Assuring Pediatric Nutrition in the Community

FREQUENTLY USED GUIDELINES:
Failure to Thrive - Assessing Nutritional Status

HOW DO I ASSESS A CHILD WHEN I SUSPECT GROWTH FAILURE? A comprehensive nutrition assessment is recommended when growth failure is suspected. This assessment typically includes a physical history and examination, laboratory tests, feeding and diet assessment, evaluation of anthropometrics and growth velocity, and psychosocial evaluation. The most comprehensive evaluation is done by an interdisciplinary team, with specialists from pediatrics, nursing, speech pathology, occupational therapy, nutrition, and social work.

Physical history and exam
Anthropometrics and growth
Laboratory tests
Feeding and diet
Psychosocial issues

What should be included in the physical history and examination when growth failure is suspected?
Medically-related reasons for compromised growth should be evaluated; this is often done by the child’s primary care provider. A history of uncomfortable oral procedures (e.g., intubation and long-term nasogastric feedings) often interferes with adequate intake. Some conditions, as mentioned above, are associated with depressed growth. An evaluation of a child’s behavior and development can provide useful information as well; since, behavioral problems can interfere with eating.

What should I include in evaluation of anthropometrics when growth failure is suspected?
Measure weight and stature for age and plot on appropriate growth charts. Weight for length or BMI for age will provide information about weight and stature proportionality. Triceps skinfold measurements, in conjunction with arm circumference, can be used to estimate fat and muscle reserves. Longitudinal growth data is more valuable than a single measurement, as it provides a comprehensive look at a child’s nutritional status. Evaluate growth velocity to monitor changes.

Weight is more sensitive to nutritional insults than height, and it is generally affected first. Changes (decreases in percentiles) in a child’s stature or head circumference are generally symptoms of chronic undernutrition. At this point, a child’s weight for height or length can appear appropriate; this is called stunting.

What laboratory tests should be considered when growth failure is suspected?
Nutrition-related laboratory tests should be done as indicated by the individual’s symptoms. For example, tests for malabsorption might be warranted if a child has a history of chronic diarrhea. A test for cystic fibrosis is recommended if a child exhibits symptoms of cystic fibrosis.

What should be included in a feeding and diet assessment when growth failure is suspected?
Assessment of feeding skills includes observation of a meal or snack and subjective reports from parents and caregivers. Parents are usually able to provide critical information about their children’s eating habits. Both observation and parent report can reveal the presence of oral-motor problems, including abnormal muscle tone, problems with coordination (suck/swallow, hand/mouth), choking, gagging, structural problems (e.g., cleft palate), and oral hyper- or hyposensitivity.

When physical barriers to effective feeding are suspected, consult with a feeding specialist. Speech, physical, and occupational therapists can provide assessments of motor-related feeding problems.

A diet record or history will help to determine whether or not a child is receiving adequate nutrition. If an infant is breastfed, determine the frequency and duration of feedings, and ask questions about maternal intake and psychosocial and environmental influences. A lactation consultant is a useful team member when problems with breastfeeding are suspected. If an infant is formula-fed, review formula preparation methods.

Estimates of food intake should be as detailed as possible and should reflect the actual intake of the child, rather than the amount of food offered or prepared. Assess overall energy intake and intakes of macronutrients (protein, carbohydrate, and fat) and micronutrients (vitamins and minerals).

Ask about the child’s pattern of intake, including when foods are offered and what types of foods are offered. Determine whether or not foods offered are developmentally appropriate.

What psychosocial issues should be examined when growth failure is suspected?
Psychosocial and environmental factors should be assessed. (This is typically done by the social worker or psychologist, but some information can also be obtained during the nutrition assessment.) Examine the access to food. Barriers to an adequate diet can include lack of financial resources, lack of caregiver knowledge, delays in feeding skills, and behaviors that interfere with eating. Inadequate parenting and neglect can also contribute to an inadequate nutrient intake. Since the parent-child relationship plays a vital role in the development of positive eating habits, this can be assessed when the clinician observes a feeding session.