Approach to growth faltering: Clinical sciences

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Introduction 0:00–0:27

Growth faltering refers to the inability to gain or maintain adequate weight as a consequence of malnutrition. Growth faltering is most frequently caused by insufficient caloric intake, but it can also result from an underlying condition that’s associated with increased metabolic requirements or malabsorption.
When a pediatric patient presents with growth faltering, you should first obtain measurements of weight and height or length; and plot the results on a standardized growth chart.

Growth parameters 0:27–1:47

Next, review the growth parameters. If your patient’s weight-for-age or BMI is more than 2 standard deviations below the mean for age and biological sex on multiple occasions; or if their weight-for-age has crossed 2 major percentile lines; your patient’s growth is faltering.
Here’s a clinical pearl! In some circumstances, a low or decelerating weight-for-age represents a normal variant of growth.
For example, preterm infants whose growth parameters haven’t been adjusted for gestational age may appear to have insufficient weight gain.
Conversely, infants born large for gestational age experience catch-down growth in the first 6 months of life, and may appear to have faltering growth while their weight is regressing to their expected growth trajectory.
Finally, a child with familial short stature may have a consistently low but appropriate weight-for-age. When in doubt, check your patient’s weight-for-length or weight velocity, to determine whether a low weight-for-age requires further evaluation.
Now that you’ve identified growth faltering, your next step is to obtain a focused history and physical exam. Be sure to ask whether your patient has a chronic health condition, a history of frequent infections, or a significant developmental delay.

H&P 1:47–2:30

Additionally, find out if your patient has had frequent vomiting or an abnormal stooling pattern. When it comes to the physical exam, some signs to look out for include characteristic facial features that suggest a genetic condition, as well as abnormal cardiac findings, hepatosplenomegaly, and lymphadenopathy.
Next, assess for the presence of an underlying health condition. First, let’s discuss health conditions that are associated with excessive energy expenditure.

Chronic illness 2:30–3:56

History might reveal genetic conditions; inborn errors of metabolism; immunodeficiencies; hyperthyroidism; anemia; or chronic cardiac, pulmonary, liver, or renal disease.
If your patient has a chronic health condition that increases energy expenditure, this is probably contributing to their faltering growth.
Here’s another clinical pearl! In some cases, faltering growth could be related to an unrecognized condition, so use clues from the history and exam to focus your diagnostic evaluation.
For example, if your patient has developmental delay, hypotonia, or characteristic facial features, consider ordering genetic studies to look for mutations or microdeletions.
For those with symptoms suggesting hyperthyroidism, order a TSH and free T4. If the exam reveals pallor, a CBC may reveal low hemoglobin; and if you suspect liver or renal disease, a CMP might demonstrate elevated transaminases or creatinine.
Finally, you can obtain a chest X-ray to look for pulmonary disease and consider an echocardiogram if you suspect structural heart disease.
Let’s move on and discuss patients whose history and exam findings do not suggest a condition that increases energy expenditure.

Malabsorption 3:56–6:08

In this case, you should assess your patient’s stooling pattern and consistency. Some patients may report constipation; diarrhea; or steatorrhea, which is a term that describes bulky, greasy, foul-smelling stools.
In this case, consider conditions associated with malabsorption, like celiac disease and cystic fibrosis. Next, order labs, including a tissue transglutaminase IgA, or anti-tTG IgA; a total IgA; and a fecal elastase level.
Also, consider ordering a sweat chloride test, especially if your patient has had recurrent respiratory infections. Now, a positive anti-tTG IgA and normal total IgA are highly suggestive of celiac disease, which you can confirm with endoscopy and duodenal biopsy.
Even though celiac disease can present with anemia, abdominal distension, and rash; in some cases, poor weight gain is the only manifestation.
On the flip side, a low fecal elastase in combination with an elevated sweat chloride is consistent with cystic fibrosis.
In this condition, pancreatic insufficiency leads to steatorrhea and malabsorption. Here’s another clinical pearl!
Shwachman Diamond syndrome is another genetic condition that is associated with pancreatic insufficiency and malabsorption.
Children with this syndrome often have skeletal abnormalities and experience frequent infections and bone marrow failure.
Additionally, intestinal infection from Entamoeba histolytica is a rare cause of malabsorption and poor weight gain. Affected patients typically develop abdominal pain, bloody diarrhea, and fever after traveling to a tropical location.
Alright, let’s switch gears and discuss patients who describe a normal stooling pattern and consistency. In this case, consider causes related to inadequate caloric intake, so assess for upper gastrointestinal losses.

Vomiting 6:08–7:25

If your patient reports vomiting or regurgitation, think of pyloric stenosis and gastroesophageal reflux disease (GERD).
(??) Patients with pyloric stenosis usually present between 2 and 6 weeks of age with postprandial projectile vomiting.
To evaluate further, order an abdominal ultrasound, and if it reveals a hypertrophic pylorus, you can confirm the diagnosis.
On the other hand, the history may reveal symptoms suggesting gastroesophageal reflux disease. For example, infants may be irritable and spit up frequently, while older children and adolescents might describe heartburn or nausea.
With these findings, you can make a clinical diagnosis of gastroesophageal reflux disease. However, in atypical cases, consider ordering an upper GI study.
If it reveals gastroesophageal reflux, you can confirm the diagnosis. Now let’s move on and discuss patients who don’t have significant upper GI losses.

Low intake 7:25–8:02

In this case, consider the possibility that behavioral factors, mechanical feeding difficulties, or psychosocial issues are interfering with adequate caloric intake.
To evaluate further, perform a dietary assessment to examine calorie intake and feeding behaviors; a feeding assessment to look at oral motor and self-feeding skills; and a psychosocial assessment to screen for issues like resource instability and family stressors.
First up, is dietary assessment. A detailed history might reveal suboptimal caloric intake as well as feeding selectivity or aversion.
For instance, some infants have difficulty accepting solid foods while transitioning from breast milk or formula. Older children with autism spectrum disorder or avoidant and restrictive eating patterns commonly develop strong sensory preferences or food neophobia, which limits their intake of high-quality macronutrients.

Dietary assessment 8:02–9:04

Additionally, a concerned caregiver may pressure their child to eat in an attempt to improve caloric intake, which often backfires and aggravates food refusal.
Finally, patients with body dysmorphic disorders often adopt restrictive diets, which might result in anorexia nervosa or other disordered eating behaviors.
If you identify any of these patterns, your patient has a behavioral feeding problem which is probably contributing to their faltering growth.
Second, let’s look at the feeding assessment. Here, you might notice poor latching, sucking, and swallowing in breastfed infants; while older, verbal children may demonstrate speech delay, difficulty articulating speech sounds, and delayed acquisition of feeding skills.

Feeding assessment 9:04–10:26

Children who cannot chew foods efficiently may have difficulty transitioning from pureed foods to solid foods. Also, the inability to use a spoon or open cup can interfere with proper nutrient intake.
Any of these findings indicates a mechanical feeding difficulty, which may cause suboptimal intake and poor weight gain.
Here’s another clinical pearl! In many cases, two or more coexisting mechanisms contribute to growth faltering.
For example, children with Down syndrome and unrepaired atrioventricular septal defect have increased metabolic demand from heart failure, in combination with insufficient intake due to maxillary hypoplasia and hypotonia.
Similarly, infants with DiGeorge syndrome might have difficulty feeding due to cleft lip and palate, in addition to increased metabolic demands from recurrent infections or an unrepaired conotruncal heart defect.
Third, and lastly, let’s discuss the psychosocial assessment. In some cases, the interview may reveal that the caretaker has a low understanding of their child’s nutritional needs.

Psychosocial assessment 10:26–12:07

For example, they might inadvertently dilute formula excessively, or they may feed the child large quantities of juice or milk.
For cultural or religious reasons, some families may adhere to a diet that does not provide the necessary macronutrients for optimal growth.
Additionally, families might experience financial or resource instability, including poverty or homelessness, which subsequently leads to food insecurity.
Household stressors, such as low social support, intimate partner violence, mental illness, or substance use disorders, can also impair a caregiver’s ability to provide adequate nutrition.
Any of these suggests that a psychosocial issue is contributing to your patient’s faltering growth. Here’s one last clinical pearl!
While most children with faltering growth can be managed in an outpatient setting, hospitalization is indicated whenever you suspect abuse or neglect.
Important historical clues that suggest child maltreatment include intentional withholding of food, a caregiver’s resistance to interventions, or caregiver disengagement.
You should also hospitalize your patient whenever a caregiver is unable to provide necessary interventions for their child; if malnutrition is severe; or if the child is not gaining weight despite outpatient treatment.
Alright, as a quick recap…Once you recognize growth faltering, perform a focused history and physical exam, and assess for underlying health conditions that are associated with excessive energy expenditure.

Review 12:07–12:47

Then, assess the stooling pattern and consistency to evaluate for conditions associated with malabsorption, like celiac disease and cystic fibrosis.
Finally, consider underlying causes that are associated with inadequate intake. These include conditions that result in upper GI losses, like pyloric stenosis or gastroesophageal reflux disease; as well as behavioral feeding problems, mechanical feeding difficulties, and psychosocial issues.
reflux disease as well as behavioral feeding patterns mechanical