Is this weight normal or is it slow weight gain?
Growth charts identify children who are lean. However, crossing percentiles or being in the lower echelons of the percentile chart does not necessarily mean the child has a problem. The charts may not distinguish between those who are sick/undernourished (i.e. true SWG) and those who are lean simply because they are meant to be (i.e. normal).
Birthweight percentile does not predict future weight and perfectly healthy children may cross percentile lines. In the first year of life, deceleration of growth may be normal, until infants equilibrate to their ‘true’ growth channels. Later in childhood, some children will be in the lower percentile for weight because of genetic or constitutional factors. These children are lean because they are meant to be. They will appear healthy, with good muscle bulk, adequate subcutaneous fat, normal activity and development.
Children who are lean because they are undernourished are usually apathetic and withdrawn with poor muscle bulk. Reference to the family’s growth parameters may be helpful. Further evidence of adequate growth can be sought in anthropometric measurements such as skinfold thickness.
Categories of slow weight gain
- Poor caloric intake – nutritional, chronic illness.
- Increased caloric losses – vomiting, malabsorption.
- Poor utilisation.
- Increased metabolic requirements.
Non-organic slow weight gain
This accounts for >50% of SWG in Australia.
- Inadeguate food intake – careful dietary history.
- Psychosocial factors in parent or child – includes maternal depression, deprivation and neglect of the child.
- Rumination.
Organic slow weight gain
This may also have a non-organic component.
- Poor intake: numerous causes.
- Renal disease: UTI, renal tubular acidosis, chronic renal insufficiency.
- Cardiorespiratory: chronic upper airway obstruction, congenital heart disease, cardiomyopathy, bronchopulmonary dysplasia, cystic fibrosis (CF).
- Gastrointestinal: cleft lip and palate, Pierre Robin syndrome, gastro-oesophageal reflux, pyloric stenosis, coeliac disease, pancreatic insufficiency (CF, Shwachman syndrome), inflammatory bowel disease (IBD), Hirschsprung disease.
- Endocrine: hyper-and hypothyroidism, adrenal insufficiency, diabetes insipidus.
- CNS: congenital and acquired CNS or muscle disease may cause inadequate feeding.
- Tumours: including diencephalic syndrome.
- Chronic infection: immune deficiency, tuberculosis.
- Genetic, chromosomal or intrauterine causes: intrauterine growth retardation, trisomy syndromes.
- Metabolic: galactosaemia, phenylketonuria, acrodermatitis enteropathica, amino and organic acidopathies, hypercalcaemia.
History should focus on intake and losses. Also consider familial patterns of weight gain and growth, psychological and developmental assessment.
- Intake: what is consumed, how it is made up, when were solids commenced.
- Output: amount and colour of vomit, stool frequency and consistency.
- Birth: weight, gestation, complications.
- Past history: chronic illness, recurrent infections.
- Family history: possible maternal depression, growth pattern of other family members, illnesses and consanguinity.
Examination should focus on growth parameters and nutritional status (see chapter 6, Nutrition). Happy, outgoing children with good muscle bulk in thighs and buttocks are unlikely to have significant undernutrition. Look for signs of macro/micronutrient deficiency and evidence of system-based disease.
Avoid random tests. The history and examination should guide the direction and tempo of investigation. If the cause of SWG is not readily apparent after history, examination and limited investigations (e.g. FBE, urine M/C/S), further investigations and management should be in consultation with a specialist.
Second line investigations might include liver function, renal function, thyroid stimulating hormone, inflammatory markers, faecal microscopy, screening for coeliac disease, rickets, occult infection, immune dysfunction and a sweat test.
The underlying cause will determine the treatment. Admit to hospital for:
- Severe undernutrition.
- Failed outpatient management.
- Child abuse or neglect.
- Extreme parental anxiety or depression that requires time to allow a constructive patient– doctor relationship to develop.
Admission may facilitate further assessment of feeding technique, the parent–child interaction and allow the involvement of a multidisciplinary team.
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