Growth has a long tradition of being used as a measure of young children's health and well-being. Weighing begins early at the ante-natal clinic with the expectant mother being anxious to put on just the right amount of weight for optimum health for her baby. Scans measure babies' growth and parents are reassured if the gestational size appears right. Subsequently parents are frequently asked after their baby is born 'how much does s/he weigh?' and visits to the clinic can often convey success or failure to parents in relation to whether the baby has gained weight. Stern (1995) has described a strong biological need within most mothers to ensure that their baby survives - if a mother feels unable to feed her infant successfully she may well experience intense anxiety and depression and a feeling of failure.

Faltering growth is a common occurrence and health visitors can play a key role in taking the failure out of faltering growth. Most children with faltering growth will be detected by the primary health care team and supported within the community. Supportive, empowering home visiting not only helps families to overcome this problem, it may well prevent children developing a worrying weight loss in the first place.

Historical context -exploding the myths 

At the turn of the century the term 'failure to thrive' was commonly used to describe children, often brought up in foundling homes, who were thought to receive adequate food but still grew poorly. Gradually it became assumed that these children failed to grow because they lacked stimulation and love from their carers. Failure to thrive was divided into two separate categories: 

The two types of failure to thrive were thought to be completely separate although later research clearly shows that these sharp divisions are not helpful, as the two categories are not mutually exclusive. Also, they usually have the same cause in that the child is receiving too few calories. In fact evidence suggests that only about 50/o of young children with inexplicable poor growth are found to have a previously undiagnosed illness and only a very small minority have faltering growth because of abuse or neglect (Boddy and Skuse,1 994; Wright and Talbot, 1994).

Faltering growth is present in all socio-economic groups yet research indicates that health visitors showed certain misconceptions. Batchelor and Kerslake's (1990) study showed that babies who were well cared for and had no signs of physical illness were just considered small and others, who were weighed regularly, passed unrecognised. Yet children from poorer families were often considered to be neglected if their growth was faltering.

In faltering growth most of the research up until the 1980s tended to focus on the distorted mother/child relationship which was thought to lead to mothers offering their child too few calories. Current research (cited Batchelor 1999) has shown that the majority of mother-child relationships in families where a child has faltering growth are no poorer than in the families where children are growing normally. Current research has become more sophisticated and moved away from the simple 'cause and effect' model. Studies now highlight an interactional perspective in which a multiplicity of factors may result in faltering growth (Batchelor, 1999).

Why is faltering growth important?

Faltering growth is not a 'syndrome' or a specific disease, but simply an observation that a child is growing exceptionally slowly. This growth can sometimes reflect serious underlying problems and, if unresolved, may result in stunted growth and delayed development. Thus it is important that all children with slow growth are identified and given support.

Health visitors must recognise that:

Prevalence

As many as 50/o of children under 5 years of age will experience an episode of growth faltering at some stage (Batchelor and Kerslake, 1990).

What causes children's growth to falter?

Growth requires a combination of a child's genetic potential and the food energy needed to achieve this. Children grow extremely fast in the first two years of life and consequently need large amounts of food to fuel this growth.

Energy needs in the first year

It is hardly surprising that many different sorts of circumstances may interrupt feeding and result in growth faltering.

How do children become undernourished?

This may occur because of decreased appetite due perhaps to illness, feeding difficulties, dietary misconceptions, late weaning or inappropriately restricted diets. There may be associated organic conditions such as asthma, chronic infection, cerebral palsy or congenital heart disease, which may lead to decreased dietary intake or increased calorie needs. In a few cases under-feeding may be a result of major social or emotional problems in the family. Inappropriately applying adults' 'healthy eating' patterns, such as high fibre, low fat diets to children may also cause growth to falter. Children's energy requirements may also vary greatly as a result of individual metabolic rates or differing levels of activity. Faltering growth only rarely results from an inability to absorb or utilise energy intake as a result of conditions such as coeliac disease, cystic fibrosis, cow's milk protein intolerance or upper gastro-intestinal obstruction.

The food to growth chain

The following 'food to growth' chain is useful in showing the basic necessary steps for nutrition and to help health visitors identify the areas where problems may occur. 

Requirements  Influencing factors
   
Purchase  Budgeting, shopping, storage
Preparation  Cooking facilities and skills
Giving  Meals offered when, where, how
Taking  Eating behaviours and skills
Using  Absorption, metabolism, growth

 Effects of faltering growth 

The long-term effects of faltering growth are not clear. Some research shows that there may be an effect on cognitive development, while other studies indicate that these effects may not be long lasting.

Clearly there is a need for more rigorous studies to determine any long-term effects of faltering growth.

Are professionals effective at identifying faltering growth?

Batchelor and Kerslake (1990) found a wide disparity in the ability of health professionals to identify faltering growth from the routine measurements.

Batchelor and Kerslake suggested several possible reasons why HVs failed to identify faltering growth:

The following guidelines are intended to aid health visitors to detect children at risk of faltering growth.

Diagnosing faltering growth

Protocols for weighing children need to be followed carefully so that measurements are accurate and consistent. The following basic guidelines should be followed at every clinic so that they become routine for parents.

Weighing 

Babies should be weighed regularly without clothes so that an accurate growth curve can be plotted. Weighing too frequently may cause anxiety. 

Age Range No more than once every: No less than once every:
1 -3 months Fortnight Month 
3-12 months Month  3 months
1-2 years  3 months 6 months
Over 2 years 6 months At 2 1/2 years and school entry

Environment and equipment

Which weight charts?

The following sections are intended to help health visitors identify children whose weight is either faltering or at risk of faltering. Patterns of growth vary from one individual child to another and health visitors will benefit from frequent discussions with colleagues about their concerns. It is recommended that staff have time allocated to discuss and share concerns. A home visit arranged to coincide with a mealtime offers invaluable insights into possible areas of difficulty.

Identifying faltering growth -when does slow growth become faltering growth?

Many people in the past have identified children as failing to thrive if their weight falls below the 0.4th centile. This is not a helpful definition as it will include some constitutionally small children and fails to identify naturally large children who have not yet fallen as far as the bottom centile. Good practice suggests using a definition for faltering growth that requires a child's weight to have shown a downward movement on the centile chart. Using the charts for children with slower growth allows a more precise measure of deterioration or improvement in growth than the simple use of centile charts.

Abdul's weight crossed completely through two inter centile spaces from a baseline position taken at eight weeks, ie. from the 75th centile at two months, to the 25th centile at five months. This would be described as moderate growth faltering with approximately 5% of children's weight falling this far. Naomi's weight fell rather more and crossed four centile spaces between two months and six months and this weight loss would be considered severe.

Why is it so difficult to offer effective support?

Social assessment findings in Newcastle suggest three key reasons why support to parents with a child with faltering growth was ineffective.

  1. Professional message was not clear
    Professionals may not have engaged successfully with parents, due to the difficulty in 'breaking bad news', lack of professional understanding of problem or cultural or language difficulties.
  2. Parents unable to receive message
    Parents may have difficulty in accepting that the growth is poor or that the diet and care may be causing poor growth.
  3. Parents unable to respond to the message
    Parents may be overwhelmed by life stresses, relationship difficulties, financial crises or lack of support. They may have experienced emotional trauma which impairs their coping abilities and parenting relationships.

Faltering growth may show in a variety of patterns on the centile chart

Normal growth is usually defined in relative terms and, in general, growth is a continuous process. Gentile charts allow a child's growth to be viewed in relation to the normal growth of a population.

Hobbs et al (1993) classified a number of different growth patterns which health visitors may identify. These growth patterns may be less easily identified than those of a child whose weight falls clearly and continuously down across centiles. The centile charts that describe children with slower growth should enable health visitors to detect patterns, such as the following, more easily.

These patterns are not always obvious, so it is good practice to discuss children's growth patterns with colleagues and time needs to be allocated for this.

Interventions for children with faltering growth

Interventions must be supportive and provided in a non-stigmatising mariner that is acceptable to the cultural norms of the family.

Parents often feel an acute sense of failure if they are not able to ensure adequate nutrition for their child. Those who have been told by medical staff that there is nothing wrong and to get calories into their child often report 'trying everything' including, games, feeding on the move, giving constant sweet snacks and force feeding. Support must reflect the family's lifestyle and must aim to raise parents' confidence.

Faltering growth should be identified early and interventions provided speedily to avoid adverse effects such as cognitive delay, feeding and behaviour problems and low maternal self-esteem. 

Research suggests that the earlier malnutrition begins and the more severe it is the greater the effect on growth and development. Many families who have fraught mealtimes would benefit from supportive advice as a preventative measure even when children's growth is not faltering.

Cycle of interactions compounding feeding difficulties

Case Study 

Nasrat, the third child of Sikh parents, was born at 35 weeks gestation weighing 830 grams, indicating a degree of intra-uterine growth retardation. Following discharge from hospital Nasrat was monitored for a short time by the neo-natal service. At ten months Nasrat was admitted as an emergency to hospital with uncontrolled eczema and poor weight gain. She had extensive investigations for failure to thrive - all results were normal. Nasrat was put on a milk-free diet because of the eczema and was then monitored as an outpatient. The eczema was well controlled, but Nasrat was referred to the hospital dietician as she was taking only Wysoy and very little solid food. Liquid food supplements were prescribed, and she was then lost to the hospital follow-up service. 

At two years Nasrat was weighed at the clinic and found to be well below the 0.4th centile. The health visitor did a home visit and discovered that Nasrat was very well cared for, although mealtimes were chaotic with Nasrat relying mainly on bottled Wysoy for nutrients. The parents felt that the hospital had not given sufficient feeding information. They had specific cultural beliefs about illness, such as the single hospitalisation would cure their child. This failure discouraged the parents from seeking further advice. 

In desperation, the parents had been attempting to force-feed Nasrat, creating a good deal of tension in the family. Both parents were working long hours which made it difficult for them to institute appropriate routines. The health visitor found difficulties at every level of the 'food to growth' chain and felt that it was vital that she was present at mealtimes. The parents had been considered to have adequate English, yet it was only when a Punjabi support worker was involved that progress was made. 

A whole range of factors contributed to Nasrat's faltering growth and, importantly, the parents were feeling under-confident in their role. An individual, structured, home-based support programme with the health visitor as key worker, and a Punjabi interpreter, worked with the family over a period of six months. During this time the difficulties with feeding decreased, Nasrat's weight increased and the parents began to feel much more confident.

Intervention Models

The Children's Society has developed a programme called Feeding Matters which has proved effective in helping families to resolve the factors which are perpetuating their child's feeding difficulties and contributing to their faltering growth and development (Hampton, 1996). The programme is based on social learning theory and the belief that every child has the right to a 'good start' in life. There is recognition that there are no easy answers to faltering growth or the parents would have already discovered solutions.

The following points are key:

The Newcastle Growth and Nutrition Team have developed a community-based service for management of children with failure to thrive which has evolved from evidence-based research of the Parkin Project. This service supports health visitors, acting as key workers, following identification of faltering growth of children in their own caseloads. The health visitors diagnose faltering growth and provide the intervention. This is carried out through an enhanced home visiting programme.

The aim of this service is to: 

The family health visitor acts as the primary worker and is supported by the multi-disciplinary team comprising: 

This intervention has been evaluated by a randomised controlled trial and has shown that health visitor intervention with limited specialist support can significantly improve growth compared to conventional management (Wright et al 1998 b).


References 


Source: The Children's Society and the Community Practitioners and Health Visitors Association