegaly, and Abnormal Tone in an Infant With Growth Faltering

A 4-month-old full-term female presented with growth faltering associated with progressive feeding difficulty, rash, abdominal distension, and developmental delays. She was found to have disconjugate gaze, abnormal visual tracking, mixed tone, bruising, and splenomegaly on examination. Initial workup was notable for thrombocytopenia and positive cytomegalovirus (CMV) immunoglobulin G and immunoglobulin M antibodies. She initially presented to the infectious diseases CMV clinic, where she was noted to have severe malnutrition, prompting referral to the emergency department for hospital admission to optimize nutrition with nasogastric tube feeding and facilitate additional evaluation. An active CMV infection with viruria and viremia was confirmed, but elements of her presentation and workup including brain magnetic resonance imaging were not consistent with isolated CMV infection. To avoid premature diagnostic closure, a multidisciplinary workup was initiated and ultimately established her diagnosis.

A 15-Month-Old with Faltering Growth

AbstractMorning Report is a time-honored tradition where physicians-in-training present cases to their colleagues and clinical experts to collaboratively examine an interesting patient presentation. The Morning Report section seeks to carry on this tradition by presenting a patient's chief concern and story, inviting the reader to develop a differential diagnosis and discover the diagnosis alongside the authors of the case. This report examines the story of a 15-month-old with faltering growth and short stature. Using questions, physical examination, and testing, an illness script for the presentation emerges. As the clinical course progresses, the differential is refined until a diagnosis is made.

Strategies to Promote Success in Oral Feedings in Infants and Children with Intestinal Failure due to Short Bowel Syndrome

Infants and children with intestinal failure are at risk for pediatric feeding disorders, which challenge their oral feeding development. This article explores these challenges and offers several practical strategies that can be used by multidisciplinary care teams and at-home caregivers to help support the development of oral feeding in these children and eventually lead to their attaining enteral autonomy.

Electrical Stimulation of Acupuncture Points Helps Resolve a Child's Failure to Thrive

Background

Failure to thrive (FTT) is a challenging childhood condition that may lead to developmental delays and requires immediate therapeutic strategies. Children are diagnosed with FTT when their weight or rate of weight gain is significantly below that of other children of similar age and sex. A Pub Med literature search revealed no published acupuncture treatments for failure to thrive or faltering growth.

Case

A 2 year, 4 month-old female was presented with FTT and a history of multiple severe congenital medical conditions. Western medical treatment with optimization of tube feeds achieved weight scores in the third-to-fifth percentile range. Acupuncture points were electrically stimulated for the child once monthly for 30 seconds with a Pointer Plus™ at each of 12 traditional Chinese/Shu Mu points and at several auricular points: Appetite, Stomach, Small Intestine, and Large Intestine bilateral.

Results

The patient gained weight during the treatment, increasing monthly as shown on fully naked weight measurements to the 25th percentile, 28th percentile, 32nd percentile, 40th percentile, 46th percentile, 61st percentile, and 65th percentile. Her treatment was spaced to every 2.5 months after the 46th percentile measurement, and her weight started to level off when it reached the 61st percentile.

Conclusions

In this particular case, electroacupuncture (EA) stimulation may have facilitated a weight gain in this female child. EA (nonneedle) research should be explored for FTT.

Successful management of pylorospasm with atropine in a failure-to-thrive neonate case report

Pylorospasm is an elusive diagnosis that can mimic the presentation of pyloric stenosis. There is limited discussion regarding its management in neonates with few case reports describing the use of antispasmodic agents. The following case reviews this management in a unique neonate. A 2-month-old female presented with persistent nonbilious, nonbloody emesis and failure-to-thrive. A thorough workup was performed due to its pronounced persistence while inpatient. Pyloric ultrasounds remained negative for pyloric stenosis; however, an upper gastrointestinal (GI) study was significant for pylorospasm. The workup also revealed hypothyroidism. Antispasmodic therapy with atropine was pursued as she was not a surgical candidate. Patient tolerated IV atropine therapy well with quick resolution of emesis and successfully transitioned to oral atropine therapy, displaying continued weight gain with exclusive oral feeds. This case displays a unique presentation of pylorospasm with successful management utilizing IV and oral atropine therapy in a neonate with failure-to-thrive and concomitant hypothyroidism.

Disparities in the Diagnosis and Management of Infants Hospitalized With Inadequate Weight Gain

OBJECTIVES

To evaluate the association between race and the named etiology for inadequate weight gain among hospitalized infants and assess the differences in management.

METHODS

This single-center retrospective cohort study of infants hospitalized for the workup and management of inadequate weight gain used infant race and neighborhood-level socioeconomic deprivation as exposures. The etiology of inadequate weight gain was categorized as nonorganic, subjective organic (ie, gastroesophageal reflux and cow's milk protein intolerance), or objective organic (eg, hypothyroidism). The management of inadequate weight gain was examined in secondary outcomes.

RESULTS

Among 380 infants, most were white and had a nonorganic etiology of inadequate weight gain. Black infants had 2.3 times higher unadjusted odds (95% credible interval [CI] 1.17-4.76) of a nonorganic etiology of inadequate weight gain compared with white infants. After adjustment, there was no association between race and etiology (adjusted odds ratio 0.8, 95% CI [0.44-2.08]); however, each 0.1 increase in neighborhood-level deprivation was associated with 80% increased adjusted odds of a nonorganic etiology of inadequate weight gain (95% CI [1.37-2.4]). Infants with a nonorganic etiology of inadequate weight gain were more likely to have social work and child protective service involvement and less likely to have nasogastric tube placement, gastroenterology consults, and speech therapy consults.

CONCLUSIONS

Infants from neighborhoods with greater socioeconomic deprivation were more likely to have nonorganic causes of inadequate weight gain, disproportionately affecting infants of Black race. A nonorganic etiology was associated with a higher likelihood of social interventions and a lower likelihood of medical interventions.

Prospective Associations between Maternal Depressive Symptoms during Early Infancy and Growth Deficiency from Childhood to Adolescence

Maternal health represents an important predictor of child development; yet it often goes unnoticed during pediatric visits. Previous work suggests that mental state affects parenting. The relationship between infant exposure to maternal depressive symptoms suggests conflicting findings on physical growth. Body mass index (BMI) has not been rigorously examined across development. Using a prospective-longitudinal birth cohort of 2120 infants (50.7% boys), we estimated the prospective relationship between symptoms of maternal depressive symptoms at 5 months postpartum and later BMI in typically developing children. We hypothesized that maternal depressive symptom severity would predict later BMI through to adolescence. Mothers self-reported depressive symptoms at 5 months. Child BMI was measured by a trained research assistant at ages 6, 8, 10, 13, and 15 years. We estimated a series of sex-stratified regressions in which BMI was linearly regressed on maternal symptoms, while controlling for potential pre-existing/concurrent individual and family confounding factors. Boys born to mothers with more severe depressive symptoms at age 5 months had a significantly lower BMI than other boys at subsequent ages. There were no such associations observed for girls. Maternal depressive symptoms were prospectively associated with later BMI for sons and not daughters, predicting risk of faltering in growth through to adolescence. Health practitioners should routinely assess maternal psychological functioning during pediatric visits to optimize parent and child flourishment.

Etiologies of Poor Weight Gain and Ultimate Diagnosis in Children Admitted for Growth Faltering

BACKGROUND AND OBJECTIVES

Growth faltering (GF) (previously failure to thrive) is a common reason for hospital admission, but there is little data on whether diagnoses made during initial admission remain accurate in follow-up. We sought to characterize infants admitted for isolated GF and identify diagnoses at discharge and ultimate diagnoses determined over 2 years of follow-up, to determine how diagnoses changed. We also sought to identify patient factors on admission associated with ultimate diagnosis.

METHODS

We conducted a retrospective study of children aged 2 weeks to 2 years with index admissions for GF from 2013 to 2017. We reviewed clinical data and documentation to determine discharge and ultimate diagnosis, and identify factors associated with ultimate diagnosis.

RESULTS

Of 497 patients, 292 (59%) had insufficient intake, 103 (20%) had organic disease including 36 genetic disorders, 52 (11%) had mechanical feeding difficulties, and 50 (10%) had mixed or unknown diagnoses 2 years after admission. Over 90% of cases of insufficient intake were diagnosed during admission. Sixty-five percent of organic diseases, and only 39% of genetic disorders, were diagnosed during admission. Patient factors associated with genetic disorders included previous NICU stay, low birth weight, dysphagia, hypotonia, and dysmorphisms.

CONCLUSIONS

Insufficient intake remains the most common diagnosis, and this diagnosis was accurately made during admission. Organic disease, especially genetic disease, was often not diagnosed during admission. Better tools are needed to identify patients with organic disease. We identified patient factors on admission associated with ultimate diagnosis, which could be used to prioritize evaluation and expedite follow-up.

New insights in pediatrics in 2021: choices in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, haematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine

In this review, we report the developments across pediatric subspecialties that have been published in the Italian Journal of Pediatrics in 2021. We highlight advances in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, hematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine.