Feeding and growth problems in the first year
Feeding and growth problems in the first year
Background
These are very common problems in primary care and cause much confusion. Most often the symptoms that babies get are a normal part of infancy. At the same time, there are significant problems which can be difficult to differentiate due to the overlap within conditions such as reflux disease and food allergy.
In many places, babies have a hand-held record which contains information about their growth. This can be a useful tool for identifying children who may have feeding and growth issues, but monitoring can also cause huge amounts of anxiety in parents and healthcare professionals when a baby crosses a line on their growth chart. The problem of trying to make a sensible assessment of the child is made worse by parents’ reports of the child’s feeding. I have frequently been presented with children who never feed, always vomit back the whole feed and more. Often they are reported to have not had a wet nappy for days or have visually lost huge amounts of weight. These babies are usually smiling at me in a knowing way, while drooling and bursting out of their baby grows. You see, parents are programmed genetically to worry. So, a posit becomes ‘the whole feed’, and all vomiting (you will notice) is projectile. Then there may be friends and relatives who accompany the parents and choose to show support by adding to the anxiety. These well-meaning people feel that it is their duty to make you see how badly this baby is wasting away. Of course, they may be correct, but in that case, it should be relatively straightforward to identify that there really is a problem.
Your task therefore is to identify the well, thriving baby in order to reassure parents and avoid inappropriate investigations. You also need to identify a child who is genuinely failing to thrive. You must then determine what the underlying problem is and decide whether to refer or initially intervene yourself.
How to assess
The first thing to understand is that there is no good or universally agreed definition for faltering growth. The way that I was taught at medical school defined the crossing down of two centiles on the growth chart as ‘failure to thrive’. However, this is a poor measure on its own. It is possible to lose the same amount of weight and yet cross different numbers of centile lines depending on where you started. It is therefore better to look at the growth chart as a whole for some idea of whether you should be concerned, but remember that it is only one part of the jigsaw. Remember to look at the baby and not just the growth chart.
The basics of assessing possible faltering growth:
•Take a history. Who is worried – the parents or health professionals? Are they feeding but not growing, or growing but not feeding?
•Ask about frequency of wet nappies.
•Ask about any watery or bloody stools.
•Ask about any family history of similar problems.
•Take a feeding history. Be specific and don’t accept vague answers.
•Plot weight, length and head circumference. Look at trends since birth.
•Examine the baby fully, as at a newborn exam.
•If a child has been small from birth and is simply tracking the centiles, check parents’ heights. Are they both short?
The ‘must do’s
Look at the baby. By this I mean the baby as a whole. Do they look well? Taking a growth chart at face value without seeing the child is a fast track to embarrassment. They may be completely well and thriving or they may be quite unwell, in which case you will be glad that you asked to see them and didn’t just refer to a routine outpatient appointment.
Examine the baby as though they have never been examined before.
Consider the mother’s appearance. Does she look well nourished? Does she seem depressed or excessively anxious?
Consider that there may be a medical problem, though most cases are not related to a problem with the baby, but rather a lack of calories.
Remember to consider neglect. Both physical neglect and emotional neglect will affect growth.
Pitfalls to avoid
Looking at the growth chart without looking at the child.
Not checking that weights etc have been plotted correctly.
Accepting statements that the baby is feeding well or feeding poorly. Always ask for exact volumes and frequencies, or (if applicable) whether breasts feel emptied after a feed.
Do not dismiss how experienced a parent is. A parent who has four other children is much more likely to know what is normal. At the same time don’t fall into the trap of dismissing a first-time parent’s concerns. They have instincts that are still valid.
Thinking that all vomiting is reflux – it is often overfeeding or just normal.
Thinking that by now someone else should have looked at baby’s palate, listened to their heart etc. It is best to examine the baby from scratch.
How to be a know-it-all
More than any other specialty, paediatrics is riddled with rare syndromes. Each is somewhere on a scale from rare to vanishingly rare, and you are unlikely to encounter most of them in your career. Paradoxically there are so many of these syndromes that you will probably encounter one unexpectedly at some point. Despite the fact that you cannot possibly learn how to recognise each one individually, you can recognise when you are seeing a child who may have a syndrome if you keep the possibility in your mind. Feeding and growth problems are a likely presentation of many syndromes and metabolic illnesses. These conditions are often initially unrecognised, and if you are the one who spots that something is a little different, you will be at risk of feeling rather pleased with yourself.
Specifically, the kinds of thing that should make you consider one of the more unusual medical causes are listed here:
•Previous child deaths or late miscarriages in the family.
•Consanguinity of parents.
•Exposure to toxins during pregnancy (eg alcohol, recreational drugs or prescribed medication) and history of antenatal infections.
•Low birth weight and persistently low weight/length/head circumference since birth.
•Dysmorphism – this is a tricky one, and often quite subjective. Many babies do look a little odd, especially in the first few hours after birth. If a child is mildly dysmorphic then I would suggest that you look for a family resemblance first, and if there is none, then you take your findings as a whole. Dysmorphism on its own is a significant clue and may prompt early referral of a child with a feeding or growth problem.
•Other abnormalities such as heart murmurs should raise suspicions, because any abnormality, even if initially assumed to be benign, may suggest an underlying condition. If a child with a heart murmur develops feeding or growth problems while awaiting a scan, urgent referral is needed.
•The tone of the baby in particular is important. Babies with congenital abnormalities are frequently floppy.
If you think that there are indicators of an underlying syndrome then, assuming that the child is well, a paediatric outpatient follow-up should be arranged.
Finally, in the well and normal child, you should still consider the possibility of a medical problem. A urinary tract infection (UTI) is one possible cause to consider early on.
Also worth knowing
•Cow’s milk protein allergy (CMPA) is over-diagnosed but still an important cause of feeding and growth problems. Every effort should be made to try simple changes to feeding, before changing to specialised formulas. If a baby does seem to be convincingly affected by CMPA, there are dozens of milks available to use. They work by breaking down the proteins so that they do not cause the problems that the whole protein would. The first stage is hydrolysed milks which have partially broken down the proteins in the milk. Some formulas go further, and contain only amino acids. See below for further advice on management.
•Because the size of the placenta affects growth in the womb, some babies will exhibit what is referred to as ‘catch down’ growth in the first few weeks. They will most likely be brought to your attention by someone who is concerned that the child has dropped through two centiles. These are large babies at birth whose natural weight is on a lower centile. These babies may maintain their weight rather than gaining any, until they find the centile where they belong, which they then grow along obligingly. They are healthy throughout and do not look like they are failing to thrive. Another clue lies in the child’s proportions. Look for symmetry of the different measurements. If weight is dropping towards the centile which the length is already on, ‘catch down’ is more likely. If weight is dropping and falls to a centile well below that of length, then a growth problem is more likely.
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