Section 4 - Management of diagnosed conditions

1. What is poor growth in children? ⁴

• An imbalance of nutrients from poor dietary intake, negatively affecting physical growth and developmentover an extended period of time
• The causes of poor growth involves many complex factors. See Table 1.
• Children with poor early nutrition are at increased risk of:
  • stunting and faltering growth (failure to thrive)
  • poor or delayed cognitive, motor and social-emotional development
  • chronic conditions as adults
  • decreased capacity to learn
  • future unemployment
  • intergenerational consequences

2. Diagnosis of poor growth in children ^1,4,5

• Identified during a Child health checks when assessing:
  • a maternal history: pregnancy and birth, maternal health, medical and family history, medicines use
  • underlying causes of poor growth. See Table 1.
  • baseline pathology: faecal OCP, Hb, iron studies, and urine
  • child's physical examination and diet history: gestational age, breastfeeding, formula feeding, solid introduction timing, type, variety and quantity of food, appetite, textures and regularity of food and drinks offered and consumed
  • reviewing plotted growth trends using the:
    • World Health Organisation (WHO) growth charts for children aged < 2 years
    • then continuing with the WHO growth charts for children aged ≥ 2 years or switching to the Centre for Disease Control (CDC) growth charts
• A diagnosis is suspected if:
  • a positive underlying cause or pathology is identified
  • the child's weight-for-age centile tracks in a flat line, crosses ≥ 2 centiles downwards, or is below the 3rd centile at first presentation. See Flowchart 1.
• Managing poor growth is determined by identifying rate of growth by plotting weight-for-length and length-for-age (standard deviation or ‘z’ scores) on the WHO z-score growth charts. See Resource 1.

Flowchart 1. Determining rate of poor growth and care pathway ^1,5,6

3. Management of poor growth in children

• The goal of managing children with poor growth is to establish a foundation for lifelong Diet and nutrition to avoid growth related complications by:
  • building a therapeutic partnership with family
  • collaborating with the multidisciplinary health care team
  • identifying and addressing causes of the child's poor growth. See Table 1.
  • support early breastfeeding in infants
  • use therapeutic supplements until appetite is restored
  • reintroduce nutritious foods once appetite is restored

1. Supporting primary carer and family ^1,5
   • Identify and address factors that impact on the primary caregiver such as:
     • poverty and domestic violence
     • limited household financial (resource) control
     • household workloads competing with child feeding practices
     • mental health e.g. depression
   • Provide the family:
     • information about the child's poor growth, causes and management
     • weekly follow up until target growth is achieved
     • nutrition resources. See Diet and nutrition.
   • Encourage the family to identify barriers to adequate lifestyle modification and
     medical adherence and create goals to overcome those barriers. See Engaging our patients.
   • Engage the school to monitor and support the child's nutritional intake
   • Acknowledge any family concerns and reassure them that provision of adequate nutrition will improve the condition
   • Refer to a social worker who can provide strategies to assist caregiver needs
2. Breastfeeding ^2,5
   • Reassure mums they are not at fault for their baby's faltering growth
   • Encourage mums to breastfeed then express any milk not taken. Offer expressed breast milk as top ups before formula. Refer to child health nurse
   • Supplementary formula feeding may increase weight gain but can result in cessation of breastfeeding
   • Continue to support breastfeeding to > 6 months of age. See Resource 2.
   • Good intake equates to weight and length gains and 5–7 wet nappies per day
   • See Diet and nutrition.
3. Formula feeding²
   • Infant formula should be used < 12 months old if not being breastfed. See Diet and nutrition.
4. Solids introduction ²
   • First foods are introduced around 6 months old, starting with iron fortified infant cereal and/or iron rich foods such as puréed meat or tofu, followed by foods from the five food groups
   • Different tasting and textured foods are introduced as the baby grows
   • Infants should consume a wide variety of nutritious foods enjoyed by the rest of the family by 12 months old
   • See Diet and nutrition.
5. Food ²
   • Small frequent serves of nutrient rich foods and snacks will restore appetite. See Table 2.
   • Continue to provide supplements until target weight and length is achieved
   • Substitute plain cow’s milk for supplements

6. Drinks ²
   • A child with poor growth should drink nutritional supplements before offering milk or water
   • Avoid unmodified cows (or other animal) milk in infants < 12 months old
   • Consider full cream milk, alone or mixed with supplement, for older children
   • Follow on formulas are not recommended
   • Avoid cordial, soft drink, tea, herbal teas, coffee, fruit juice and sports drinks which displace nutritious supplements. See Diet and nutrition.
7. Encouraging eating ¹
   • Children with poor appetites need persistent positive encouragement to eat enough food
   • Strategies for amounts and types of food include:
     • small regular amounts of nutritious food
     • the same foods the family are eating
     • finger foods
     • avoid drinks and snacks immediately before and during meals
   • Mealtime environment:
     • model behaviour by eating together as a family at the table
     • avoid negative comments about food
     • keep calm and relaxed, avoid nagging, punishment or force feeding
     • allow independence
     • avoid distractions e.g. television, electronic devices
   • Mealtime routines:
     • provide consistent time and location for meals
     • allow 20–30 minutes for main meals, 10–20 minutes for snacks
   • Food exploration:
     • make food look appealing e.g. favourite foods in the shape of a face
     • serve foods or drinks in colourful cups, bowls or plates
     • try different foods and often
     • involve children in choosing ingredients
     • encourage children to cook, mix and prepare food
   • Praise good behaviour, ignore poor behaviour:
     • encourage good eating behaviours with cuddles, smiling and voicing how well they are eating. Praise regularly
     • ignore poor eating behaviours e.g. not eating, eating slowly or spitting food out. Avoid nagging or berating
   • Avoid unhealthy food rewards:
     • unhealthy food rewards reinforces these are preferable to healthy foods e.g. ice cream if the child eats their vegetables
     • avoid substituting unhealthy foods (e.g. chips) for uneaten healthy foods because of parental fear a child 'will go hungry'. Children learn they will be rewarded for refusing foods
     • offer non-food rewards for eating well e.g. a game, book, park trip or stickers
   • It takes 1–2 months and a lot of perseverance to restore a child's healthy appetite
   • Encourage parents to keep a food intake diary of food types and amounts, mealtime issues, settings and behaviours
8. Nutritional supplements ¹
   • A high energy oral (or enteral) fluid that helps restore normal appetite and growth by providing micronutrients and energy
   • A dietitian will ensure a supplement is nutritionally complete according to child's age, weight and medical condition for children who are:
     • < 2 years age
     • weigh < 8 kg
     • lactose intolerant
     • allergic to certain foods
     • deficient in particular micronutrients
   • Once appetite is re-established, interest in eating solids increases
   • Family education includes:
     • demonstrating supplement mixing as per product requirements
     • encouraging child to take as much of the recommended supplementary amount
     • demonstrating tube/enteral feeding flow rate, volume, dilution and additional fluid requirements
     • using a food diary to record daily supplement and food intake
     • offer food ideas and preparation. See Table 2.
     • Discuss 3.7 Encouraging eating
   • See local policies and guidelines for eligibility, supply and costing of enteral products. See Resource 3.
9. Growth monitoring ^1,4,5
   • A child with poor growth should have their weight-for-age monitored according to level of concern:
     • weekly if < 1 month old
     • fortnightly between 1–6 months old
     • monthly > 6 months old
   • A child's weight will naturally fluctuate over time. Weighing children too frequently may add to parental anxiety
   • A child's weight and length should trend consistently along their centile
   • Refer a child to the MO/NP/child health nurse if weight-for-age:
     • centile continues in a flat line
     • crosses 2 centiles downwards or
     • remains below the 10th centile
     • > 15% weight loss in last 3 months
     • dehydrated or minimal oral intake > 14 days
     • diarrhoea and/or vomiting for 5 days

4. Medicines for poor growth in children
   • Medicine use in a child with poor growth primarily targets underlying medical presentations such as:
     • giardia
     • intestinal parasites (hookworm, roundworm, threadworm, whipworm and strongyloidiasis)
     • anaemia
   • See the Primary Clinical Care Manual for further details

5. Cycle of care

6. References

• All Chronic Conditions Manual references are available via the downloadable References PDF

7. Resources

1. The World Health Organization (WHO) Child Growth Standards charts
2. The Infant Feeding Guidelines
3. Guideline for home enteral nutrition service (HENS) for outpatients: eligibility, supply and costing