Faltering Growth: Risk Factors

00:01 We're going to be talking about failure to thrive, which is now starting to be known as faltering growth.

00:07 When we're interacting with parents and their children might have failure to thrive or faltering growth, the reason that the term failure is coming out of use is that we don't want to give the parents the idea that it's their fault, it's something that they're doing.

00:24 In very occasional circumstances, this might be due to neglect or something that the parent is actually doing, but most of the time, faltering growth, failure to thrive is due to many other factors that the parents may not have control over.

00:40 You may also hear terms such as poor weight gain, growth deficit, head circumference deficit.

00:50 It's also referred to as chronic malnutrition, sometimes failure to cope, weight faltering and then of course, the faltering growth.

00:59 I would like to point out that failure to thrive or faltering growth is not a diagnostic term.

01:04 This describes a problem, and the problem can have definite, multifactorial things that are feeding into this problem.

01:13 So we have to look at this problem from many different perspectives.

01:17 Poor weight gain that results in malnutrition can contribute to short stature. It can contribute to a secondary immunodeficiency for children, putting them at risk for infections, and can also put them at risk for damage to the brain and CNS symptoms systems because they are not getting the nutrition they need to support these systems in their growth.

01:42 So poor weight gain is actually somewhat common, especially out in the primary care setting.

01:50 So 5 to 10% of children in primary care settings at some point in time are not going to be reaching their projected growth, 3 to 5% of those in the referral settings.

02:03 So these kiddos that are really at risk and you're going to refer out, um, are also dealing with faltering growth or failure to thrive.

02:14 There are a lot of different risk factors for poor weight gain.

02:18 And some of these include prematurity, and especially if that child had intrauterine growth restriction.

02:26 Developmental delay can be associated with faltering growth congenital anomalies. So for example, if you have a cleft lip or palate, that child might have more difficulty actually taking calories in and being able to get the milk, especially if the parents don't have access to specialized equipment, whereas other genetic or chromosomal disorders make it difficult for the child to actually use the nutrition that they're taking in, and they are unable to change those calories into weight gain. Intrauterine exposures can cause faltering growth.

03:04 So alcohol, anticonvulsants, um, any kind of medications the mom might be taking for infection, those can affect growth. Lead poisoning and anemia, especially in young children, can definitely affect growth.

03:21 And really any medical condition that could result in inadequate intake. So if you have an increased metabolic rate, for example, a child that has sepsis or infections, that's requiring a hospital stay for a long period of time, and that can result in growth issues and GI issues that result in maldigestion or malabsorption.

03:45 Those are going to impact the growth of the child, and virtually every organic disease process may be able to contribute to poor weight gain, depending on how long this process is going on.

04:00 There are also some psychosocial risk factors for poor weight gain.

04:04 So those patients that are at the poverty level, certain health and nutrition beliefs, for example, fear of obesity in certain cultures that results in calorie restriction can cause faltering growth.

04:18 Prolonged exclusive breastfeeding, those types of practices that would end up limiting calories can all impact the growth of children.

04:28 Social isolation could be a problem.

04:32 Living in a food desert where the parents don't have access to nutritious and healthy foods.

04:39 Life stressors.

04:42 Poor parenting skills.

04:43 Sometimes parents just don't have the skills that they need to to cope with being a parent. There's a lot that goes into that disordered feeding techniques. So an example of that would be a mom who wants to breastfeed but doesn't have a good latch, and they may not have the ability to work with somebody to help them with their breastfeeding experience, or a child that doesn't like a particular bottle nipple, but the parent doesn't realize that there may be another one that is easier to use for that child.

05:20 Substance abuse and other psychopathology can also affect the children, and this is parents who have substance abuse or an inability to pay attention to the child and pay attention to their nutrition.

05:35 It can also result in, if we have parental substance abuse, children having access to toxins that they wouldn't otherwise have access to.

05:47 Violence in the home can result in failure to thrive or faltering.

05:51 Growth and abuse can also result in faltering growth or failure to thrive. And those are things that we really need to be keyed into screening for when these children come in, especially for their well-child checks.

06:07 So poor weight gain is caused by insufficient usable nutrition.

06:12 And this can be secondary to multiple different things.

06:16 You could have inadequate nutrient intake, inadequate nutrient absorption. So you're getting enough calories and nutrients in, but your body's not able to use those calories and nutrients.

06:27 Increased urinary or intestinal losses.

06:30 In certain GI conditions, you might have, um, diarrhea or constipation that impacts your absorption.

06:39 Increased nutrient requirements.

06:42 For example, those children that do have congenital heart disease, they need a lot more energy to be able to even just take in calories and breathe. So their metabolic demands are quite a bit higher just at baseline. Some children have ineffective metabolic utilization, so children with inborn errors of metabolism often are going to have difficulty really using all of those nutrients.

07:10 And then medical, nutritional and developmental behavioral, um, as well as psychosocial factors may all contribute.

07:19 So there really isn't anything that doesn't touch on growth, especially for children.

07:26 That's their main job of being a child is to grow and develop.

07:31 So any interruptions in that could cause a failure to gain sufficient weight, failure to gain sufficient height, and to have these growth difficulties. The majority of cases in primary care practice or secondary to inadequate dietary intake, and a lot of times those are related to psychosocial factors or a disturbance in feeding behavior.

07:56 Insufficient dietary intake is also a common cause of poor weight gain among infants referred to specialty clinics.

08:03 As mentioned before, there's also poverty and food insecurity, parenting skills and knowledge, and psychosocial stressors.

08:11 And it's really incumbent upon us as practitioners to make sure that parents have the resources they need to ameliorate any of these types of issues that are going on.

08:23 And then we also need to keep an eye out for child neglect.

08:27 This is reportable.

08:29 And we need to make sure that if neglect is the cause of a child failing to thrive and grow, that we have resources to be able to help with that.