Medical providers need to monitor growth at every visit. Weight status is influenced by genetics, medical conditions, socioeconomic status, and family environment. Screening for food security and psychosocial risk factors is an integral tool to identify families at risk for nutritional deficits and child maltreatment. Nutritional rehabilitation is best accomplished in an outpatient, multidisciplinary setting. Medical neglect should be considered in failure to thrive and obesity when there is a serious risk of harm from identified medical complications, additional or worsening medical complications occurring despite a multidisciplinary approach, and/or non-adherence with the treatment plan.
Key points
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Weight status and interval weight gain should be documented at every medical visit.
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Screening for psychosocial risk factors and food security is integral to prevention of nutritional deficiencies and child maltreatment.
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The etiology of FTT or obesity is seldom the result of a single causative medical, genetic or socioeconomic factor.
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The approach to nutritional rehabilitation in FTT or obesity requires multidisciplinary assessment and management.
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Weight status, in the absence of medical complications, does not necessarily constitute neglect.
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Weight status, with concern for future health, may reflect neglect, and a report to child protective services (CPS) may be needed.
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Medical neglect should be considered in both failure to thrive and obesity when there is a serious risk of harm from identified medical complications, additional or worsening medical complications occurring despite a multidisciplinary approach, and/or noncompliance with the treatment plan.
Introduction
Discussions on malnutrition in childhood and adolescence have traditionally centered on inadequate growth as well as nutrient deficiencies, such as iron or vitamin D. Malnutrition is a “cellular imbalance between nutrient requirement and intake” and should encompass both undernutrition and overnutrition. Undernutrition may negatively affect both physical growth and development. Inadequate growth in weight or height, based on serial observations on a growth chart, is often referred to as failure to thrive (FTT). Whereas FTT is the result of inadequate nutrition, the focus of the medical system often shifts to etiology (organic or nonorganic) and to determine whether there is caregiver neglect or maltreatment. In 2013, the American Society for Parenteral and Enteral Nutrition pediatric malnutrition working group recommended defining malnutrition or FTT as illness related or non–illness related, encouraging an approach that includes the role of illness, as well as environment and behavioral factors. Overnutrition, in the form of obesity, can have medical complications in childhood that predict serious morbidity in adulthood with much current debate as to the role of caregiver neglect and referrals to child protective services (CPS). Both forms of malnutrition involve a complex interaction of medical and psychosocial factors and necessitate a comprehensive, multidisciplinary approach to evaluation and treatment.
Introduction
Discussions on malnutrition in childhood and adolescence have traditionally centered on inadequate growth as well as nutrient deficiencies, such as iron or vitamin D. Malnutrition is a “cellular imbalance between nutrient requirement and intake” and should encompass both undernutrition and overnutrition. Undernutrition may negatively affect both physical growth and development. Inadequate growth in weight or height, based on serial observations on a growth chart, is often referred to as failure to thrive (FTT). Whereas FTT is the result of inadequate nutrition, the focus of the medical system often shifts to etiology (organic or nonorganic) and to determine whether there is caregiver neglect or maltreatment. In 2013, the American Society for Parenteral and Enteral Nutrition pediatric malnutrition working group recommended defining malnutrition or FTT as illness related or non–illness related, encouraging an approach that includes the role of illness, as well as environment and behavioral factors. Overnutrition, in the form of obesity, can have medical complications in childhood that predict serious morbidity in adulthood with much current debate as to the role of caregiver neglect and referrals to child protective services (CPS). Both forms of malnutrition involve a complex interaction of medical and psychosocial factors and necessitate a comprehensive, multidisciplinary approach to evaluation and treatment.
Defining age-appropriate growth
The approach to malnutrition requires an understanding of normal growth in childhood. Measurements of height and weight should be obtained at serial visits and compared with growth standards for males and females as well as special populations (eg, prematurity, Down syndrome). In 2010, the Centers for Disease Control and Prevention (CDC), the National Institutes of Health, and the American Academy of Pediatrics recommended the adoption of the World Health Organization (WHO) 2006 growth charts for children ages 0 to 2 years and the CDC 2000 growth charts for children ages 2 to 19 years. The WHO 2006 growth charts include longitudinal serial data on children younger than 2 from multiple countries, whereas the CDC 2000 charts are based on cross-sectional, nonserial data from only the United States. The infants differ; 100% of WHO infants were still breastfeeding at 4 months versus only one third of CDC infants. Although the CDC 2000 charts use the 5% and 95% to designate underweight and obesity, WHO 2006 utilizes z-scores of -2.0 and 2.0 translating to 2.3% and 97.7%, respectively. There are concerns that the WHO 2006 growth charts, in comparison with the CDC 2000 growth charts, underestimate the percentage of children who are underweight or stunted in height and overestimate the percentage of children who are overweight and obese. If the WHO growth chart is utilized correctly, similar results occur for height and overweight. Despite these concerns, WHO 2006 charts are considered growth standards “that describe how healthy children should grow under optimal environmental and health conditions.”
Traditionally, FTT has been identified in children who have a weight for age that drops below 3% to 5% or who have crossed two major growth percentiles. Crossing of major growth percentiles, however, is not uncommon in healthy children. Acute malnutrition or wasting is defined as inadequate growth for fewer than 3 months and is reflected in weight for age. Chronic malnutrition, defined as inadequate growth for longer than 3 months, includes deficits in height velocity or stunting. There are multiple classification strategies ( Table 1 ) for determining the degree of malnutrition (mild, moderate, or severe). The use of WHO or Cole z-scores may have some benefits over other methods, because neither requires the determination of an ideal weight or ideal weight for height for the individual child. Overweight or obesity is best represented by weight for height or body mass index (BMI) with 85% to 94% defining overweight, 95% to 98% obesity, and 99% or greater severe obesity. However, caution is urged in classifying adolescents because their BMI can exceed adult criteria for obesity (BMI ≥30 kg/m 2 ).
| Classification | Definition | Severity | |
|---|---|---|---|
| Gomez | % median WFA (current weight/median WFA) | Mild | 75%–90% WFA |
| Moderate | 60%–74% WFA | ||
| Severe | <60% WFA | ||
| Waterlow | Z-score (SD) WFH | Mild | 80%–90% WFH |
| Moderate | 70%–80% WFH | ||
| Severe | <70% WFH | ||
| WHO (wasting) | Z-score (SD) WFH | Moderate | −2 to −3 |
| Severe | −3 or less | ||
| WHO (stunting) | Z-score (SD) HFA | Moderate | −2 to −3 |
| Severe | −3 or less | ||
| WHO | MUAC | Severe | <115 mm |
| Cole | Z-score for BMI for age | Mild (grade 1) | −1 to −2 |
| Moderate (grade 2) | −2 to −3 | ||
| Severe (grade 3) | −3 or less | ||
Prevalence
Based on WHO growth standards, it is estimated that 16% of children younger than 5 years in developing countries were underweight in 2011. This translates to more than 100 million children. Moderate or severe wasting was noted in 8% or 51.5 million children, with stunting occurring in 26% or an estimated 165 million children. Based on data from the National Health and Nutrition Examination Survey for 2007 and 2008, it is estimated that only 3.7% of children and adolescents in the United States are underweight with a trend toward improvement from 5.1% in the National Health and Nutrition Examination Survey I (1971–1974). The prevalence of underweight among adults in the United States has also decreased from 4% of adults (20–74 years of age) in the 1960s to 1.7% in 2007 through 2010. These estimates, however, include children and adults who are small but healthy.
Overweight and obesity have demonstrated an opposite trend. Worldwide, United Nations International Children Emergency Fund estimates that 7% or 43 million children are “overweight,” with an increase of 54% noted over 1990. The prevalence of obesity in adults in the United States has doubled as measured between National Health and Nutrition Examination Survey data from 1976 through 1980 and 2007 through 2008. Weight status, as measured by BMI in childhood, is predictive of weight status and obesity in adulthood. This is especially true for adolescents over 13 years of age who have a more than 50% increased risk of adult obesity if they have a BMI greater than the 95th percentile. As of 2010, it is estimated that obesity affects 35.7% of US adults and 16.9% of children 2 to 19 years of age, which includes 9.7% of toddlers (0–2 years) and 12.1% of preschoolers (2–5 years). Most alarming, severe childhood obesity (BMI >99th percentile) affects 4% or 2.7 million children between the ages of 2 and 19 years.
Etiology
The etiology of either FTT or obesity is rarely the result of a single causative factor. Nutritional status has associations with race, sex, and even geographic location (state-based rates of obesity). Beyond these associations, there are multiple complex interactions that require a systems-based approach to both recognizing risk factors for inadequate nutrition as well as for treatment and prevention. Contributory factors include socioeconomic status, community and health care supports, family environment and the individual child. It is not surprising that low- and middle-income countries have higher rates of malnutrition; strong negative associations exist between socioeconomic status (poverty, food security, and education), nutritional status, and child development.
Food Insecurity
Women and children in the United States have higher rates of obesity at lower income or educational levels. In 2012, an estimated 21.8% or 16.1 million children under 18 years of age lived in poverty and 15.9 million children lived in food-insecure households. As defined by the US Department of Agriculture, food security is the ability to have consistent and dependable access to enough food for an active, healthy life; food insecurity implies a reduced access to food owing to limited money. Food insecurity is associated with poor health for children and caregivers, as well as risk for impaired development. Growth parameters alone are not adequate screens of food insecurity; older children and adolescents may not demonstrate growth deficits. Furthermore, there are also associations between food prices, food insecurity, and obesity.
Many food insecure families live in food deserts (urban and rural) where ready access to affordable healthy food is very limited. Food deserts occur in both low-income and low-access communities. Communities are considered “low-access” food deserts if a significant percentage of families reside more than 1 mile from a grocery in urban areas, and more than 10 miles in rural areas. Food insecure families are more likely to report problems with transportation, limited income, prioritizing payment of utilities and rent over food, and a reliance on low-cost foods to feed children. Although many families are eligible for participation in the Supplemental Nutritional Assistance Program, statewide access rates vary considerably. Caregivers not receiving Supplemental Nutritional Assistance Program benefits such as WIC owing to access problems report higher levels of food insecurity and are more likely to have underweight and short infants. Access to Supplemental Nutritional Assistance Program not only lowers rates of food insecurity, but improves academic outcomes and paradoxically may reduce risk for obesity owing to less reliance on low-cost, energy-dense foods.
Complex psychosocial issues challenge caregivers’ abilities to nurture and feed children. Health care providers have a unique opportunity throughout childhood to interact with families with an ability to screen for nutritional and psychosocial issues, such as poverty, food insecurity, knowledge deficits, depression, substance abuse, domestic violence, and access to resources (eg, transportation, health insurance). Screening can be incorporated into health supervision utilizing questionnaires and psychosocial assessments administered before or during the appointment. Food insecurity can be assessed with a sensitivity of 97% utilizing an affirmative response (true or sometimes true vs never true) to either of two following statements:
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“Within the past 12 months we worried whether our food would run out before we got money to buy more.”
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“Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more.”
Many of the risk factors for nutritional deficits such as FTT and obesity are the same risk factors associated with child maltreatment. Furthermore, the patterns of family dysfunction are quite similar between families with undernourished children and those with severely obese children. Screening for psychosocial risk factors in primary care practice is an important tool in the prevention of nutritional deficits and child maltreatment.
Assessment of Growth and Nutrition
Medical providers need to assess children for abnormalities in weight status. Although physicians perform similarly to parents in the identification of a child’s weight status from photos, calculation of BMI or weight for height does not occur at every medical visit. In a large survey, few physicians calculated BMI at every visit and the majority of physicians discussed weight issues only when they identified it as a concern. Fewer than one half of the physicians knew the criteria for overweight and obesity. Documentation of nutritional status, dietary history, activity level, and education provided to families also needs improvement. Multiple barriers hinder physicians from addressing nutrition in daily practice, including inadequate identification of weight status, fear of offending families, a belief that families do not want weight issues addressed, as well as not having ready access to a nutritionist. Because of these barriers and the demands of busy clinical practices, physicians would benefit from the development and validation of a brief screening tool for food insecurity and nutritional status.
There are syndromes, monogenic and polygenic conditions associated with FTT and obesity. Obesity genes (monogenic causes), such as LEP (leptin), LEPR (leptin receptor), proopiomelanocortin (POMC), and melanocortin 4 receptor (MC4R), are associated with early onset severe obesity. Through recent advances in genetic testing, copy number variants (polygenic) have been found on almost every chromosome that are associated with obesity and concomitant developmental disorders. Although there are genetic and metabolic conditions that predispose to abnormalities in weight status, the imbalance of energy intake with energy expenditure is still the most significant determinant of weight status.
Sequelae
Inadequate nutrition, including both FTT and obesity, is associated with medical complications affecting multiple organ systems and with serious developmental consequences, independent of socioeconomic risk factors. Adipose tissue is an endocrine organ responsible for passive storage of excess energy and the production of leptin, a hormone integral in hunger signaling. Leptin release suppresses appetite, and ghrelin signals hunger. Abnormalities of hormones in hunger signaling include low leptin levels in FTT and starvation, and paradoxically elevated leptin and insulin levels in obesity. Leptin plays a central role in metabolism through regulatory effects on the hypothalamus. High levels of leptin are seen in children with severe obesity, implying leptin resistance. Published literature suggests a role for multiple other gastrointestinal hormones such as obestatin and glucagon-like peptide-1. Children and adults who are underweight may have low levels of growth hormone markers (insulin-like growth factor-1, insulin-like growth factor-BP3) and thyroid function.
Nutrient deficiencies occur in children on restricted diets, in starvation, in illness-related FTT, and in obesity. Perhaps the most common nutrient deficiencies in childhood remain iron and vitamin D deficiency. Vitamin D deficiency can be seen in both forms of malnutrition owing to inadequate dietary intake. There are, however, numerous other nutrient deficiencies that occur with severe malnutrition, including thiamine (B 1 ) and other B vitamins, zinc, selenium, and fat-soluble vitamins. Skin and oral manifestations of these nutrient deficiencies can be seen in children with moderate to severe FTT on physical examination with skin lesions responding to nutritional therapy.
Fluid and electrolyte abnormalities can complicate initial management of these patients, including dehydration, hypoglycemia, hyponatremia (eg, from dilution of formula, excessive water consumption) and hypernatremia (eg, from breastfeeding failure, dehydration). The most serious constellation of fluid and electrolyte abnormalities remains the refeeding syndrome (RFS). During periods of malnutrition, whether through inadequate intake of calories or intentional starvation, insulin levels decrease and glycogen stores become depleted. RFS is a life-threatening complication that occurs when a child or adult with malnutrition goes from catabolism (utilization of lipids and protein for gluconeogenesis) to anabolism. As sources of energy such as carbohydrates are reintroduced, anabolism begins immediately with a release of insulin. Insulin surges drive the process of RFS with rapid cellular uptake of critical electrolytes, leading to hypokalemia, hypophosphatemia, hypomagnesemia, and hypoglycemia, as well as fluid and sodium retention owing to insulin’s natriuretic effects. RFS cannot be predicted by body habitus or initial electrolytes. Clinical deficiency of electrolytes is not usually present until catabolism is reversed with initiation of nutrition. Although multiple electrolytes are affected, low phosphorous levels are the hallmark of RFS and perhaps the best indicator of its occurrence. Medical providers are urged to check phosphorous levels both as part of initial laboratory screening and after nutritional rehabilitation has been initiated. The risk factors for RFS are well outlined in the literature and include inadequate nutrition and neglect.
Management of RFS requires correction of electrolyte abnormalities and hydration status before feeding, as well as a targeted approach to glycemic and metabolic control. Complications of RFS include vomiting, gastroparesis, ileus, diarrhea owing to villous atrophy and malabsorption, elevated liver enzymes, fatty liver disease owing to excess glycogen, brain atrophy, osteomalacia, infections, and anemia. Electrolyte abnormalities and fluid shifts in RFS can lead to cardiac arrhythmia and sudden death. Children with concerns for neglect and intentional starvation deserve special attention. There are multiple published reports on the associations among malnutrition, child fatality, and blunt force injuries. Mortality from RFS is difficult to predict; the literature consists primarily of case studies. A review of the literature in 2002 noted 9 deaths (33%) in 27 children with RFS.
The risk of morbidity and mortality associated with a child or adolescent who is underweight or malnourished may seem obvious to the medical provider. Media reports on children dying of obesity are scant and focus on such alarming cases as the death of a 13-year-old girl in California who weighed 680 lb. As noted, children with obesity have an increased risk of obesity in adulthood and face similar medical complications as obese adults. The Bogalusa Heart Study included more than 10,000 children 5 to 17 years of age who were examined for risk factors associated with cardiovascular disease, including weight status, blood pressure, insulin, and lipid panels. A nutritional status of “overweight” (defined as BMI of ≥95%) was noted in 12% of children with severe obesity occurring in 2%. Two risk factors for cardiovascular disease were found in 39% of overweight children and 59% of those considered severely obese. Four or more risk factors were noted in 11% of children with severe obesity. A longitudinal cohort study of children born between 1930 and 1976 demonstrated an association between obesity in childhood and adult cardiovascular disease. For example, a 13-year-old boy with a BMI z -score of +2.0 had a 33% increased risk of a coronary event in adulthood. Similar associations between obesity and earlier development of type 2 diabetes mellitus have also been observed in children and adolescents.
Children and adolescents with obesity benefit from annual health surveillance for multiple medical complications, including hypertension, hyperlipidemia, insulin resistance, type 2 diabetes mellitus, nonalcoholic fatty liver disease, obstructive sleep apnea (OSA), asthma, restrictive lung disease, skin infections, and orthopedic complications (eg, Blount disease, slipped capital femoral epiphysis). These medical conditions occur along a spectrum of severity progressing from complications reversible with weight management to irreversible complications and death. For example, a child with snoring and OSA may have an abnormal sleep study requiring nightly continuous positive airway pressure. This would be a potentially reversible complication through weight loss, still considered the primary treatment of obesity-associated OSA. Without treatment, the child can develop pulmonary hypertension, cor pulmonale, and progress to death. Unfortunately, the neurocognitive deficits associated with OSA and severe obesity may not be easily reversed. Additional complications of obesity whose severity and consequence are not easily estimated, treated, or reversed include diminished quality of life and psychosocial functioning, weight-based victimization, and bullying.
Clinical assessment and approach
The approach to the child with FTT or obesity starts with a detailed medical and psychosocial assessment of the caregiver–child dyad by the medical provider. Medical evaluation should include maternal pregnancy history, past medical history, review of systems, developmental history, medications, allergies (food and medications), family medical history to include parental stature and weight, feeding and physical activity history, psychosocial assessment, and physical examination. A complete review of the facets of the medical history is well outlined in the literature.
The medical history and review of systems for FTT should focus on areas of imbalance in energy, such as (1) inadequate intake of calories (illness or non–illness related), (2) increased metabolism or requirement for calories (eg, burn injury, cancer, HIV), (3) excessive losses of calories (eg, burn injury, diarrhea, proteinuria, vomiting, protein-losing enteropathy), and (4) inadequate absorption of calories (eg, cystic fibrosis, celiac disease). In children with obesity, additional attention is needed to identify medical complications. A separate sleep history should be performed assessing for signs and symptoms of OSA. Screen time, or time spent watching television and playing video games, is a proxy measure for sedentary activity and consumption of energy-dense foods, and has strong associations with weight status for children and adults.
A structured approach to the feeding and physical activity history will provide the greatest understanding of the child’s energy balance and weight status ( Table 2 ). With infants, the history should include a step-by-step description by the caregiver on bottle preparation. Improper or dilute formula mixing as well as food fads can be seen in FTT. In obese infants, complementary foods such as cereal or jar foods may have been added to the bottle. It is also helpful to have the parent complete a food log or provide a 24-hour dietary recall. As the infant transitions to toddlerhood, the feeding approach changes from formula as the primary nutrition, to age-appropriate meals and snacks. Beverage consumption needs to be assessed, because excessive juice or sugar-sweetened beverage consumption can lead to weight loss or gain. The psychosocial assessment ( Table 3 ) includes identification of risk factors with an approach focusing on the role of the child, family, environment, and personal and community resources. This assessment is ideally completed by a social worker, but can be completed by the primary care provider. Particular attention should be spent on the caregiver’s knowledge deficits, because these deficits may interfere with the ability to prepare formula, read educational materials, and follow a treatment plan.
| Age | Nutrition | History |
|---|---|---|
| Infant | Breast feeding | Success with latching and nursing Breast or pumped milk feeds Feeding schedule Amount expressed with pump Use of supplemental formula Access to lactation consultant Length of nursing: age at weaning Maternal dietary and fluid intake |
| Formula feeding |
| |
| Complementary foods | Age at introduction: jar foods; mashed table foods; cow’s milk Feeding schedule Texture and amounts at meals Assess for food fads Juice and sugar-sweetened beverages (amount daily) Water consumption (amount daily) Introduction of sippy cup or straw | |
| Activity | Developmental history Physical limitations History of occupational or physical therapies | |
| Child and adolescent | Liquids | Cow’s milk: nonfat, 1 or 2%, whole milk, lactose-free milk (amount daily) Juice and sugar-sweetened beverages (amount daily) Water consumption (amount daily) |
| Food | Schedule for meals and snacks Food diary or 24 h recall Plate and portion size (include number of servings) Fast food or take-out meals: number of times weekly or daily; types of meals ordered Advice or education: from medical provider or nutritionist, from family member or friends | |
| Activity | Level of physical activity (eg, sedentary, light activity, etc) Participation in physical education, sports, extracurricular activities Time spent daily in physical activity (hours) | |
| Screen time | Time spent daily in hours: television, video games, handheld devices (eg, Nintendo DS, cell phones), computer | |
| Sleep | Hours spent nightly in sleep Symptoms of obstructive sleep apnea: snoring, cessation of breathing or gasping during sleep, number of pillows, nighttime or daytime enuresis; daytime somnolence or napping; daytime inattention | |
| Feeding behaviors (any age) | Drooling and swallow dysfunction Spit-up, vomiting, reflux Oral aversions (including nipples, pacifiers, spoons) Texture aversions History of speech therapy Does child have age-appropriate seating for meals Responsive feeding pattern (infants/toddlers): observation of parent–child interaction during bottle or spoon feeding including eye contact, facial expressions of caregiver and child. Does parent know when child is hungry and respond to cues? Does parent know when child is full and respond to cues? Child’s perception of weight status Cooperativeness of child with nutritional plan Number of meals eaten as family weekly | |
| Caregiver | Nutrition and activity | Maternal dietary history (if breastfeeding) Weight status (underweight, overweight) Vegetarian or food allergies (eg, celiac disease) |
| Psychosocial | Completion of psychosocial assessment Screening for food security Eating disorder (eg, anorexia nervosa) Perception of child’s weight status | |
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