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Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Growth failure

Author Dr Jenny James
Expert reviewer Dr Hasantha Gunesekara

Background

Growth failure is the principal manifestation of malnutrition in children. The terms growth failure and failure to thrive (FTT) are used interchangeably and refer to the failure to achieve the growth potential expected for a child. The term is usually applied when the growth crosses two or more centile lines downwards on a standard growth chart.25 There are three different growth charts (Centers for Disease Control, World Health Organization and National Center for Health Statistics) used in Australia by various health authorities and medical software companies,65 so it is important to be consistent with the chart being used and to consider the growth parameters in the context of the health of the child.66

The most common dietary problem in Aboriginal and Torres Strait Islander children is insufficient weaning foods from 6–24 months of age.24 In Aboriginal and Torres Strait Islander children this usually involves a vicious cycle of malnutrition and infection.67 In all populations it may reflect any one or a combination of the following: multicomponent feeding difficulties (often related to lack of food security), chronic ill health, living in a context of poor social determinants of health or carer neglect. Some Aboriginal and Torres Strait Islander communities continue to have paediatric populations with disturbingly high rates of FTT, and these communities often show high rates of other paediatric complex and chronic conditions such as chronic suppurative otitis media, rheumatic fever, rheumatic heart disease and fetal alcohol syndrome. Such communities may also have high rates of notifications of child abuse and neglect, though how many of these notifications are substantiated is not clear from the data.68

The long term health sequelae from childhood growth failure are significant. There is evidence that intrauterine growth restriction and growth failure in early childhood is associated with the development of obesity in later childhood and adult cardiovascular disease.69,70 Increased risks for secondary disability from FTT, including cognitive, neurological and psychomotor deficits persist despite interventions. However, permanent growth retardation may be able to be prevented with early and intensive secondary interventions once a child has FTT. These findings underscore the importance of primary prevention of FTT, because despite rapid and appropriate interventions in a child diagnosed with FTT, some of the serious secondary disabilities will be unable to be prevented.71,72 Approaches to FTT in different parts of the world share some similarities, but need to be context specific.73 In Aboriginal and Torres Strait Islander community settings, interventions to prevent FTT need to address the social determinants of health, which implies improvements in areas such as overcrowded living conditions, housing, hygiene, education and employment. Evacuating children to hospital for tube-feeding in an attempt to achieve rapid catch-up growth may have deleterious effects in the long term.74

Interventions

A detailed history, physical examination and assessment for psychosocial deprivation and developmental assessment are important. In the primary care setting, major organic disease is uncommon (<5%) and can usually be suspected on clinical assessment and appropriate lab testing. If there is an absence of other signs or symptoms, it is usually appropriate to embark on a trial of improved nutrition prior to proceeding immediately to further investigation.23,24,75 There is evidence that action plans are lacking after identification of growth faltering in Aboriginal and Torres Strait Islander children. This is of particular concern in areas with high staff turnover, where there are practitioners providing services for short blocks of time. Existing systems may not always be providing for adequate follow up of growth faltering.62 

Growth monitoring is often recommended as an opportunistic activity to undertake with usual clinical care, rather than as a specific screening tool. This is particularly the case when growth monitoring is reviewed with regards to its usefulness in diagnosis of FTT.76 One important systematic review67,77 recommended that growth monitoring be integrated into a broader primary healthcare program and stressed the need for effective follow-on action. Some guidelines recommend minimum intervals, and the current RACGP Guidelines for preventive activities in general practice (‘red book’) recommend weight/height/head circumference at 7 days, then at 6–8 weeks, then at 4, 6, 12 and 18 months.52,78 It makes the point that weight may need to be monitored more frequently if there are clinical concerns. One guideline for Aboriginal and Torres Strait Islander health settings recommends even more frequent monitoring of weight, height and head circumference.75 Some guidelines recommend against such regular monitoring.23 Irrespective of frequency, growth monitoring in situations of malnutrition should be coupled with history gathering and counselling, finding out about food intake patterns and understanding from the caregiver’s perspectives what they feel about their child’s development and growth. In many growth monitoring programs it has been noted that the skill and experience necessary for such counselling are not available because use is made of low skilled staff or volunteers. Health professionals do not often engage in counselling because they do not receive adequate training in counselling, are not supervised when beginning to practise it or because workloads do not permit it.76 Interpretation of growth charts is not necessarily straightforward either. In non-Indigenous communities, the weights of breastfed babies may fall below two centile lines, and use of complementary formula can increase weight. Such babies are not necessarily described as having FTT.79 Interpretation of growth charts needs to be done with a knowledge of the health context of the community within which a health professional works.

FTT has been associated with depressed developmental test scores.71 There is strong evidence to support publicly funded, centre based, comprehensive early childhood development programs for children from low income backgrounds aged 3–5 years, based on their effectiveness in preventing delay of cognitive development and increasing readiness to learn, but evidence is insufficient to determine the effectiveness of early childhood programs on child health screening outcomes.80 However, such programs may be useful as secondary strategies to prevent some of the possible deleterious follow-on effects of FTT.

Routine developmental screening is recommended in the current edition of the RACGP red book and is timed to coincide with growth monitoring checks and other important interventions such as immunisations.78 Other Australian guidelines also recommend developmental surveillance be tied in with routine child checks rather than singled out.23 However, there is no consensus on the correct developmental assessment tool to use with Aboriginal and Torres Strait Islander children and none have been validated in Aboriginal and Torres Strait Islander populations. Use of parent reporting as in ASQ or PEDS can be used, or others administered by the health professional such as DDST.23,81 

While it is important to consider neglect if a child has FTT secondary to an inadequate diet, it is clearly difficult to distinguish between neglect and material poverty. There is some evidence that neglect may be more common in communities that experience poverty.82 It is useful to consider the constraints on the parents’ or carers’ ability to meet their children’s needs within a framework of understanding of how other people in similar circumstances have been able to meet those needs.42,78,83 The effects of many programs to prevent neglect are not known84,85 and outcome evaluations of child maltreatment prevention interventions are exceedingly rare in low and middle income countries.86 A Cochrane review showed insufficient evidence to support parenting programs as an intervention in child abuse including neglect.87 The Triple P parenting program is a well known multilevel program aimed at helping caregivers find solutions to parenting and child rearing problems. If it is being considered for Aboriginal and Torres Strait Islander families it is recommended that child health professionals consult with their local community regarding the cultural appropriateness and acceptability of Triple P before implementing the program, and that the program be facilitated in partnership with an Indigenous child health worker.23 

There is some evidence to suggest that home visiting helps prevent neglect, particularly first episode neglect, and particularly when used as part of a preventive, multicomponent package including parent education and possibly enhanced paediatric care.85 Cost effectiveness of home visiting programs aimed at preventing neglect has been evaluated in vulnerable families with maternal sensitivity and infant co-operativeness being among the operational outcomes. No author judgement was made on whether the benefits were worth the costs.88,89 It has been suggested that interventions to prevent neglect should focus more on the community level, for example by using media campaigns to promote a ‘norm’. Neglect predicts future maltreatment, hence any interventions need to be sustained and ongoing.90 

There is evidence that fetal alcohol syndrome, independent of the effects of poor nutrition, is associated with growth deficits in children. Not drinking during pregnancy is the safest option.91,92 Brief interventions have been shown to be effective in reducing alcohol use during pregnancy and postnatally.93 

There are many studies providing evidence that providing multiple micronutrients (MMN) to pregnant women improves birthweights of babies, and may have other beneficial effects on pregnancy outcomes as well. Supplementation with single nutrients does not appear to have the same effect. Single micronutrient (MN) zinc supplementation given during pregnancy may decrease prematurity of infants but does not increase birthweight.94

In contrast, the evidence is more mixed with regards to whether MMN given to children in the first 2 years of life improves growth. One important systematic review found the research evidence supported neither implementation of new programs nor withdrawal of existing MMN supplementation programs.67,77 Study variability is large, in terms of what was given, what dose, what duration, baseline characteristics of children, and whether MN were combined with other strategies to enhance growth. Some studies show that MN do not improve growth,59,63,95–97 and others show that MMN do improve growth.24,74,98–100 It has also been noted that there is still a lack evidence of any deleterious effects of MMN on children. It appears single MN have no effect on growth, though zinc supplementation is recommended by some Australian experts in cases of FTT to reduce infections, rather than to prevent growth faltering. Most evidence states that zinc supplements given to children in the first year of life can reduce illnesses such as respiratory infections or acute and chronic diarrhoea.97,101–103 There is evidence that zinc supplementation is of no benefit in preventing growth faltering.67,77 There is evidence of benefit from vitamin A supplementation in populations with moderate to severe vitamin A deficiency.67,77 Chemoprophylaxis using deworming regimens has also been shown to confer benefit to children living in areas known to have high rates of infestation.67,75,77 Prophylactic albendazole appears to be well tolerated.

Nutrition education coupled with growth monitoring can improve a mother’s knowledge of good diets, but may not translate into improved health outcomes for a child.104 However, it has been noted to be very context specific63 and the potential for an impact on growth appears to be greater with interventions that combine nutritional information with provision of complementary food with or without fortification, or increased energy density of complementary foods. There is evidence suggesting that for nutritional counselling to be effective it should involve52 ‘hands-on’ skills development, be tailored to the educational level and needs of the mother’s and to family resources and include strategies for behaviour change, and be ongoing and delivered by nutrition paraprofessionals and/or peer supporters. One important systematic review found evidence that effective nutrition counselling was often part of a multifaceted intervention and involved education to not only carers, but also to community health workers and community representatives.67,77 Parenting in an Aboriginal and Torres Strait Islander community often includes the role of extended family and kin and in particular acknowledges the role of grandparents in transmission of cultural knowledge and customs, so nutritional education is best provided at multiple levels in the community.23 Postnatal peer support programs can reduce cessation of exclusive breastfeeding, as can face-to-face support from health professionals, some antenatal education and postnatal home visiting support. Written information such as leaflets is not very effective.52 In the context of Aboriginal and Torres Strait Islander health, home visits to relay nutritional information are recommended.24 There is evidence that if doctors improve their knowledge and counselling skills around nutrition this may be helpful in the prevention of FTT.24,67,78,93 

Interventions attempting to favourably alter the intake of nutrients include treating lactose intolerance. However, in cases of acute diarrhoea, there is no benefit in using a non-lactose formula over a lactose containing formula in the re-feeding period following rehydration in studies continued for up to 7 days. Guidelines recommend confirmation of lactose intolerance with Clinitest tablets before treatment.75,105 There is evidence that encouraging certain eating behaviours may be helpful in improving nutrition for children in low income households. This includes encouraging and supporting parents and carers to make home prepared foods for infants and young children, without adding salt, sugar or honey; encouraging families to eat together and encouraging parents and carers to set a good example by the food choices they make for themselves; and advising parents and carers not to leave infants alone when they are eating or drinking.52 

There are similarities and differences in scientific versus lay perspectives on growth. Scientific perspectives focus on the extreme ends of poor health and look forward to adult outcomes, but lay perspectives are more focused on framing discussions around what is normal and the current health status of the child. This may have implications for how healthcare providers should pitch discussions with carers of children at risk of FTT to promote maximum engagement in preventive strategies. It has been noted that children who are stunted may look ‘normal’, albeit young for their age. Caregivers may be unaware that their child’s growth is very poor and that their idea of a ‘norm’ may not reflect a healthy nutritional status.24,106,107

Food insecurity is a major problem in many remote and urban Aboriginal and Torres Strait Islander communities (see Chapter 1: Lifestyle, overweight/obesity). Food insecurity involves a problem with both the supply of nutritious food, which can be limited in remote Australia, and a family’s ability to access it. The latter may be compromised by high prices for fresh fruit and vegetables, poverty, not having a refrigerator, lack of transport to get to the shop, and excess expenditure on substances such as cigarettes and alcohol, and other substances. Such problems need to be addressed by long term co-operation and commitment of intersectoral bodies working with local communities so that appropriate action plans can be enacted.108

Community feeding programs supply supplementary foods to children at risk of FTT, often on a population basis, though children can be individually targeted if there are risk factors for FTT. Food may be distributed for no cost through childcare centres and schools, exceeding what is usually provided in such places or given out through health services. Such programs have been used to overcome food insecurity barriers, without the need to alter community infrastructure. Using community feeding programs has mixed evidence, with one systematic review67,77 stating such programs should only be relatively short term and must be supported by the community. Another review shows support for this approach.74 

Recommendations: Growth failure
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Screening All children Recommend growth monitoring (including weight, length, head circumference, nutritional and psychosocial assessment to coincide with child health visits for immunisation* (see Table 2.1) At 2, 4, 6, 12, 18, 24 and 36 months and between 4 and 5 years52,62,67,104 IA
Monitor weight more frequently if there are concerns24,52,67,75,77,78
Behavioural All children Discuss growth monitoring findings with the family, explaining how weight gains are linked to good health and always link the discussion with any nutritional intervention currently being undertaken Opportunistic IA24,74,106,107
Assess developmental milestones (gross motor, fine motor, speech and language, social interactions) with growth monitoring checks
Consider using parent report questionnaires and questions in patient held record (see Chapter 7: Table 7.1)
Maintain a high index of suspicion in children with following risk factors: possible fetal alcohol syndrome, microcephaly, convulsions and prematurity
At 2, 4, 6, 12, 18, 24 and 36 months, and between 4 and 5 years IA25,78
Mothers Promote breastfeeding by discussing the health benefits, use of peer support, face-to-face health professional and postnatal home visits Opportunistic IB52
All families Provide nutrition education counselling targeting both families and community workers Opportunistic IB23,52,67,73,77
Counselling should focus on behaviour change, be community driven and integrated with other preventive child health programs
Consider referral to a dietitian if simple measures are not helpful
GPP
Children in families experiencing socioeconomic hardship or psychosocial stress Provide home visiting support by referral to an early intervention program Opportunistic IA67,77,85,109
Ensure regular communication between primary healthcare staff and other agencies so that nutritional support programs are integrated with psychosocial support GPP
Chemoprophylaxis Children living in areas with high rates of helminth infections Recommend anti-helminth treatment with a single dose of albendazole
Refer to Australian Therapeutic Guidelines for dosing regimen64
Opportunistic IA67,75,77
Environmental Community food supplementation programs may be used short term to overcome issues of lack of food security, providing they have the support of the community and are part of a multifaceted intervention N/A IA67,77
* Correction for prematurity must be made until 18 months for head circumference, 2 years for weight and 40 months for height. Measure length if <2 years and height if >2 years. Measure head circumference until 36 months of age and body mass index (BMI) from 2 years of age. Be sure equipment is calibrated and measurements are accurately done78
Table 2.1. Conducting a growth monitoring action plan
  • Document carer concerns and the barriers they perceive to breastfeeding and healthy nutrition
  • Explore issues of finances, transport, home storage (refrigerator) availability, numbers of people living at home, food preferences, food preparation equipment availability, facilities to maintain hygiene and hygiene practices
  • Involve the carer in finding solutions to problems, and focus on finding solutions that are practical and context specific, paying particular attention to family needs and resources
  • Give information about appropriate weaning foods and amounts
  • Consider linking the child to a team approach involving an Aboriginal and Torres Strait Islander health worker, community nurse, family support worker and dietitian if there are indications that the child is at risk of FTT or showing early signs of growth faltering
  • Document review dates and begin next review by review of previous action plan

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