Failure to Thrive in the Outpatient Clinic: A New Insight

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.

Prospective Associations between Maternal Depressive Symptoms during Early Infancy and Growth Deficiency from Childhood to Adolescence

Maternal health represents an important predictor of child development; yet it often goes unnoticed during pediatric visits. Previous work suggests that mental state affects parenting. The relationship between infant exposure to maternal depressive symptoms suggests conflicting findings on physical growth. Body mass index (BMI) has not been rigorously examined across development. Using a prospective-longitudinal birth cohort of 2120 infants (50.7% boys), we estimated the prospective relationship between symptoms of maternal depressive symptoms at 5 months postpartum and later BMI in typically developing children. We hypothesized that maternal depressive symptom severity would predict later BMI through to adolescence. Mothers self-reported depressive symptoms at 5 months. Child BMI was measured by a trained research assistant at ages 6, 8, 10, 13, and 15 years. We estimated a series of sex-stratified regressions in which BMI was linearly regressed on maternal symptoms, while controlling for potential pre-existing/concurrent individual and family confounding factors. Boys born to mothers with more severe depressive symptoms at age 5 months had a significantly lower BMI than other boys at subsequent ages. There were no such associations observed for girls. Maternal depressive symptoms were prospectively associated with later BMI for sons and not daughters, predicting risk of faltering in growth through to adolescence. Health practitioners should routinely assess maternal psychological functioning during pediatric visits to optimize parent and child flourishment.

Implementation of STRONGkids for identifying nutritional risk in outpatients of child health care clinics: Results of a multicentre study

AIM

To investigate nutritional risk across children in their first 2 years at child health care clinics in Jiangsu, China, and to highlight the importance of nutritional risk screening in outpatient clinics.

METHODS

A multi-centre, cross-sectional, observational study was conducted among outpatients in child health care clinics. Nutritional risk screening using the STRONGkids tool and anthropometric assessments were performed on children under 2 years old at outpatient initial visits in ten hospitals from March 2021 to March 2022.

RESULTS

There were 11,454 children enrolled. The percentages of children with high, moderate and low nutritional risk were 2.0% (228), 28.2% (3229) and 69.8% (7997), respectively. The occurrence rate of high nutritional risk was higher in female children than in male children (p < 0.05). The incidence of moderate nutritional risk in infants was significantly higher than in children aged ≥12 months (p < 0.01). Children with moderate or high nutritional risk more frequently answered 'yes' to the STRONGkids item 'high risk disease or major surgery planned'. The top three diagnoses related to nutritional risk were prematurity (50.5%), food allergy (14.3%) and recurrent respiratory disease (10.7%). In addition, the incidence of chronic undernutrition in children with moderate (14.0%) or high nutritional risk (36.4%) was significantly higher than acute undernutrition (p < 0.01).

CONCLUSION

Among children up to 2 years of age seen in child health clinics, nutritional risk associated with prematurity and potential disease requires special attention. Nutritional risk screening should be part of child health care, and STRONGkids is a useful screening tool.

Effect of oral nutritional supplements on outcomes in children presenting with, or at risk of, faltering growth in clinical settings: A systematic review and meta-analysis

This systematic review summarises evidence regarding oral nutritional supplement (ONS) use in children with, or at risk of, faltering growth (FG). Ten randomised controlled trials (RCTs), compared changes in outcomes amongst children receiving ONS versus control were included. Overall, 1116 children (weighted mean (WM) age 5 years; n658 (59%) male) were recruited, of which 585 (52%) received ONS (WM intake contribution 412 kcal, 16.3 g protein, 395 ml) for 116 days (WM). ONS use was associated with significantly greater gains in weight (mean difference (MD) 0.4 kg, 95% CI [0.36, 0.44]) and height (MD 0.3 cm, 95% CI [0.03, 0.57]), likely related to improvements in nutritional intake. Mean compliance to prescribed dose was 98%. Data suggested an association between ONS use and reduced infections. Further research is warranted to establish ONS dosage and effects upon other outcomes. This review provides evidence to support use of ONS in the management of children with, or at risk of, FG.

Effects of parent- and child-related behavioral feeding problems in early childhood on malnutrition

OBJECTIVE

Children's responses to food and their caregivers during normal developmental periods are known as feeding behavior. For the healthy development of these behaviors, parent and child relationships must also be healthy. Therefore, we aimed to investigate the effect of behavioral feeding problems on primary malnutrition (PM).

METHOD

The Behavioral Pediatric Nutrition Assessment Scale (BPFAS) was administered to 300 malnourished and 300 control pediatric patients aged from 9 months to 4 years who were referred to our pediatric gastroenterology outpatient clinic. Pre- and posttreatment data were compared between the two groups.

RESULTS

There was no statistically significant difference between patients with and without malnutrition in terms of gender and age (p = 0.191, p = 0.128, respectively). Total behavioral frequency (TBF) and total behavioral problem (TBP) scores were significantly higher in the malnutrition group (p < 0.001). In the logistic regression analysis of risk factors that may affect malnutrition we found that a total TBF score of ≥85 increases the risk of developing malnutrition 3.731 times, a child TBF score of ≥62 increases it 2.644 times, and a parental TBF score of ≥21 increases it 4.82 times (p < 0.001). When anthropometric measurements and BPFAS scores of 127 PM patients who received behavioral therapy with enteral products and who attended follow-up were compared with their pretreatment data, there was a significant improvement (p < 0.05).

CONCLUSION

Our study showed that behavioral feeding problems may increase the risk of PM and that behavioral therapy together with enteral products has a positive effect on treatment. Therefore, in addition to nutritional support in patients with PM, offering behavioral feeding therapy to parents will positively affect both the child's physical development and the relationship between the parents and their child.

Prenatal Mercury Exposure and Infant Weight Trajectories in a UK Observational Birth Cohort

Mercury is highly toxic metal found in trace quantities in common foods. There is concern that exposure during pregnancy could impair infant development. Epidemiological evidence is mixed, but few studies have examined postnatal growth. Differences in nutrition, exposures, and the living environment after birth may make it easier to detect a negative impact from mercury toxicity on infant growth. This study includes 544 mother-child pairs from the Avon Longitudinal Study of Parents and Children. Blood mercury was measured in early pregnancy and infant weight at 10 intervals between 4 and 61 months. Mixed-effect models were used to estimate the change in infant weight associated with prenatal mercury exposure. The estimated difference in monthly weight gain was -0.02 kg per 1 standard deviation increase in Hg (95% confidence intervals: -0.10 to 0.06 kg). When restricted to the 10th decile of Hg, the association with weight at each age level was consistently negative but with wide confidence intervals. The lack of evidence for an association may indicate that at Hg levels in this cohort (median 1.9 µg/L) there is minimal biological impact, and the effect is too small to be either clinically relevant or detectable.

New insights in pediatrics in 2021: choices in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, haematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine

In this review, we report the developments across pediatric subspecialties that have been published in the Italian Journal of Pediatrics in 2021. We highlight advances in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, hematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine.

Underweight in the First 2 Years of Life and Growth in Later Childhood

IMPORTANCE

Few studies have examined the association between underweight in the first 2 years and growth in later childhood in high-income countries.

OBJECTIVE

To evaluate the associations of underweight in the first 2 years of life with body mass index (calculated as weight in kilograms divided by height in meters squared) z score (zBMI), weight-for-age z score (WAZ), and height-for-age z score (HAZ) from ages 2 to 10 years.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study was conducted between February 2008 to September 2020 in The Applied Research Group for Kids! practice-based research network in Toronto, Canada. Participants included healthy children aged 0 to 10 years. Data were analyzed from October 2020 to December 2021.

EXPOSURES

Underweight (ie, zBMI less than -2, per the World Health Organization) in the first 2 years of life.

MAIN OUTCOMES AND MEASURES

The primary outcome was zBMI from ages 2 to 10 years. Linear mixed-effects models were used to account for multiple growth measures over time.

RESULTS

A total of 5803 children were included in the primary analysis. At baseline, the mean (SD) age was 4.07 (5.62) months, 2982 (52.2%) were boys, and 550 children (9.5%) were underweight. Underweight in the first 2 years was associated with lower zBMI (difference, -0.39 [95% CI, -0.48 to -0.31]) at 10 years and lower HAZ (difference, -0.24 [95% CI, -0.34 to -0.14]) at age 2 years. Stratified by sex, at age 10 years, girls and boys with underweight in the first 2 years both had lower zBMI (girls: difference, -0.47 [95% CI, -0.59 to -0.34]; boys: difference, -0.32 [95% CI, -0.44 to -0.20]). At age 10 years, children with underweight and a lower zBMI growth rate in the first 2 years had lower zBMI (difference, -0.64 [95% CI, -0.77 to -0.53) and HAZ (difference, -0.12 [-0.24 to -0.01]), while children with underweight and a higher zBMI growth rate in the first 2 years had similar zBMI (difference, -0.11 [95% CI, -0.22 to 0.001]) and higher HAZ (difference, 0.16 [95% CI, 0.05 to 0.27]) compared with children who did not have underweight in the first 2 years.

CONCLUSIONS AND RELEVANCE

In this prospective cohort study, children with underweight in the first 2 years of life had lower zBMI and HAZ in later childhood. These associations were attenuated among children with a higher growth rate in the first 2 years.

Benefits of Newborn Screening for Vitamin D-Dependant Rickets Type 1A in a Founder Population

BACKGROUND

Vitamin D-dependant rickets type 1A (VDDR1A) is a rare autosomal recessive disorder caused by pathogenic variants in the CYP27B1 gene. This gene is essential for vitamin D activation. Although VDDR1A is a rare condition worldwide, its prevalence is high in the Saguenay-Lac-Saint-Jean (SLSJ) region due to a founder effect. Daily intake of calcitriol before the onset of clinical manifestations can prevent them in affected children.

METHODS

A genetic screening test was developed and validated for the CYP27B1 gene c.262del pathogenic variant. Newborn screening was implemented in the SLSJ region for this variant, and the feasibility and acceptability were assessed. Sixteen medical records of children affected with VDDR1A were reviewed to document the consequences of the disease at diagnosis.

RESULTS

A total of 2000 newborns were tested for VDDR1A. Most families (96.5%) accepted the genetic test. We found a carrier rate of 1/29 for the c.262delG variant in our cohort, which is suggestive of a founder effect. We identified one child affected with VDDR1A and treatment was initiated before the onset of clinical manifestations. On average, children with VDDR1A were diagnosed at 13.8 ± 5 months of age, they had a significant failure to thrive at diagnosis, among other harmful health consequences.

CONCLUSION

Our study showed that in our population, the newborn genetic screening program is safe and feasible, it has high acceptability, and it is efficient to identify affected children. VDDR1A health consequences can be prevented by early initiation of treatment. Therefore, screening programs should be available for populations where it is deemed as beneficial from a public health perspective.

Effects of cyproheptadine on body weight gain in children with nonorganic failure to thrive in Taiwan: A hospital-based retrospective study

Failure to thrive (FTT) impairs the expected normal physical growth of children. This study aimed to evaluate the effects of cyproheptadine hydrochloride on growth parameters in prepubertal children with FTT. The medical records of prepubertal children who were newly diagnosed with FTT at China Medical University Hospital between 2007 and 2016 were retrospectively examined. The patients were divided into two groups depending on whether they had (T-group) or had not (NT-group) received cyproheptadine hydrochloride (0.3 mg/kg daily) for at least 14 days. The mean length of the treatment period was 97.22 days (range: 14–532 days). Weight, height, and body mass index were adjusted for age using the median values in the growth charts for Taiwanese boys and girls as the reference. A total of 788 patients aged 3–11 years were enrolled, 50 in the T-group and 738 in the NT-group. No statistically significant difference in the median age-adjusted weight value was noted between the T-group and NT-group during the follow up period. In the T-group, age-adjusted weight and body mass index were inversely associated with age (P <0.001, P <0.001) and positively associated with medication duration (P = 0.026, P = 0.04). Our findings underscore the positive association between cyproheptadine hydrochloride treatment and weight gain among prepubertal children. Further prospective clinical studies with a. longer and consistent treatment course is warranted.

Changes in Learning Outcomes after Dietary Intervention in Preschoolers: A Pilot Study

The executive functioning skill set, which includes working memory, cognitive flexibility, and inhibitory control, begins developing in early life and continues into adulthood. Preschoolers' abilities to perform those skills may be influenced by diet. The purpose of this study was to explore the acute effects of consuming a low-GI diet compared to the usual childcare diet on preschoolers' self-reported feelings of hunger and fullness and their performance on learning-associated tasks. This study was a prospective feeding trial in n = 20 children 3-4 years of age, completed in a laboratory setting where children attended "day camps" and consumed two days of usual diet (CON) and two days of low-GI (INT) diet. Learning outcomes were evaluated using select learning assessments including the Kansas Reflection-Impulsivity Scale for Preschoolers (KRISP), Track-it, Peg Tapping, and Happy/Sad. Repeated measures, full-factorial analysis of covariance revealed that diet was significantly related to impulsivity (p > 0.05), and univariate analysis of variance indicated that feelings of hunger and fullness differentially affected cognitive constructs in that feeling full improved impulsivity and attention, while feeling hungry improved inhibitory control. These findings highlight that the connection between diet and learning-related skills of children are independently mediated by both diet composition and feelings of hunger and fullness.