Failure to thrive: still a problem of definition

Characteristics and Outcomes of Failure to Thrive in Pediatric Patients Referred to the King Abdulaziz Medical City Pediatric Clinic

BACKGROUND

Failure to thrive (FTT) in pediatric populations is a diagnostic challenge with implications for growth and development. Despite its prevalence, detailed epidemiological data, especially concerning organic versus non-organic etiologies, are sparse. This study examines the prevalence, characteristics, and outcomes of organic and non-organic FTT in a pediatric outpatient setting at King Abdulaziz Medical City, Jeddah.

METHODS

This retrospective chart review included pediatric patients aged three months to 14 years diagnosed with FTT at KAMC from 2016 to 2023. FTT was defined by weights below the 3rd percentile or a decline across two major growth percentiles. Patients were stratified into organic and non-organic FTT groups based on predefined criteria. Prevalence rates, clinical characteristics, and outcomes were compared to draw distinctions between the two categories.

RESULTS

Out of 349 evaluated patients, organic FTT was present in 160 patients (45.8%), with gastrointestinal conditions and endocrine disorders being the most common etiologies. Non-organic FTT, accounting for 189 (54.2%) of cases, was primarily associated with inadequate nutritional intake and behavioral factors. Notably, the non-organic FTT group exhibited a significantly higher rate of condition resolution (45.0%) compared to their organic counterparts (32.5%). Furthermore, significant laboratory parameter differences were noted, indicating a higher white blood cell count in organic cases, among other findings.

CONCLUSIONS

Non-organic FTT was more prevalent and demonstrated higher resolution rates, suggesting better outcomes with timely intervention and appropriate care strategies. The study advocates for increased educational efforts for caregivers and healthcare providers and calls for further research to explore effective management protocols for FTT.

The Incidence, Prevalence and Clinical Characteristics of Failure to Thrive in Children at King Abdullah Specialized Children Hospital, Riyadh, Saudi Arabia

Introduction Failure to thrive (FTT) in children involves insufficient weight or height gain, affecting general and hospitalized populations which leads to cognitive and behavioral changes. Causes include inadequate caloric intake and underlying diseases (organic - OFTT) or psychosocial factors (non-organic - NOFTT). Our study in King Abdullah Specialized Children Hospital (KASCH) aims to assess FTT incidence, prevalence, and clinical characteristics, and also, to distinguish between different causes. Methodology It is a retrospective cohort study, conducted at KASCH, Riyadh, Saudi Arabia. This study includes children under three years old with documented FTT from 2017 to 2019. Data was collected from the hospital's electronic system and it was analyzed by the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 29.0, Armonk, NY). Results Our study, including 214 FTT patients, revealed a balanced gender distribution of 109 males (50.9%), and 105 females (49.1%), with a majority of Saudi nationality 208 (97.2%). In most cases, 120 (56.1%) are in the 0-12 months age group. The prevalence of FTT was 26.75% (267 cases per 1000). Antenatal/post-natal features showed diverse delivery modes and NICU admissions. Chronic diseases like gastrointestinal diseases 62 (29.1%), cardiac 50 (23.4%), and pulmonary 50 (23.4%) conditions were prevalent. Associations were found between NICU admission and pre-term births, birth weight status, and congenital anomalies, highlighting significant clinical correlations. Conclusion Our study concluded the significant burden of FTT at KASCH. Chronic diseases were playing a major role as a cause of FTT. Thus, emphasizing the causes and knowing the importance of addressing the prevalence and incidence is effective for appropriate intervention.

Prevalence of Reproductive Health Issues among US Female Law Enforcement Officers

Reproductive health is a considerable concern among US female law enforcement officers (LEOs). Miscarriage and preterm birth rates are significantly higher in women firefighters than published US averages. Since law enforcement and firefighting share occupational conditions and practices, adverse birth outcomes were hypothesized to be greater in female law enforcement officers (LEOs) than the US averages. Occupational hazards may place pregnant LEOs at a higher risk for complicated pregnancies and adverse birth outcomes. This study quantified pregnancy outcomes in female LEOs using a cross-sectional survey and compared them to US averages and large prospective studies. The participants (N = 162, 72.2% aged 31-49, 85.2% Caucasian) averaged 2.5 ± 1.4 pregnancies. Stress (59.1%) and shiftwork (59.8%) were the most common reported exposures. Miscarriage and preterm birth rates were 19.1% and 16.4%, respectively. Miscarriages were significantly greater among participants compared to prospective studies [χ2 (1, N = 911,971) = 20.51, p < 0.001]. Female LEOs of childbearing age should receive education about potential reproductive health hazards and take precautions against them. Moreover, policymakers, human resources, and healthcare providers should understand how law enforcement work might affect maternal health.

Failure to thrive among asylum-seeking children: A descriptive study from Turkey

OBJECTIVE

The aim of the study was to determine failure to thrive among asylum-seeking children.

DESIGN

The study was a descriptive study.

SAMPLE

The sample of the study comprised of 187 children who were registered in an Afghan Association. The power of the study was found to be 97% at 0.5% (moderate) effect size and 95% confidence level.

MEASUREMENTS

The data was collected between November 8, 2021 and January 10, 2022 using a sociodemographic form and the children's anthropometric measurement.

RESULTS

57.2% of children were male and 44.9% were 6-12 years old. It was determined that female and male infants less than 1 year of age were underweight (z-score = -2) and male infants were stunting (z-score ≤-1).

CONCLUSIONS

Childhood growth and development problems are significant issues among asylum-seeking families. Public health nurses need to develop their roles in organizing the healthcare service for vulnerable and underrepresented groups.

Growth assessment in down syndrome after cardiac surgery

Objective

To assess the effect of cardiac surgery on growth catch-up of Down syndrome (DS) children with failure to thrive (FTT) and congenital heart disease (CHD) and investigate other causes of FTT in DS children.

Method

We conducted a retrospective observational study in tertiary cardiac center from 2015 to 2018. We included all cases of DS diagnosed with CHD and FTT who completed a 1-year follow-up after cardiac surgery. We divided the cases into two groups; “normalize group” includes children who normalized their growth parameters and “underweight group” includes those who remained in FTT category during the follow-up period. We compared both groups for multiple risk factors.

Result

Most of DS had FTT upon surgery. Fifty percent of cases completed 1-year follow-up including 29 (60%) in the normalized group and 19 (40%) in underweight group. Within 6 months post-surgery, the normalized group though did not reach yet normalization of growth parameters, demonstrated statically significant improvement in weight for age, weight Z-score in compared to underweight group.

Within 12 months post-surgery, the normalized group achieved normalization of growth parameters and continue to show more statistically significant differences in growth parameters.

Both groups had comparable post-operation course. Univariate analysis of possible peri-operative risk factors showed no difference between both groups except for presence of untreated subclinical hypothyroidism in 58% of the underweight group versus 17% in control group (p = 0.005).

Conclusion

FTT in DS patient is multifactorial which needs thorough investigation and work up by multidisciplinary team. Cardiac surgery may not guarantee the improvement of growth parameters.

A novel screening tool to predict severe acute malnutrition through automated monitoring of weight‐for‐age growth curves

Weight‐for‐age (WFA) growth faltering often precedes severe acute malnutrition (SAM) in children, yet it is often missed during routine growth monitoring. Automated interpretation of WFA growth within electronic health records could expedite the identification of children at risk of SAM. This study aimed to develop an automated screening tool to predict SAM risk from WFA growth, and to determine its predictive ability compared with simple changes in weight or WFA z‐score. To develop the screening tool, South African child growth experts (n = 30) rated SAM risk on 100 WFA growth curves, which were then used to train an artificial neural network (ANN) to assess SAM risk from consecutive WFA z‐scores. The ANN was validated in 185 children under five (63 SAM cases; 122 controls) using diagnostic accuracy methodology. The ANN's performance was compared with that of changes in weight or WFA z‐score. Even though experts' SAM risk ratings of the WFA growth curves differed considerably, the ANN achieved a sensitivity of 73.0% (95% confidence interval [CI]: 60.3; 83.4), specificity of 86.1% (95% CI: 78.6; 91.7) and receiver‐operating characteristic curve area of 0.795 (95% CI: 0.732; 0.859) during validation with real cases, outperforming changes in weight or WFA z‐scores. The ANN, as an automated screening tool, could markedly improve the identification of children at risk of SAM using routinely collected WFA growth information.

Growth faltering preceding severe acute malnutrition (SAM) is poorly identified during routine growth monitoring, and opportunities for preventative interventions are missed.

Consistently identifying growth faltering is challenging, even for experts in child growth. Digitized growth monitoring tools incorporating automated pattern recognition by an artificial neural network (ANN) can assist clinicians in identifying growth faltering.

In this study, an ANN was trained to identify children at risk of SAM based on weight‐for‐age growth curves, with promising results. With further refinement, the ANN could greatly improve the identification of children with growth faltering and facilitate earlier interventions to prevent SAM.

The Effects of Nutritional Interventions on the Cognitive Development of Preschool-Age Children: A Systematic Review

The developing human brain requires all essential nutrients to form and to maintain its structure. Infant and child cognitive development is dependent on adequate nutrition. Children who do not receive sufficient nutrition are at high risk of exhibiting impaired cognitive skills. This systematic review aimed to examine the effects of nutritional interventions on cognitive outcomes of preschool-age children. PubMed, PsycInfo, Academic Search Complete, and Cochrane Library electronic databases were searched to identify Randomized Controlled Trials (RCTs) published after the year 2000. Studies assessing the effects of food-based, single, and multiple micronutrient interventions on the cognition of nourished and undernourished children aged 2-6 years were deemed eligible. A total of 12 trials were identified. Eight out of the twelve studies found significant positive effects on cognitive outcomes. Iron and multiple-micronutrients supplementation yield improvements in the cognitive abilities of undernourished preschool-age children. Increased fish consumption was found to have a beneficial effect in the cognitive outcomes of nourished children. On the other hand, B-vitamin, iodized salt, and guava powder interventions failed to display significant results. Findings of this review highlight the importance of adequate nutrition during preschool years, and the crucial role sufficient nutrition plays in cognitive development.

Estimated Energy Requirements of Infants and Young Children up to 24 Months of Age

BACKGROUND

Establishing energy requirements in infants and young children is important in developing age-appropriate diet recommendations but most published guidelines for energy requirements have 1 or more limitations related to the data underlying the calculations.

OBJECTIVE

To develop a comprehensive set of daily energy requirements for infants and young children aged 0-24 mo meeting the ideals of worldwide applicability to all healthy children based on the use of the doubly labeled water (DLW) technique to measure total energy expenditure (TEE), the use of recent, international growth charts, and calculation of values across a wide range of body weight.

METHODS

Daily estimated energy requirements (EERs) were calculated in 1-mo increments from 0 to 24 mo for boys, girls, and combined, using as inputs the following: 1) TEE measured using the DLW technique, 2) energy deposition estimates from the Institute of Medicine, and 3) body weight values from the 25th to 75th percentiles from the 2006 WHO growth charts. EERs were combined for age groups 0 to <6, 6-8, 9-11, and 12-24 mo by averaging EERs from individual months. The EER calculations were supported by a systematic literature review and a meta-regression of existing studies.

RESULTS

Energy requirements naturally increase with age and are slightly higher in boys than in girls. The EERs derived in this study are similar to those in other recent international efforts.

CONCLUSIONS

This updated set of EERs for infants and young children expand and improve upon the methodology used to establish previous published guidelines. These estimates have multiple potential uses including planning age-appropriate menus for the complementary feeding period, the development of foods that are more precisely targeted to the needs of infants and children at particular ages, and establishing macronutrient requirements within specific age groups based on a percentage of energy, such as dietary fat.

Failure to thrive in infant and toddlers: a practical flowchart-based approach in a hospital setting

Background

Failure to thrive is a common reason for referral to paediatric services. Malnutrition or inadequate caloric intake is the most common cause, while organic form is unlikely in children who are asymptomatic and healthy on examination. By this study we evaluate the application of a cost-effective flow chart that helps the clinician in a hospital setting discern accurately organic and non-organic failure to thrive.

Methods

Conduct a prospective single-center study in children up to 2 years of age with growth faltering. The pediatricians used a practical flow chart, took the medical history, created a growth chart, performed clinical examinations, and requested blood test and consultations in a step by step approach.

Results

Among the 74 subjects included in the study, the diagnosis of organic failure to thrive was reached by 42%. Gastrointestinal and genetic diagnoses were the most frequent. Patients with organic failure to thrive had significantly lower gestational age and birth weight. Age at diagnosis and Z-score weight were lower in organic than in non-organic forms. Most patients with non-organic forms (88%) did not undergo in-depth blood test or specialist advice.

Conclusion

The flow chart we presented was accurate for diagnosing children with failure to thrive in a hospital setting and distinct organic and non-organic forms. It was cost-effective to avoid unnecessary blood test or consultations in most non-organic diagnoses.

Failure to Thrive in the Outpatient Clinic: A New Insight

Failure to thrive (FTT) is an abnormal growth pattern determined by inadequate nutrition. It is a common problem in children, representing 5% to 10% of patients seen in an outpatient setting. Many definitions have been proposed based on anthropometric deterioration; however, they show poor concordance. No single definition is sufficiently sensitive in identifying faltering growth whilst a combination of multiple criteria seems more accurate. In light of the recent redefinition of pediatric malnutrition as a disequilibrium between requirements and intakes of energy, and macro- and micronutrients, a wider conception of FTT as an unsatisfactory nutritional status related to poor growth and health is useful. Although the most severe problems of micronutrient malnutrition are found in developing countries, people of all regions of the world can be affected by micronutrient deficiencies (MNDs), a form of undernutrition with relevant effects on growth and health. Changes in diets and lifestyle, elimination diets, food insecurity, and food intake disorders create the conditions at risk of faltering growth and MNDs. This new insight integrates the "classical" anthropometric criteria for definition and treatment, in the aim of warranting both a regular increase in size and an overall adequate development and health status.

Effect of nutritional supplement formula on catch-up growth in young children with nonorganic faltering growth: a prospective multicenter study

BACKGROUND/OBJECTIVES

Inadequate nutrition in infants and young children affects physical growth and neurocognitive development. Therefore, early nutritional intervention is important to promote catch-up growth in young children with faltering growth. The aim of this study was to evaluate the effect of nutritional supplementation with a pediatric concentrated and balanced nutritional supplement formula on promoting growth and improving nutritional status in children with nonorganic faltering growth.

SUBJECTS/METHODS

Children aged 12–36 months whose body weight-for-age was < 5^th percentile on the Korean Growth Charts were enrolled. Children born premature or having organic diseases were excluded. Children were instructed to consume 400 mL of formula per day in addition to their regular diet for 6 months. Pediatricians and dietitians educated the parents and examined the subjects every 2 months. Anthropometric parameters were measured at baseline and at 2, 4, and 6 months, and laboratory tests were done at baseline and 6 months. The good consumption group included children who consumed ≥ 60% of the recommended dose of formula.

RESULTS

Total 82 children completed the 6-month intervention. At baseline, there were no significant differences in all variables between the good consumption and poor consumption groups. Weight and weight z-scores were significantly improved in the good consumption group compared to the poor consumption group at the end of the intervention (P = 0.009, respectively). The good consumption group showed a significant trend for gaining weight (P < 0.05) and weight z-score (P < 0.05) compared to the poor consumption group during 6 months of formula intake. The concentration of blood urea nitrogen was significantly increased in the good consumption group (P = 0.001).

CONCLUSIONS

Nutritional supplementation with a concentrated and balanced pediatric nutritional formula along with dietary education might be an effective approach to promote catch-up growth in children with nonorganic faltering growth.

Clinician Diagnoses of Failure to Thrive Before and After Switch to World Health Organization Growth Curves

OBJECTIVE

To evaluate change in the incidence of failure to thrive (FTT) based on selected growth percentile criteria and diagnostic codes before and after a switch in growth curves.

METHODS

We performed a retrospective cohort study of children 2 to 24 months of age in a large primary care network that switched its default growth curve from the Centers for Disease Control and Prevention (CDC) reference to the World Health Organization (WHO) standards in 2012. We compared the incidence of FTT defined by growth percentile criteria (using the default growth curve at the time of each measurement) and by International Classification of Diseases, Ninth Revision, codes in the 3 years before and after the CDC-WHO switch using an interrupted time series analysis. We performed these analyses stratified by age group (≤6 months and >6-24 months).

RESULTS

We evaluated 83,299 children. Among those ≤6 months, increases in FTT incidence were found in both growth-percentile and clinician-diagnosis criteria at the CDC-WHO switch (P < .05). Among those >6 to 24 months, decreases in FTT incidence were found by growth-percentile criteria at the CDC-WHO switch (P < .05), but no significant changes were found in FTT incidence by diagnostic codes.

CONCLUSIONS

When switching from the CDC to the WHO growth curves, changes in the incidence of FTT by growth-percentile and clinician-diagnosis criteria differed for younger versus older infants. Factors beyond growth likely influence the decision to diagnose a child as having FTT and may differ in younger compared to older infants.

May Failure to Thrive in Infants Be a Clinical Marker for the Early Diagnosis of Cow's Milk Allergy?

Objectives—Failure to thrive (FTT) in infants is characterized by growth failure. Although, cow’s milk allergy (CMA) may have an impact on growth and leads to FTT, data are still limited. We focused on FTT as a possible clinical marker for an early diagnosis of CMA. The aim of the present study was to evaluate the implications of cow’s milk hypersensitivity in infants with FTT and the growth catch-up after a cow’s milk-free diet (CMFD). Methods—A cross-sectional study of all consecutive infants evaluated at the Pediatric Nutrition and Allergy Unit of the University Hospital of Bari (Italy) from January 2016 to April 2018 with a medical-driven diagnosis of FTT. Eligible infants were investigated for possible IgE mediated or non-IgE mediated CMA. Results—43 infants were included, mean age 5.7 months. 33/43 (77%) FTT presented a CMA related disease: 3/43 (7%) were diagnosed as presenting an IgE mediated CMA, 30 (93%) had a non IgE-mediated CMA, confirmed by the elimination diet for diagnostic purposes, that led to a significant improvement of symptoms and recrudescence after milk reintroduction. A total of 29 out of 30 patients (one patient was lost at follow-up) moved up to their original growth percentile after dietary changes. Growth z-scores were computed based on WHO anthropometric data. In 10 out of 43 patients (23%) were diagnosed with gastro-esophageal reflux disease (GERD). Conclusions—when evaluating an infant with FTT, physicians should include in their evaluation an extensive search for IgE mediated and non IgE mediated CMA. When in vivo and in vitro analysis are not conclusive, a 4- to 8-weeks trial of CMFD and a consecutive re-introduction of milk proteins may be helpful in less common diagnoses.

Effects of oral zinc supplementation on zinc status and catch-up growth during the first 2 years of life in children with non-organic failure to thrive born preterm and at term

BACKGROUND

We aimed to analyze the effect of oral zinc supplementation on serum insulin-like growth factor-1 (IGF-1) levels and catch-up growth in infants with non-organic failure to thrive (NOFTT) who were born preterm as compared to those born at term.

METHODS

Totally, 105 NOFTT infants aged 2 years or less were enrolled and divided into two groups according to gestational age at birth. Oral zinc sulfate was administered for 6 months to 49/66 children born at term, and 21/39 children born preterm. Serum zinc, IGF-1, weight, and height were measured at baseline and at 6 months.

RESULTS

There were no differences in baseline serum zinc levels between the two groups. In preterm NOFTT infants, zinc supplementation significantly increased serum zinc levels compared to those in the non-supplementation group (Δ zinc _{0-6 month} 10.3 ± 26.4 μg/dL vs. -8.8 ± 23.7 μg/dL, p = 0.018), but it did not significantly change serum IGF-1 levels or weight- and height for age Z-scores. In NOFTT infants born at term who received zinc supplementation, serum zinc levels, IGF-1, weight for age Z-score, and height for age Z-score increased at 6 months (p = 0.001, p = 0.014, p = 0.049, and p = 0.029, respectively), but this increase was not significantly greater than in the non-supplementation group. Only the increase in serum zinc levels was significant after 6 months (Δ zinc _{0-6 month} 16.8 ± 32.0 μg/dL vs. -10.0 ± 22.6 μg/dL, p = 0.002).

CONCLUSION

Zinc supplementation in NOFTT infants improves serum zinc status, regardless of gestational age at birth. Zinc supplementation in NOFTT infants born at term may improve serum IGF-1 levels and growth, but it does not in NOFTT infants born preterm. Overall nutritional support rather than supplementation of a single nutrient may be more effective for catch-up growth in NOFTT infants born preterm.

Defining Pediatric Failure to Thrive in the Developed World: Validation of a Semi-Objective Diagnosis Tool

There is no concordance between current diagnostic criteria for failure to thrive (FTT). We analyzed validity of the Semi-Objective Failure to Thrive (SOFTT) diagnosis tool, which uses a combination of subjective and objective components to make the diagnosis of FTT. The tool was used to diagnose FTT in 94 patients who met 1 of 7 accepted criteria for FTT. Concurrent and predictive validity were demonstrated using anthropometric z-scores and change in anthropometric z-scores, respectively. SOFTT results correlated with differences in anthropometric z-scores for length ( P = .011), weight, weight-for-length, body mass index, mid-upper arm circumference, and triceps skinfold thickness ( P < .0001) between those diagnosed as normal and those with FTT. At follow-up, children with FTT compared with children rated as normal had significantly higher change in weight ( P ≤ .001) and body mass index ( P = .026) z-scores. The SOFTT tool leads to the accurate diagnosis of FTT demonstrated by concurrent and predictive validity.

Micronutrients Are Not Deficient in Children with Nonorganic Failure to Thrive

PURPOSE

Inadequate calorie intake is one of the most important causes of nonorganic failure to thrive (NOFTT) and is thought to lead to multiple micronutrient deficiencies. However, there have been few studies on NOFTT and micronutrients. The aim of this study was to evaluate the micronutrient status of children with NOFTT.

METHODS

We conducted a retrospective cohort study in 161 children (106 with NOFTT and 55 health controls) at a single institution. Data on weight for age, height for age, body mass index, and biochemical parameters, indicating the children's nutritional and micronutrient status were reviewed via electronic medical records, and the two groups were compared.

RESULTS

Except inorganic phosphate levels, no statistically significant differences were seen in the laboratory findings indicating the children's nutritional and micronutrient status; notably, the inorganic phosphate levels were within the normal range in both groups. We then compared the severe NOFTT (weight for age below the first percentile) and control groups; however, no statistically significant differences were seen for any of the measured parameters.

CONCLUSION

Most children with NOFTT in this study had normal micronutrient levels and other laboratory findings. Therefore, element deficiencies should not be considered a natural consequence of NOFTT or in healthy children. Close monitoring and additional evaluations are needed.

Diagnostic Workup and Micronutrient Deficiencies in Children With Failure to Thrive Without Underlying Diseases

OBJECTIVES AND STUDY

Failure to thrive (FTT) is an interruption in the normal pattern of growth. We aimed to evaluate the clinical characteristics, underlying etiologies, diagnostic workup, and frequency of micronutrient deficiencies (MDs) in children with FTT.

METHODS

This retrospective study was done with 729 children (319 male, mean age 6.8 ± 5.5 years) with FTT (weight for age <3rd percentile) who had visited the Pediatric Gastroenterology outpatient clinic between 2011 and 2016. Children who had previously known chronic diseases, inadequate intake, or inadequate absorption were excluded. Acute malnutrition was considered if weight-for-age z-scores were below -2 and height-for-age z-scores were above -2, and chronic malnutrition was defined if height-for-age z-scores were below -2.

RESULTS

The malnutrition rate was 57.1% (acute: 37.8%, chronic: 19.3%). Of children, 98.7% had laboratory evaluation. We found that 1.1% of laboratory tests, 0.4% of imaging studies, 27% of endoscopic findings, and biopsy results led to a specific diagnosis, equating to a total of 1.3% of diagnostic workup leading to a diagnosis related to FTT. The causes of FTT were inadequate nutrition (61.4%), psychiatric and behavioral disorders (17.2%), endocrinologic disorders (9%), recurrent infections (6.4%), gastrointestinal diseases (1.9%), and cardiac disorders (0.1%). Vitamin A and D deficiencies were the most common MD.

CONCLUSION

We showed that the most common cause of FTT is "purely nutrition" FFT because of inadequate caloric intake, and extensive diagnostic workup is rarely helpful to reveal the etiology. These results implicate the importance of clinical evaluation and anthropometry to evaluate a child with FTT.

Weight Gain Trajectory Predicts Long-term Overweight and Obesity After Pediatric Liver Transplant

OBJECTIVE

The aim of the study is to identify early predictors of long-term overweight and obesity in pediatric liver transplant recipients.

METHODS

Single-center, retrospective review of children who underwent liver transplant before age 6 years. Body mass index (BMI), weight, and height percentiles at transplant and post-transplant were calculated. BMI, weight gain trajectories, and failure-to-thrive (FTT) were examined as predictors of overweight/obesity at 3 and 5 years post-transplant.

RESULTS

Children (n = 70) were median 0.9 years at transplant. Median BMI percentile increased from 37 (interquartile range (IQR) 12-73) at transplant to 83 (IQR 64-97) at 12 months, with median weight percentile 47 (IQR 26-67) and height percentile 9 (IQR 2-32). Overweight/obesity prevalence peaked at 3 years post-transplant (44%). Children who were overweight/obese at 3 years post-transplant were more likely to be overweight/obese at transplant, and at 6 and 12 months post-transplant (odds ratio (OR): 9.4, P = 0.02; OR: 6.7, P = 0.013, OR: 6.4, P = 0.007, respectively). The prevalence of overweight/obesity decreased to 26% at 5 years. Rapid weight gain post-transplant did not predict overweight/obesity at 3 or 5 years. Over one-third of children who were FTT at transplant were overweight/obese at 3 or 5 years, but FTT at transplant did not increase later obesity risk.

CONCLUSIONS

Most children gain weight rapidly after liver transplant. Nearly half of transplant recipients are overweight/obese at 3 years, but the prevalence decreases by 5 years. Those who become overweight/obese tend to do so within 1 year post-transplant, making this an important time to identify high-risk children and provide counseling.

The shifting relationship between weight and pediatric obstructive sleep apnea: A historical review

OBJECTIVES

For more than a century, pediatric obstructive sleep apnea (OSA) was associated with failure to thrive. However, that association has faded over the last few decades. A 21st century child with OSA is much more likely to be overweight than underweight. This raises the question: Has pediatric OSA changed over time, or has the rise of childhood obesity in the United States created a new, separate disease? This literature review explores the historical shift in the relationship between weight and OSA, and the associated changes in treatment.

RESULTS

We demonstrate a clear transition in the prevalence of failure to thrive and obesity in the OSA literature in the mid-2000s. What is less clear is whether these two clinical phenotypes should be considered two distinct diseases, or whether subtle differences in one set of pathophysiologic pathways-adenotonsillar hypertrophy, altered inflammation, and increased energy expenditure-can lead to divergent metabolic outcomes. More research is needed to fully elucidate the pathophysiology of OSA in children with obesity.

CONCLUSIONS

We may need new and different treatments for obesity-associated OSA as adenotonsillectomy-which is effective at reversing failure to thrive in OSA-is not as effective at treating OSA in children with obesity. One option is drug-induced sleep endoscopy, which could personalize and improve surgical treatment of OSA. There is some evidence that therapies used for OSA in adults (e.g., weight loss and positive airway pressure) are also helpful for overweight/obese children with OSA. Laryngoscope, 129:2414-2419, 2019.

Failure to Thrive: An Expanded Differential Diagnosis

The patient is a term 6-month-old male, who presented with failure to thrive since birth. History was remarkable for suspected milk and soy protein allergy, gastroesophageal reflux, constipation, and abdominal distension that was present since birth. He was losing weight despite oral intake of over 100 kcal/kg per day. Prior workup including laboratory studies, abdominal X-ray, upper gastrointestinal series with fluoroscopy, barium enema, and abdominal ultrasound were all within normal limits. The patient's history, diagnostic evaluation, and final diagnosis are revealed. This case highlights a rare condition presenting as failure to thrive, a common problem with a wide differential diagnosis.

Limitations of Weight Velocity Analysis by Commercial Computer Program Growth Analyser Viewer Edition

Commercial software package “Growth Analyser Viewer Edition” (“GAVE”) aims to document, monitor and analyze growth and development in children and adolescents. Although its clinical and scientific use is widespread, there are no published studies that describe the method and its validation. We were informed that GAVE calculates the weight velocity (kg/year) at age t from the weight difference between t and 448 days earlier or at birth, divided by the time difference. We recently discussed a case of false child abuse diagnosis (Pediatric Condition Falsification), resulting in the separation of the child from its parents, in which GAVE played a negative contributing role. To prevent such inappropriate diagnoses, we analyzed GAVE from a schematic representation of the measured clinical weight curve, with precisely defined weight velocities. In conclusion, the 448 days included for weight velocity predictions by GAVE caused the erroneous outcomes. Until the necessary changes to the software are implemented and validated, we advise against the use of GAVE in infants younger than 1.5 years, if multiple weight changes occur within 448 days, and following a long-lasting weight velocity change. Our analysis suggests to discard all medical software packages that lack public description and proof of validation.

Pediatric Condition Falsification Misdiagnosed by Misjudged Weight Growth from the Curve of Measured Weights

Patient: Male, 0–2

Final Diagnosis: Cow milk allergy

Symptoms: Obstipation • airway infections

Medication: —

Clinical Procedure: Elementary feeding

Specialty: Pediatrics

A Quality Improvement Initiative to Improve Feeding and Growth of Infants With Cleft Lip and/or Palate

Objective:

The purpose of this quality improvement initiative was to improve feeding and growth outcomes in infants with cleft lip and/or palate (CL/P).

Design:

Institute for Healthcare Improvement quality improvement model.

Setting:

Large pediatric academic medical center in the Midwestern United States.

Participants:

One hundred forty-five infants with nonsyndromic CL/P ages 0 to 12 months.

Interventions:

Key drivers included (1) caregiver education and resources, (2) care coordination and flow, and (3) provider education and training. Interventions were designed around these themes and included targeting improved team communication, increased social work consultations, patient tracking, staff education, improved access to feeding equipment, and the launch of a new cleft palate feeding team.

Main Outcome Measure(s):

The primary outcome measure was the percentage of new patients with CL/P who met criteria for failure to thrive (FTT) per month. The secondary outcome measure was the frequency of hospitalization for infants with CL/P with a primary reason for admission of feeding difficulties or FTT.

Results:

The institutional FTT rate for infants with CL/P decreased from 17% to 7% ( P < .003). The frequency of hospitalization for FTT improved from once every 30 days to once every 118 days.

Conclusions:

Targeted interventions aimed at improving feeding efficiency and effectiveness, as well as changes in care delivery models, can reliably promote improvements in feeding and growth outcomes for infants with CL/P, even with psychosocial risk factors present.

Parental Socioeconomic Status and Weight Faltering in Infants in Japan

Background: Previous studies in the UK and Denmark found no significant association between low socioeconomic status (SES) and weight faltering. However, to our knowledge, there are no studies from other developed countries. We examined the association between parental SES and weight faltering in infants up to 1.5 years of age, and investigated whether the inequalities changed between 2001 and 2010 in Japan. Methods: We used data from two Japanese population-based birth cohorts started in 2001 (n = 34,594) and 2010 (n = 21,189). Parental SES was assessed as household income and parental education when the infant was 6 months old. Weight faltering was defined as the slowest weight gaining in 5% of all children in each cohort. Logistic regression analyses were conducted with adjustment for covariates. The relative index of inequality was used to assess relative impact of parental SES on weight faltering. Results: Infants in the lowest quartile of household income were 1.29 (95% confidence interval [CI]: 1.10, 1.52) and 1.27 (95% CI: 1.03, 1.56) times more likely to experience weight faltering than those in the highest income quartile both in the 2001 and 2010 cohorts, respectively. The relative index of inequality for household income was 1.66 (95% CI: 1.36, 1.96) in 2001 and 1.86 (95% CI: 1.42, 2.31) in 2010. Conclusions: Infants from lower income families have a greater risk of weight faltering in Japan. Additionally, the income-related inequalities in weight faltering did not change between the two cohorts. Social policies to address maldistribution of weight faltering due to household income are needed.

Serum and Hair Mineral Levels in Children with Failure to Thrive According to the Type of Feeding Difficulties

This study evaluated serum and hair mineral and trace element levels as well as levels of other nutritional factors affecting growth and appetite in young children with non-organic failure to thrive (NOFTT) based on the presence or types of feeding difficulty (FD). Between August 2012 and July 2015, 136 children less than 6 years of age with NOFTT were included. FD was diagnosed based on Wolfson criteria and divided into subtypes according to Chatoor's classification. Clinical data were reviewed, and serum and hair mineral levels were measured. Of all assessed serum and hair minerals, only hair sulfur contents differed significantly between subjects with and without infantile anorexia (39,392 ± 2211 vs. 40,332 ± 2551 μg/g, P = 0.034). There were no differences in serum and hair mineral levels between children with and without sensory food aversion. Hair copper contents were significantly lower in children with FD of reciprocity (12.3 ± 6.0 vs. 22.4 ± 25.1 μg/g, P = 0.049). While hair zinc contents were also lower, the difference was not statistically significant (49.2 ± 26.8 vs. 70.6 ± 41.0 μg/g, P = 0.055). Only hair manganese contents were significantly lower in children with posttraumatic FD (0.12 ± 0.04 vs. 0.26 ± 0.73 μg/g, P = 0.037). In conclusion, there were no differences in most serum and hair mineral levels in children with NOFTT, except for relatively lower hair levels of sulfur, copper and possibly zinc, and manganese in infantile anorexia, reciprocity, and posttraumatic types of FD, respectively.

Synthetic growth reference charts

OBJECTIVES

To reanalyze the between-population variance in height, weight, and body mass index (BMI), and to provide a globally applicable technique for generating synthetic growth reference charts.

METHODS

Using a baseline set of 196 female and 197 male growth studies published since 1831, common factors of height, weight, and BMI are extracted via Principal Components separately for height, weight, and BMI. Combining information from single growth studies and the common factors using in principle a Bayesian rationale allows for provision of completed reference charts.

RESULTS

The suggested approach can be used for generating synthetic growth reference charts with LMS values for height, weight, and BMI, from birth to maturity, from any limited set of height and weight measurements of a given population.

CONCLUSION

Generating synthetic growth reference charts by incorporating information from a large set of reference growth studies seems suitable for populations with no autochthonous references at hand yet.

Use of growth charts in Canada: A National Canadian Paediatric Surveillance Program survey

BACKGROUND

In 2010, the WHO Growth Charts for Canada were recommended for use in Canada, while the US Centers for Disease Control and Prevention (Georgia, USA) charts remained in active use.

OBJECTIVE

To assess the availability, utilization of and satisfaction with growth charts in clinical practice in Canada.

METHODS

In October 2012, a one-time survey was sent through the Canadian Paediatric Surveillance Program (CPSP) to 2544 paediatricians and 280 family physicians with a stated interest in paediatrics.

RESULTS

The response rate was 24% (63% general paediatricians, 36% subspecialists, 1% family physicians). Of these respondents, 68% preferred the WHO charts for infants and 49% for children and youth. Regarding the WHO charts, 49.7% of respondents reported concerns with their inability to assess weight for children >10 years of age, and many believed that there were too few percentile lines between the third and 97th percentiles for infant (24%) and for child and youth measures (19%). The addition of extreme percentiles (0.1 and 99.9), shading on charts and lack of availability with electronic medical record providers were other concerns mentioned by 10% to 13% of respondents.

CONCLUSION

There is support for the use of the WHO data for monitoring the growth of Canadian children. Concerns regarding the design of the charts were raised. These survey results lend support to the redesign of the WHO Growth Charts for Canada, as was recently completed in 2014.

Diencephalic syndrome: a frequently neglected cause of failure to thrive in infants

Purpose

Diencephalic syndrome is an uncommon cause of failure to thrive in early childhood that is associated with central nervous system neoplasms in the hypothalamic-optic chiasmatic region. It is characterized by complex signs and symptoms related to hypothalamic dysfunction; such nonspecific clinical features may delay diagnosis of the brain tumor. In this study, we analyzed a series of cases in order to define characteristic features of diencephalic syndrome.

Methods

We performed a retrospective study of 8 patients with diencephalic syndrome (age, 5-38 months). All cases had presented to Seoul National University Children's Hospital between 1995 and 2013, with the chief complaint of poor weight gain.

Results

Diencephalic syndrome with central nervous system (CNS) neoplasm was identified in 8 patients. The mean age at which symptoms were noted was 18±10.5 months, and diagnosis after symptom onset was made at the mean age of 11±9.7 months. The mean z score was -3.15±1.14 for weight, -0.12±1.05 for height, 1.01±1.58 for head circumference, and -1.76±1.97 for weight-for-height. Clinical features included failure to thrive (n=8), hydrocephalus (n=5), recurrent vomiting (n=5), strabismus (n=2), developmental delay (n=2), hyperactivity (n=1), nystagmus (n=1), and diarrhea (n=1). On follow-up evaluation, 3 patients showed improvement and remained in stable remission, 2 patients were still receiving chemotherapy, and 3 patients were discharged for palliative care.

Conclusion

Diencephalic syndrome is a rare cause of failure to thrive, and diagnosis is frequently delayed. Thus, it is important to consider the possibility of a CNS neoplasm as a cause of failure to thrive and to ensure early diagnosis.

Early attained weight and length predict growth faltering better than velocity measures in infants with CF

BACKGROUND

CF infants often do not grow as expected which adversely affects later clinical outcomes, thus sensitive early measures of growth deficiency are important. This study compared attained growth for age with velocity standards to determine which better predicts growth deficits at 24 months of age.

METHODS

Growth deficiency in infancy based on weight and length velocity, and attained growth was calculated for 1992 infants in the US CF Foundation National Registry using the World Health Organization (WHO) and US growth standards. One, two and three month increments were used for calculating velocity and pooled for each age interval. Sensitivity and specificity of early indicators to predict growth deficiency at 24 months were calculated.

RESULTS

Observed prevalence of weight deficiency (<10th percentile) during the first year of life was 26.8% higher (95% CI=(25.6, 28.1%), p<0.001) on average when measured by attained weight for age than velocity. Attained weight for age at four months was a more sensitive predictor of diminished weight for age (<10th percentile) at 24 months (sensitivity=100%, 95% CI=(87, 100%)) than weight velocity (sensitivity=40%, 95% CI=(23, 59%)). Attained length at four months was more sensitive to detecting subsequent stunting (<10th percentile length for age) (77%, 95% CI=(62, 87%)) than length velocity (30%, 95% CI=(19, 45%)).

CONCLUSIONS

In CF infancy, attained weight or length is more sensitive than velocity-based definitions for predicting subsequent diminished growth.

Extending World Health Organization weight-for-age reference curves to older children

BACKGROUND

For ages 5-19 years, the World Health Organization (WHO) publishes reference charts based on 'core data' from the US National Center for Health Statistics (NCHS), collected from 1963-75 on 22,917 US children. To promote the use of body mass index in older children, weight-for-age was omitted after age 10. Health providers have subsequently expressed concerns about this omission and the selection of centiles. We therefore sought to extend weight-for-age reference curves from 10 to 19 years by applying WHO exclusion criteria and curve fitting methods to the core NCHS data and to revise the choice of displayed centiles.

METHODS

WHO analysts first excluded ~ 3% of their reference population in order to achieve a "non-obese sample with equal height". Based on these exclusion criteria, 314 girls and 304 boys were first omitted for 'unhealthy' weights-for-height. By applying WHO global deviance and information criteria, optimal Box-Cox power exponential models were used to fit smoothed weight-for-age centiles. Bootstrap resampling was used to assess the precision of centile estimates. For all charts, additional centiles were included in the healthy range (3 to 97%), and the more extreme WHO centiles 0.1 and 99.9% were dropped.

RESULTS

In addition to weight-for-age beyond 10 years, our charts provide more granularity in the centiles in the healthy range -2 to +2 SD (3-97%). For both weight and BMI, the bootstrap confidence intervals for the 99.9th centile were at least an order of magnitude wider than the corresponding 50th centile values.

CONCLUSIONS

These charts complement existing WHO charts by allowing weight-for-age to be plotted concurrently with height in older children. All modifications followed strict WHO methodology and utilized the same core data from the US NCHS. The additional centiles permit a more precise assessment of normal growth and earlier detection of aberrant growth as it crosses centiles. Elimination of extreme centiles reduces the risk of misclassification. A complete set of charts is available at the CPEG web site (http://cpeg-gcep.net).

Weight for length/height percentiles in infants and young children in Kayseri/Turkey

OBJECTIVE

To produce weight for length/height (WLH) percentiles to be used for the screening of growth and assessment of failure to thrive in infancy and early childhood.

METHODS

The data (2009-2010) of the Anthropometry of Turkish Children aged 0-6 years (ATCA-06) study were used. A cross-sectional study was designed to calculate the WLH references. Reference weight values for each 5-cm LH intervals were determined using the LMS Chart Maker Pro version 2.3 software program (The Institute of Child Health, London).

RESULTS

A total of 3123 children (1573 female, 1550 male) aged 0-6 years were included in the calculation of the 3rd, 5th, 10th, 25th, 50th, 75th, 85th, 90th, 95th, and 97th WLH percentiles. The difference between the 3rd and the 97th percentiles for males was 2.02 cm to 12.64 cm in the 50-54.99 cm and 125-130 cm LH ranges. In the girls, the differences between the 3rd-97th percentiles ranged from 2.02 cm to 12.64 cm in the 50-54.99 cm and 125-130 cm LH groups. The maximum difference between the 3rd and 97th percentiles was about half the variation of mean WLH throughout the first six years of life. The most rapid change in WLH was observed in the 0-2-year period. Turkish references for WLH were not different from the World Health Organization standards.

CONCLUSIONS

This is the first study in Turkey presenting WLH references in 0-6 year old children. We suggest that the use of WLH in the first two years of life may be more useful than age-adjusted references in assessment of nutritional status and diagnosis of failure to thrive.

Clinical Characteristics of Failure to Thrive in Infant and Toddler: Organic vs. Nonorganic

PURPOSE

To investigate the clinical characteristics and outcomes among infants and toddlers with failure to thrive (FTT).

METHODS

This retrospective study was done with 123 patients who had visited Pusan National University Children's Hospital during their first two years of life and had received an FTT diagnosis. We compared the clinical characteristics of the patients based on the causes of their FTT and their ages at the time of first hospital visit. We investigated triggering factors, feeding practices, and outcomes in 25 patients with nonorganic FTT (NOFTT).

RESULTS

Eighty cases (65.0%) were NOFTT. The gestational ages, birth weights, and weights at the first visits were significantly lower in patients with organic FTT (OFTT) (p<0.05). Infants who had first visited the clinic at age <6 months had the least z-score. The percentage of patients with severe weight decline was higher in OFTT than in NOFTT (60.0% vs. 17.3%). The z-scores at the follow-up visits were improved after treatment in both of the groups. Preceding infection was the most common triggering factor of NOFTT and persecutory feeding as abnormal behavior of caregiver was observed in 22 cases (88.0%). After treatment with feeding method modification, all patients with NOFTT showed normal growth.

CONCLUSION

Weight decline is more severe in OFTT patients and in younger patients at the first visit. Infants with FTT can attain normal weight gain growth by treating organic diseases and supplying proper nutrition in OFTT, and by correcting abnormal dietary behavior of caregiver in NOFTT.

Growth failure in children: a symptom or a disease?

One of the most important aspects of a well-child examination is an assessment of a child's growth. Children who are failing to grow are often labeled "failure to thrive." However, close examination of the pattern of growth on standardized growth charts often allows the caregiver to characterize the growth failure as failure to grow, failure to gain weight, or failure to grow and gain weight. Such refinement of the pattern of growth failure allows for a more specific differential diagnosis and helps to focus laboratory and radiographic evaluation.

Microcephaly is associated with early adverse neurologic outcomes in hypoplastic left heart syndrome

BACKGROUND

Hypoplastic left heart syndrome (HLHS) is associated with significant mortality and morbidity. Fetal head growth abnormalities have been identified in a subset of HLHS fetuses, but it is unclear whether specific patterns of maladaptive growth affect clinical outcomes. We hypothesized that poor fetal head growth is associated with an increased frequency of adverse clinical outcomes.

METHODS

We retrospectively examined a cohort of HLHS patients from midgestation to 1 y of age. Fetal and birth anthropometric measurements were analyzed using the Olsen standard, and clinical outcomes were obtained.

RESULTS

A total of 104 HLHS patients were identified over a 12-y period; fetal data were available in 38 cases. HLHS neonates demonstrated a high incidence of microcephaly (12%), small head size (27%), and poor head growth (32%). All-cause mortality was 31% at 30 d and 43% at 1 y. Neurologic outcomes were observed in 12% of patients and were significantly increased with microcephaly (43 vs. 4%; P = 0.02). The average length of hospital stay following stage I palliation was 33.4 ± 33 d, correcting for early death.

CONCLUSION

In term nonsyndromic HLHS, fetal and neonatal microcephaly are associated with early adverse neurologic outcomes but not mortality.

Health of children classified as underweight by CDC reference but normal by WHO standard

OBJECTIVE

To ascertain measures of health status among 6- to 24-month-old children classified as below normal weight-for-age (underweight) by the Centers for Disease Control and Prevention (CDC) 2000 growth reference but as normal weight-for-age by the World Health Organization (WHO) 2006 standard.

METHODS

Data were gathered from children and primary caregivers at emergency departments and primary care clinics in 7 US cities. Outcome measures included caregiver rating of child health, parental evaluation of developmental status, history of hospitalizations, and admission to hospital at the time of visit. Children were classified as (1) not underweight by either CDC 2000 or WHO 2006 criteria, (2) underweight by CDC 2000 but not by WHO 2006 criteria, or (3) underweight by both criteria. Associations between these categories and health outcome measures were assessed by using multiple logistic regression analysis.

RESULTS

Data were available for 18 420 children. For each health outcome measure, children classified as underweight by CDC 2000 but normal by WHO 2006 had higher adjusted odds ratios (aORs) of adverse health outcomes than children not classified as underweight by either; children classified as underweight by both had the highest aORs of adverse outcomes. For example, compared with children not underweight by either criteria, the aORs for fair/poor health rating were 2.54 (95% confidence interval: 2.20-2.93) among children underweight by CDC but not WHO and 3.76 (3.13-4.51) among children underweight by both.

CONCLUSIONS

Children who are reclassified from underweight to normal weight in changing from CDC 2000 to WHO 2006 growth charts may still be affected by morbidities associated with underweight.

Child undernutrition in affluent societies: what are we talking about?

In this paper we set out to explore the prevalence of child undernutrition found in community studies in affluent societies, but a preliminary literature review revealed that, in the absence of a gold standard method of diagnosis, the prevalence largely depends on the measure, threshold and the growth reference used, as well as age. We thus go on to explore describe the common clinical ‘syndromes’ of child undernutrition: wasting, stunting and failure to thrive (weight faltering) and how we have used data from two population-based cohort studies, this paper to explore how much these different ‘syndromes’ overlap and the extent to which they reflect true undernutrition. This analysis revealed that when more than one definition is applied to the same children, a majority are below the lower threshold for only one measure. However, those with both weight faltering and low BMI in infancy, go on in later childhood to show growth and body composition patterns suggestive of previous undernutrition. In older children there is even less overlap and most children with either wasting or low fat seem to be simply growing at one extreme of the normal range. We conclude that in affluent societies the diagnosis of undernutrition is only robust when it relies on a combination of both, that is decline in weight or BMI centile and wasting.

Harmonizing national growth references for multi-centre surveys, drug monitoring and international postmarketing surveillance

AIM

National European growth references differ. We aimed to convert (harmonize) currently used charts into a single unified interchangeable LMS format for each European nation.

METHODS

Nine currently used national European growth references from Belgium (2009), France (1979), Poland (2001), Sweden (2002), Switzerland (1989), the UK (1990), Italy (2006) and Germany (1979 and 1997) were harmonized and compared with the international WHO child growth standards and WHO growth reference data for 5-19 years.

RESULTS

European growth charts can be harmonized. The approach appears useful as height, and body mass index (BMI) is inappropriately represented by WHO references. European height references exhibit warping when plotted against the WHO reference. The French appears too short, the other Europeans too tall. Also, the BMI is not appropriately represented by the WHO references.

CONCLUSIONS

Harmonizing references is a novel, convenient and cost-effective approach for converting historic and/or incomplete local or national growth reference charts into a unified interchangeable LMS format. Harmonizing facilitates producing growth references 'on demand', for limited regional purposes, for ethnically, socio-economically or politically defined minorities, but also for matching geographically different groups of children and adolescents for international growth and registry studies.

Nutritional approach to failure to thrive

Failure to thrive (FTT) is a term generally used to describe an infant or child whose current weight or rate of weight gains is significantly below that expected of similar children of the same age, sex and ethnicity. It usually describes infants in whom linear growth and head circumference are either not affected, or are affected to a lesser degree than weight. FTT is a common problem, usually recognized within the first 1-2 years of life, but may present at any time in childhood. Most cases of failure to thrive involve inadequate caloric intake caused by behavioral or psychosocial issues. The most important part of the outpatient evaluation is obtaining an accurate account of a child's eating habits and caloric intake. Routine laboratory testing rarely identifies a cause and is not generally recommended. FTT, its evaluation, and its therapeutic interventions are best approached by a multi-disciplinary team includes a nutritionist, a physical therapist, a psychologist and a gastroenterologist. Long term sequelae involving all areas of growth, behavior and development may be seen in children suffering from FTT. Early detection and early intervention by a multi-disciplinary team will minimize its long term disadvantage. Appropriate nutritional counseling and anticipatory guidance at each well child visit may help prevent some cause of FTT.

The impact of prenatal vitamin A and zinc supplementation on growth of children up to 2 years of age in rural Java, Indonesia

OBJECTIVE

To determine whether prenatal vitamin A and/or Zn supplementation affects postnatal growth.

DESIGN

Follow-up of a randomized controlled trial monitoring growth in children from birth up to 24 months of age.

SETTING

Central Java, Indonesia.

SUBJECTS

Children (n 343) of mothers participating in a double-blinded, randomized controlled study of vitamin A and/or Zn supplementation during pregnancy. We report the effects of prenatal supplementation on infant growth, measured as weight-for-age Z-scores (WAZ), height-for-age Z-scores (HAZ) and weight-for-height Z-scores (WHZ ), from 0 to 24 months, as well as differences in growth faltering among the supplementation groups.

RESULTS

For HAZ, the absolute differences between the vitamin A-only and vitamin A + Zn groups at 3 and 9 months were 0·34 SD and 0·37 SD, respectively, and the absolute difference between the vitamin A-only and Zn-only groups at 18 months was 0·31 SD. Compared with placebo, none of the supplements affected growth. Defining growth faltering as a downward crossing of two or more major percentile lines, 50-75% of the children were found to be growth faltering within 9 months of age, whereas 17% and 8% scored <-2 SD for WAZ and HAZ, respectively. Prenatal supplementation did not reduce the prevalence of growth faltering.

CONCLUSIONS

Prenatal vitamin A supplementation had a small but significant effect on postnatal growth of children's length until 18 months of age compared with supplementation with either vitamin A + Zn or Zn alone, but not compared with placebo. It had no effects on other anthropometric measures and did not reduce the prevalence of growth faltering. Future studies should duplicate these findings before recommendations can be made.

Malnutrition in pediatric hospital patients: current issues

Malnutrition in hospitalized children is still very prevalent, especially in children with underlying disease and clinical conditions. The purpose of this review is to describe current issues that have to be taken into account when interpreting prevalence data. Weight-for-height and height-for-age standard deviation scores are used for classification for acute and chronic malnutrition, respectively. Body mass index for age can also be used for the definition of acute malnutrition but has a few advantages in the general pediatric population. The new World Health Organization child-growth charts can be used as reference but there is a risk of over- and underestimation of malnutrition rates compared with country-specific growth references. For children with specific medical conditions and syndromes, specific growth references should be used for appropriate interpretation of nutritional status. New screening tools are available to identify children at risk for developing malnutrition during admission. Because of the diversity of medical conditions and syndromes in hospitalized children, assessment of nutritional status and interpretation of anthropometric data need a tailored approach.

Statistical agreement and cost-benefit: Comparison of methods for constructing growth reference charts

BACKGROUND

Growth reference charts are important tools for adequate paediatric decisions.

AIM

In view of the workload required to construct empirical growth reference charts we debate practicable and less demanding alternatives and took the recent national 2000-2002 Lithuanian growth charts as an example. Two options appeared reasonable: (1) applying international WHO child growth standards and WHO growth reference data for 5-19 years that are recommended for global use; or (2) replacing the costly empirical method of deriving national growth references by more convenient low-cost statistics, e.g. the method of generating synthetic references for the Lithuanian population.

METHODS

We analysed the degree of agreement between the 2000-2002 Lithuanian growth charts, and the international WHO child growth standards and WHO growth reference data for 5-19 years and synthetic references for the Lithuanian population using the Bland-Altman method.

RESULTS

Synthetically generated references for the Lithuanian population slightly surpassed the national Lithuanian reference for body height (males +0.3 (SD 0.9) cm; females +0.2 (SD 0.6) cm) particularly at young age, which may be regarded clinically irrelevant. WHO international child growth standards and the WHO growth reference data for 5-19 years, however, failed to match the Lithuanian references as they underestimated mean height in boys by -2.8 (SD 1.4) cm and in girls by -2.9 (SD 1.1) cm, with extremely discrepant estimates of more than -6 cm occurring in several adolescent cohorts.

CONCLUSIONS

The analysis revitalizes the debate on clinically relevant and at the same time practicable but less demanding alternatives for constructing growth reference charts, and for economic reasons, strongly suggests replacing the traditional empirical methods by synthetic growth references.

Etiology of failure to thrive in infants and toddlers referred to a pediatric endocrinology outpatient clinic

The aim of this study is to determine the underlying etiology of failure to thrive (FTT) in infants and toddlers referred to an outpatient pediatric endocrinology clinic. A chart review was done on FTT referrals to a pediatric endocrinology outpatient clinic between 2002 and 2005. Majority of patients (51.5%) had a purely nutritional deficiency. The endocrine etiologies included short stature due to being small for gestational age, constitutional or familial short stature (28.9%). The third most common etiology was gastrointestinal disease. Endocrine causes of FTT seem to be rare even in the selected population of patients referred to pediatric endocrine outpatient clinics. In the primary care setting, nutritional assessment and consultation seem to be adequate in the majority of cases. Only a small percentage of the patients with FTT will require a multidisciplinary approach and more extensive work-up.

Risk factors for failure to thrive in infancy depend on the anthropometric definitions used: the Copenhagen County Child Cohort

Failure to thrive (FTT) is the term widely used to describe poor weight gain in infancy, a condition associated with cognitive deficiency in later childhood. FTT has been investigated in earlier population studies, but little is known about risk factors for FTT or the sequence of events as this requires data to be collected prospectively within the first year of life. Furthermore, several different anthropometric criteria have been used to define FTT, and it is not known whether children identified by the different criteria are comparable. In the present population study we compared risk factors for FTT in a general infant population using different definitions of FTT. Three different criteria of FTT mirroring those used in previous population studies were applied to a birth cohort of 6090 infants. Sociodemographic data and prospectively collected information concerning physical and mental development of the children were obtained from National registries and standardised public health nurse records. Risk factors preceding each of the three 'types' of FTT were compared. The three criteria for FTT identified children with very different profiles and a prevalence of FTT ranging from around 2% to 21% in this affluent population. The criterion of slow weight gain conditional on birthweight (conditional weight gain) was associated with lower birthweight, small-for-gestational-age and deviant overall development. Adding low body mass index did not change this profile. In contrast, the commonly used criterion of downward crossing of centiles on an ordinary weight-for-age chart was associated with factors normally linked with low risk of adverse physical and mental development. Slow conditional weight gain, irrespective of additional thinness, seemed to identify infants with prenatal growth retardation and early developmental delays. In contrast, simple downward crossing of centiles seemed mainly to identify healthy low-risk infants, and thus, seems a poor screening measure of FTT in this affluent infant population. Thus, conditional weight gain appears to be the most sensible measure of FTT at present. However, only longitudinal studies including different anthropometric measures and different outcomes can unravel the discriminating power of the different FTT definitions concerning long-term prognosis.