Here’s help with the tricky business of deciding whether a patient’s sluggish weight gain or growth is a normal variation or warrants a workup. Pediatric gastroenterologist Robert J. Rothbaum, MD, describes how to consider various factors; breaks down the reasons for abnormal growth patterns; and offers tips on assessing feeding habits, selecting age-appropriate lab tests, and knowing when imaging is helpful. Bonus: Learn about online growth charts for specific disorders, such as cerebral palsy.
All right. The so I know how to read a growth chart but I don't know how to like get this organized. They. Alright, so then we're gonna talk about what evaluations are are pertinent for very for particular variations and uh weight gain and growth. So part of the challenge is to define what failure to thrive means. I think because this column here on the left is all the different definitions that are used in different papers And you know usually you would think they overlap but clearly not everybody who crosses two major percentile lines for weight or length, it really ends up less than the 5th%ile. The and you know not everybody may have weight for height less than 70%. So even after however many years this terminology has been around Which is at least 50, it's not completely uniform. And I think it requires um sort of looking at the growth chart examining the child and a lot of clinical judgment uh and experience about how to interpret those things because we can look at this growth chart here for weight and the first six months of life and you know, the the weight is sort of sinking in percentile, Not really less than the 50 has crossed two major lines. So might qualify for failure to thrive. The might be considered inadequate weight gain, but we may need to know some background and then though, if we continue to follow this ah sorry, the growth curve can develop into what is in the lower right and maybe instead of failure to thrive it was the assumption of a new growth pattern. So often the diagnosis of failure to thrive requires can require a considerable amount of time to in terms of several months to reach that conclusion. Because we could have started to work out up here and we're not looking at this now we're not likely to have found anything in particular. So it certainly is possible to change percentiles without an underlying disorder. And 25% of infants are gonna change one or more major percentiles uh within the first year or two of life. And it can occur any time in this a spare. And what's happening here is the intra uterine environment is what's determining the birth weight uh And length more so than the stature of size of the parents and it's genetic influences. They're starting to predominate over intra uterine factors with these changes in percentiles. And for the for us this can this can be sort of a nerve wracking time. Uh I think if we're worried about failure to thrive because the the child maybe sinking a little bit in percentiles and we keep hoping they're they're going to level off on a particular percentile and we have to sort of endure that until that's likely to happen. Clearly we you know if the parents have short stature were more likely to our small size were more likely to sort of consider this as a likely diagnosis then some units some pre matures. Some I. G. I. U. G. R. Davies and some STB a baby's there many of them are going to catch up or they're going to be normal on appropriate growth charts but not all of them. And so some babies with intra uterine growth retardation or particularly if they're low in weight some who are S. G. A. And that is all their parameters are affected. A significant percentage are not gonna to get to be normal science. And something happens in utero in terms of you know potential body mass. I think that has long term effects. So many of these infants will catch up. They're not specific growth charts for these guys. Um and but some will not and you know it's it's not 2%. It could be more in the range of 14 or 15%. The these these Children tend to be lean but not always short. Although some will also end up actually. Then you might predict based on their mid parental height and then babies who are born L. G. A. You know which is usually infants of diabetic mothers they actually have catch down growth So They may start at the 95th or above percentile and then they sink in percentiles until they get down to their genetic uh expectations. So this can be of concern to if we're following them you know every few months and we're watching the percentiles fall and we're worried that there's some kind of reason for that. So catch down growth uh babies who start out bigger then we might have expected and doesn't doesn't represent uh disease. Alright. So what if we are concerned that there's failure to gain weight and what we think is inappropriate cabin and this almost always represents insufficient net energy balance. And you know, there's sort of three ways to get there. Either inadequate intake, insufficient digestion and absorption or increased energy utilization. This is at the bottom because it's the rarest of all and many things that we think might um sort of increased energy expenditure. Actually, when you measure energy expenditure it does not. The and I'm going to use um congenital heart disease as an example. And it's often said that all they need extra calories. And but what it usually turns out is is that if if they are having trouble gaining weight, then the problem actually often relates more to this inadequate intake, not because of lack of effort of people trying, it's because their intake is irregular and they may have some extra losses often through vomiting. So that their net energy intake actually ends up to be on an irregular basis less than we would expect. More so than there being somehow hyper metabolic. So that's why a lot of attention and those babies goes to maintaining their intake as best we can. Either orally or changing formulas are using uh tube field. Okay. And you are all very familiar with all these reasons for inadequate intake. I think everything from not enough, you know, intake available, I think to sort of misreading of baby's cues and behaviors um in terms of when they want to eat and how much they eat and then we get down to, you know, are there some physical reasons either an atomic abnormalities in the oral pharynx or esophagus or neurologic abnormalities or chronic respiratory or cardiac disease? That that makes it very difficult for babies to take in enough orally. And you know, as you would expect these things are usually evident from physical exam if they're severe enough that to interfere with intake. And so you can you can identify those um either by history and symptoms are by example, the this is not, we're not going to go over each of these. This is this is just how I sort of, you know, remind myself of things that I should think about. I think in terms of um kind of things to look for the in terms of anatomical abnormalities and neurologic abnormalities and this, as I said, chronic respiratory or cardiac disease. So I usually have somewhere that I kind of keep a list like this that I was sort of a mental checklist for me, the uh so that I don't kind of overlook anything like I sometimes don't think about, you know, cohen latricia and partial nasal obstruction. Uh but the baby has got to be able to breathe through their nose if they're going to be able to suck a bottle and swallow at the same time. Often in if this is if insufficient intake is the problem and you have the time and space than seeing what the baby looks like when they're eating can be really helpful in terms of how organized is there suck? And do they have any cough or gagging while they're sucking? Is their nasal regurgitation and things like that, that the parents may certainly tell you about it in the history, but sometimes, you know, they're not as they're not always looking for the same things that we're looking for. So if it's possible to kind of observe a feeding and, you know, oftentimes it's difficult because maybe just ate before they got to the office or a variety of things uh can often give a lot of good information. And these are these are these are the things here that I'm usually looking for. Um it's kind of physical reasons that might interfere with eating it. So we also get into when it comes to eliminating oral intake, some areas that are much more difficult to quantitative and evaluate. And one of these is oral aversion, which I kind of defined as a refusal of oral intake. And there's a variety of reasons for this that we encounter. Sometimes it's just an immature baby, I can't, you know, coordinate sucking and swallowing. Sometimes it's adverse experiences. You know, they've been intubated the days, you know, had multiple procedures I think, and the adverse experience has interfered with their ability to be interested in eating. And then sometimes it we we we are sort of encourage encouraging the parents to feed more but they get kind of overzealous and they're trying to overcome the baby's usual cues for when it's time to eat. And then the infant unfortunately gets more and more resistant, which of course then leads to more and more efforts at feeding and then the infant gets more and more resistant. And this can be a very difficult um situation to to overcome but usually can be be handled I think on the outpatient side and without a lot of aggressive intervention as long as we were able to kind of recognize that pattern. If there's disorganized, suck and swallow, then it's often a neurologic disorder. You know, sometimes many, most of the time there's other neurologic signs uh and symptoms as well. And then this I find to be a very difficult area, which is this area of silent aspiration and using video swallows for evaluation in infants who are slow or sort of clumsy eaters who make off a little bit, you know, while they're eating. And this is, you know, as I'm sure you're aware that has become very popular, you know, evaluation tool for babies who are having trouble eating. But it's and and it often leads to a recommendation for changing the consistency or thickness of feedings or sometimes eating even for two feedings I think, and switching to to N. G. These things. And it's very hard to know what some of these things mean. Like silent aspiration. The definition is basically it's a baby who has seen two aspirating on a video swallow but has no symptoms of that going on and the hard part is what do we do with that if that is seen on a video swallow? But the baby really has not had any pulmonary or respiratory symptoms or findings. And what does that mean? And does that really mean that the baby is at risk of aspirating with every feeding? And that's the problem? What does it mean that that's what happened during the period of observation and it's not necessarily with every feeding or is it related to age? There's some recent literature that suggests that infants having video swallows at less than 50 weeks Estimated distance. So less than a 10 week old infant may not have the same Lauren geo reflexes as every other as older babies. And you may see more of this without the presence of pulmonary disease, Then when they get to be a little bit more mature, does it have to do with having an energy in place? Does it having to do with having an acute illness? So they're both, there are studies that look at both doing a swallow study with an energy in place and doing a small study and babies who were like recovering from bronchiolitis. And there's more quote silent aspiration unquote scene in these instances, uh, than in an otherwise completely healthy injury. So this is an area of a lot of clinical observation and investigation, but I'm not sure that we necessarily understand everything about it. And I wish I could give you some definitive guidelines, but it depends a lot on um sort of what else is going on with the baby. And is there another underlying disorder? And have there been pulmonary symptoms as well and your therapists? And um, they're sort of interpretation of risk. So it's kind of a collaborative effort about how to handle this. All right. So if the baby seems to be able to eat enough and we're worried that there's a problem with digestion and absorption, what things do we think about it? And really in a baby who appears generally healthy, that is not a baby who's not having, you know, dehydrating diarrhea on a chronic basis, the most common mucosal injuries or either celiac disease, which happens, you know, after gluten has been introduced. And I think one of the questions had to do with how much gluten does it take, you know, before you might have immunological reaction to a new coastal damage to celiac too gluten. And I don't think we know it in in trials, in adults who are willing to go through this. It takes very small amounts of pollutants to lead to new coastal changes in celiac disease in the order of you know, a milligram or less. So it's tiny amounts of gluten. So if there's usually if there's been any gluten exposure on a fairly regular basis, I and I see this kind of growth pattern. I'm screening for celiac disease. Um So the other phases of digestion that we think about are the patriots of which almost everybody with execution pancreatic insufficiency has CIA It's in the newborn screen now, but about a little over around 1-2% of CF patients, we'll have a negative newborn screen. And so it is possible, you know, to have Cf and to pass their newborn screen and then to develop mexican insufficiency later on the and the test for this is to do a fecal, a last case. So it's a no it's just a random stool specimen available through Children's or through quest or labcorp. And you know, it made a last taste is a protein that's not that survives through the G. I. Tract. And so it's relatively easy to measure. And then the others causes of excellent insufficiency again are so rare that they usually don't and have other manifestations. Uh besides just not gaining weight very well. And then cola static liver disease, you know, most people are jaundiced with that not everybody, but they clearly have abnormal trans am in aces uh and or alkaline foster taste or gamma GT and well, I'll show you later that that's kind of part of the usual general screening that we do. Okay, so how do we assess? We do a dietary history can watch them feed if we can physical exam. These are the sort of lab tests that may be useful. I think almost they're they're not positive very often if you take all infants who have been diagnosed with failure to thrive and do them. The even even celiac, You know, the frequency of Celiac, the general population is one in 300. So, you know, that's that's a lot. That's even less than this. So the so we do these things, but they're often, you know, not not very revealing. And then sometimes radiology of their specific diagnoses that are of interest or questions. Hospitalization has become an uncommon thing. Sometimes it's useful for observation of the baby's feeding. You know, sometimes it's hard to get a history of quantity or the regularity of intake or this there there's a lot or there's a lot of symptoms described during feeding that we need to try to sort out. Sometimes it helps get additional resources either from social word or feeding therapy or things in kind of a relatively rapid way looking for weight gain is certainly possible in an infant. But it becomes very problematic for, you know, Children who are above age one because their rate awaking is so slow at that age, You know, there Gaining five or 10 g a day. So it would take a long time to decide if they're going to gain it out. The I think. So it's it's really it's it's much more if if if if you're looking for weight gain it's going to be much more useful in infants than it is in somebody who's over there. Okay. One group I wanted to talk about in particular and that we often are dealing with these kids with cerebral policy or and because it's a really good example of the importance of having growth charts that are specific to disorders. So this is this is on the left here is a growth chart for normal boys and the age in years and what their weights are. And this is this is kilos. The and this is the growth chart for Children with quadriplegic. For boys with quadriplegia cp. and you can see so where what's 5th%ile here is 55 kg at age 20 fifth percentile here. Yes. Mhm. The 25 kg B. And so the expected weight gain or the anticipated weight gain and somebody with cp. And this is both orally fed and and some too the the expected weight gain in somebody with significant cp uh particularly quadriplegic is far different than what we would expect from somebody who's normal. And so we have to be careful about you know plotting the planting kids with cp on a normal growth curve because it's not gonna look good. Their length tends to be less effective. There are many growth charts available online for cp and they have them for uh dia please tick ah Children for quadriplegic Children and for hemiplegic Children. And so if you're patient fits into any of those categories, you can you can obtain growth charts of what would might be expected for them. So where is the deficit And kids with CP And and if we give them supplements, what are we fixing? So this is a study that looked at several parameters. Weight, body mass index, two sides, skin folds. So what's that? What that is measuring is fact thickness, how much fat stores that are. And then this mid arm upper fat index is kind of doing the same. So what do we see? We see that it's a relatively small number of Children. So all of them had a relatively low body weight the and that's the block and they all had a relatively low body mass index. But interestingly Very few had a less than 5th%ile. Two fat ladies. And they're fat. And here very few were in these better percentiles for weight, the black ones or for BMI. This sort of cross hatch one. And you know, they were stayed in lower percentiles. But you can see the fat fel thickness actually it was not bad. You know, intended to be in the upper percentile. The so they were generally and we often use fat fold thickness as an indication of adequacy of calories being provided. Since you don't tend to put on fat until you've burned up all your calories putting on lean body. So yes, Children with CpR underweight. Yes, there B. M. I. Is low but it's not because they're lacking fast and what they're lacking is lean body mass and it is mostly sarka pina or mostly lack of muscle. So what are we looking at here we're looking at this is this dave measured through a variety of external measurements the muscle girth of the upper arm. So the clear boxes normal. I mean sorry, the upper arm, the thigh and the cat. So the white boxes normal chunk. And then the the sort of cross hatch here is orally fed kids with CP. And the black box is to fit the seafood. So what do we see? So we see that when you're measuring the muscle and this is boys and when you're measuring the muscle and you compare this muscle girth of normal in the thigh in particular, less so in the arm and in the lower leg to in the caf, that's what the kids with CP are missing. And that's kind of what you would expect because um you know, your muscle bulk is determined by how much use you have. So if you're not using those muscles very much, you're not going to put on muscle books. So yes our weight is low. Yes their weight is there B. M. I. Is low 25% of your weight actually turns out to be the muscle bulk in your legs. So if your muscle bulk is low there your weight is going to be low. But we already saw that it's not and it doesn't matter if you are orally fed or tube fed, it's still gonna be low and two feeding is not going to increase the muscle mass. The it will increase the fact. So I think the takeaway is for kids with CP of which we follow many in all of our practices, their specific growth charts for them uh that can be used to analyze their weight and if we intervene and have them gain weight then that maybe that may well be fat mass and not but hopeless. Alright, so when we talk about failure to thrive, we also, I mean we're interested in the weight but really we'd like to know so what what happens, You know the kids were failure to thrive slow. You know, slow weight gain over time. You know. Is there some long term effect of this? And that's not an easy thing to figure out as you would imagine because it means you have to find kids when they are being diagnosed but then you have to find them again, you know when they're several years old and see what happened to them and if anything sort of was outcome. So this has been done a few times you can see not often because this is from 2007. So when they looked at these three groups adequate growth FTt control. That is not a lot of in for intervention. And then home intervention about advice and counseling. There was a gradual improvement in weight and height over the preschool years. But there was a residual deficit in height and weight at age eight five cm and four Cuba with And without home intervention. Now, was that the way they were gonna be? Or is that related to the FTT? We don't know exactly. This was associated with maternal height. So their parents tended to be smaller or mother tended to be smaller as well. So maybe there's a long term growth effect on this. And the B. M. I though it was adequate growth was better than FTT Home intervention was better than FTP control. But this was not you know, 20% different. It was like two uh between the groups. So maybe some long term effect on growth, but not a tremendous amount of data. So do you end up with a different eye q if you were undernourished as an infant? And the answer is doesn't really look like that as long as you match socioeconomic backgrounds, Maybe you're a little better than that if you had a little if you had adequate growth or if you had an intervention, the and then there were more behavior problems and less developed work habits in school, depending on more so an ftt control. But again, we don't know was this a primary part of why they had failure to thrive? Or is it really do too this short period of under nutrition? And there's not a lot of there's not a there's not a lot of data to look at it in adolescence. So it's very hard to figure out if there's a long term effectiveness. So we've talked a lot about fair to gain weight and fair to grow is somewhat different because it usually is not due to caloric deficit. Uh And we're talking about, you know, a growth chart that looks like this or like this where the weight and the length are sort of tailing off together. And this tends to be disorders that I don't manage as much and tends to be endocrine disorders, skeletal problems, syndromes or genetic short steps the and not not so much a nutritional problem. And do I do some evaluation for this? Yes. I mean we can send thyroid studies and we can you know, send the surrogate markers for growth hormone if they're a little bit older. You know, I. G. F. One and the I. G. F. You know, BP three. We certainly can see if they are dysmorphic or um or if they have body, you know disproportion uh that might suggest a skeletal dysplasia and get the parental but we're often, you know, looking to our colleagues in endocrine or sometimes genetics to help us figure this out. So short stature. These are the things that we think about and we're gonna talk and these are this is this is the evaluation that, you know, we would think about in various circumstances. The and or if we think it relates to their genetics, not in terms of the syndrome diagnosis, but in terms of familiar short stature or constitutional delay, then we really want we really need the family history of how tall are the parents. And when did the parents go through puberty? In terms of constitutional delay. Yeah. And the difference will look like this. And the first of all, we're usually talking about older Children rather than really young Children. So in familiar short stature, which is I know it's hard to tell the difference from these two. It's it's this purple line uh with the circles, so they are, here's the mean height on the growth curve and they are consistently below the mean height. And you know, you can plot the mid parental height and see if they're going to end up wherever that mid parental height, constitutional delay is. They may be. They may start out somewhat short, but then when everybody else is starting to have a growth spurt in terms of puberty, they are not. And so everybody else is going faster, they are still growing but at a slower rate. So they're gonna fall in percent times compared to everybody else. The and their bone age may be delayed, which is a good thing, but because it means that they have longer to grow the and so they will look like they're you know, sort of falling off the growth curve at this point. But then with time they will get back and they will end up actually with a normal type. But this period this period can be a little distressing for both parents and professionals And but if we have this history of delayed puberty, the in both the family and the youngster, then we can be a little more uh I feel a little more safe that it's going to be constitutional delay. Now we worry a lot about inflammatory bowel disease. You know, when we see a growth curve like this which has impacted height, I'm sorry, wait more so than height and you are all very familiar with the, you know sort of symptoms, physical findings, lab findings, they go along with inflammatory bowel disease. The we had one question uh, pre about fecal cal protected and and when do we start? And there's a couple of cautions about locale protecting one is there are some non disease conditions which can elevate people to protect them in anyone. And those are the most common things will be Nsaids and proton pump inhibitors. Now they don't usually elevate locale protect into a 1000 but they can elevate people calm protected too. A couple of 100 The which is above the usual listed value of normal, which is 50. So we have to be cautious about that. The other thing that we can see is that if you're less than age four, you can have an elevated sequel count protecting and that can go up to a few 100 and you're still normal. You don't have any disease. So we tend to shy away from doing people can protect and kids who are younger and if we get an elevated value that's sort of middling, middling and not really high, then we go back and take a little more history and make sure they're not on any medications that might affect. And then if not, then we have a lot of these parameters, then we think about upper and lower endoscopy, looking for inflammatory bowel diseases. Okay, so if we have somebody who has an acquired, you know, poor weight gain or a little slowing and pipe, what are the things that we think about? And, you know, any acquired disease in these realms. But you're going to find that, you know, if they, you know, develop significant valvular heart disease, you're you're going to recognize that on exam or significant chronic lung disease or with screening tests, renal disease, you're going to find those things. This is, you know, as you get older, you get into patterns of disordered eating. Either anorexia nervosa or bulimia actually more common. Maybe now this avoidant restrictive, you know, food intake disorder or orphaned these kids, they tend to eat very little. They often talk about G. I. Symptoms that interfere with their eating. I feel full fast, I feel like I'm gonna throw up, I feel bloated, but they don't actually throw up and they don't actually have diarrhea and they don't actually look bloated on exam. So they have a lot of subjective reasons that maybe limiting their intake and they often are rather anxious. One thing that I think is still evolving is in the in the older child who has a fall off in weight. We know about cannabis hyperemesis where they have severe abdominal pain, repeated vomiting end up in the emergency room multiple times. But there's they're all there's also when I talked to the eating disorders folks and through sort of recent anecdote, we're wondering if there's a phase that's kind of pre vomiting where that leads to a lot that's a lot of cannabis use and associated decrease, marked decrease in intake but not actual bombing. And this is when you read about cannabis hyperemesis, they actually talk about a pre vomiting phase of nausea and decreased intake and weight loss, but you can see it's very hard to assign that diagnosis, you know, to an adolescent who has lost a lot of weight without looking into it somewhat. Plus, you know, it can be confusing because, you know, if you ingest or smoke cannabis, your urine test can be positive for days to weeks and it doesn't help you quantitative, you know how much cannabis they're using and there's not a clear guideline about, oh, you're going to have G. I. Or weight side effects from cannabis if you're using it four times a week versus once. There's just not that that you would think there would be. But there's not that kind of data. And then we often ask about stimulus stimulant medications because they can have a effect on or appetite and lead to pauses in weight, not so much height. It goes away when they change medicines and they end up with a normal adult weight or height. Alright, this is sort of a little shorthand of you know, what causes abnormal which might be useful to you uh sort of as a office resource. Just sort of what's the growth pattern over years of these, different of constitutional delay, familiar short stature, nutritional deficiency, growth hormone deficiency and a genetic syndrome like Turner syndrome. That's kind of a reminder. Uh and uh for a differential. And that's why I was I was going to make sure that we sent out the slide. Alright, so variations in pattern of weight gain and growth. You can have benign changes in the first year and we've got to think about pre existing conditions and whether we need to do specialized growth. They're fair to gain weight is usually net energy deficiency. Most common reasons, low intake either maybe by disease because maybe because of disease, maybe because of lack of availability of food. Maybe because of psychological we can think about male absorption, but it's not very common. The fair to grow in height comes from endocrine genetic syndrome, maker skeletal disorders. And the in later childhood we have to consider non G. I. Disorders and medication effects for effects on weight and then inflammatory bowel disease often begins early in the second decade. So that's, you know, Age 10, 11, 12. And now we're also seeing much younger Children. But those much younger Children are rather ill with bloody diarrhea. Fair to gain weight. Anemia, low albumin. You know, indications that there's lots of inflammation and as for most things, the history and exam give you the most information the observation can help. And, you know, there are a few lab tests that can help uh, figure things out. Mm hmm.
