Faltering growth

Faltering growth is caused by:[8][9]

Inadequate caloric intake: this is the most common cause of faltering growth. The child does not consume enough calories and other nutrients to support adequate growth. Contributors include:

Environmental factors: poor access to healthy food; environmental distractions that disrupt focus on meals and eating
Social/family factors: lack of knowledge regarding appropriate food; household chaos that interferes with regular mealtime routines; poor carer feeding skills that may be associated with depression or anxiety, or child neglect; lack of responsivity between carer and child in recognising and responding to signals about hunger and satiety.[20]
Poor appetite: chronic fever, chronic infections, anaemia, neurological tumours
Feeding problems: poor oral motor skills after prolonged nasogastric tube feeding, cerebral palsy, neuromuscular disorders, cleft lip and/or palate, gastro-oesophageal reflux
Avoidant restrictive food intake disorder (ARFID): lack of interest in eating or food; avoidance based on the sensory characteristics of food; oral aversion and sensory feeding disorders (e.g., with autism spectrum disorder)
Swallowing problems: eosinophilic oesophagitis or other anatomic causes of swallowing dysfunction e.g., oesophageal webs, vascular rings
Catch-up growth: prematurity and its potential complications might be associated with poor feeding and increased caloric demands
Some conditions have been ruled out as a cause of growth faltering, such as vitamin D deficiency[21]

Increased caloric demand or expenditure:

Chronic infections with persistent fever increase caloric requirement
Surgery
Chronic illnesses such as gastrointestinal (GI) disorders (coeliac disease, inflammatory bowel disease), cardiorespiratory disorders (cystic fibrosis, severe asthma, congenital heart disease, obstructive sleep apnoea), malignancies, endocrine disorders (diabetes mellitus, hyperthyroidism), renal failure, and systemic inflammatory disorders such as lupus erythematosus

Excess caloric loss:

Persistent vomiting
Pyloric stenosis

Inefficient utilisation of calories or loss of calories:

GI disorders: coeliac disease, chronic diarrhoea, chronic vomiting
Endocrine/metabolic disorders: diabetes mellitus, hyperthyroidism, uraemia, and inborn errors of metabolism decrease efficient utilisation of calories
Burns, GI problems, or other chronic illnesses

Several other medical and behavioural conditions can impede growth. Children with neurological problems such as spastic cerebral palsy or genetic disorders (such as Silver-Russel syndrome) may also have limited growth, although the precise mechanism may not be clear. Toxins such as lead may also impair growth. Some children may under-eat for no specific reason.[22]

Faltering growth is often the result of interacting medical, behavioural, developmental, and psychosocial factors. Healthcare professionals need to be guided by the history and examination.[8][9] A difficult parent-child relationship may involve coercive feeding, with the parents feeling pressure from their healthcare professional to do everything they can to ensure their child eats enough. Children of parents who use forceful feeding strategies often find mealtimes aversive and may react by food refusal and have poor weight gain.

The Academy of Nutrition and Dietetics (the Academy) and the American Society for Parenteral and Enteral Nutrition (ASPEN) recommend using a standardised set of diagnostic indicators to identify and classify paediatric malnutrition. Previously, definitions of malnutrition included a decrease in 2 centile channels or a deceleration of weight over time. Faltering growth was defined as weight below the fifth percentile.[5]

The Academy and ASPEN now recommend the use of z-score, decline in z-score, and negative z-score to identify paediatric malnutrition/undernutrition. Primary indicators can be found in the Academy and ASPEN consensus statement.[5] The CDC also recommends the use of z-scores (where a z-score of 1 represents 1 standard deviation from the reference median).[6]

Pathophysiology

Classification