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

Background

Growth failure is the principal manifestation of malnutrition in children. The terms growth failure, growth faltering 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.¹ There are two main sets of sex-specific growth charts used in Australia: World Health Organization (WHO) charts for children aged 0–2 years, and US Centers for Disease Control and Prevention (CDC) charts for children aged 2–18 years.^2,3 Correction for prematurity should continue until at least two years of age. There are also specific growth charts for many specific chromosomal conditions such as trisomy 21.^4,5 It is important to be consistent with the chart being used and to consider the growth parameters in the context of the overall health of the child.⁶

Inadequate nutrient intake (which includes food and nutritious fluids such as breast milk and formula), decreased absorption of nutrients and/or increased metabolism are the main factors affecting undernutrition.⁷ Most growth failure is due to inadequate nutrient intake; however, underlying causes, such as thyroid disease, should be excluded with a careful history, examination and investigation of positive findings.^2,7 Aboriginal and Torres Strait Islander peoples have an increased rate of preterm and low birth weight compared to non-Indigenous children, and this is an independent risk factor for growth failure.^7–9 While there are some medical causes for growth failure, once excluded, the most significant contributors are social and economic factors.^2,7

The most common dietary problem for Aboriginal and Torres Strait Islander children is insufficient weaning foods at ages 6–24 months.¹⁰ 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, high rates of adverse 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 have high rates of other complex and chronic paediatric conditions such as chronic suppurative otitis media (CSOM,) acute rheumatic fever, rheumatic heart disease, and fetal alcohol syndrome (FAS). Such communities may also have high rates of notifications of family abuse and violence, although there is less clear data on what proportion of these notifications are substantiated.¹¹

The long-term health sequelae from childhood growth failure are significant. There is evidence that intrauterine growth restriction and growth failure in early childhood are associated with the development of obesity in later childhood and adult cardiovascular disease.^12,13 Increased risks for secondary disability from FTT, including cognitive, neurological and psychomotor deficits, persist despite interventions. However, permanent growth retardation may be prevented. Even though some of the serious consequent disabilities may not be prevented,^14,15 rapid and appropriate interventions in a child with FTT are recommended to prevent other consequences. Although approaches to FTT in different parts of the world share some similarities, it is important that they are context specific.¹⁶ In Aboriginal and Torres Strait Islander community settings, interventions to prevent FTT need to address the social determinants of health, which implies improvements in non–health-related areas such as overcrowded living conditions, housing, hygiene, education and employment. Admitting children to hospital to provide intragastric tube feeding in an attempt to achieve rapid catch-up growth may have deleterious effects in the long term.¹⁷

Interventions

FTT assessment includes not only detailed history and physical examination, but also an assessment for psychosocial deprivation and developmental assessment. 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.^10,18,19 The importance of empathy and close follow-up reviews must be emphasised. However, there is evidence that action plans are lacking after identification of growth faltering in Aboriginal children. This is of particular concern in areas with high staff turnover, where there are practitioners providing services for short blocks of time. As a result, existing systems may not always provide adequate follow-up of growth faltering.²⁰ Growth monitoring as an opportunistic activity to undertake with usual clinical care, rather than as a specific screening tool, has been found to be particularly useful in diagnosing FTT.²¹ One important systematic review^22,23 recommended that growth monitoring be integrated into a broader primary healthcare program and stressed the need for effective follow-on action. While high-level evidence for the effectiveness of growth monitoring is lacking, monitoring is now being recommended for early detection of overweight and obesity (refer to Chapter 1: Lifestyle: ‘Overweight and obesity’).

The current RACGP Guidelines for preventive activities in general practice (Red Book) recommend weight/ height/head circumference at seven days, then at six weeks, then at four, six, 12 and 18 months.^24,25 It makes the point that weight may need to be monitored more frequently if there are clinical concerns. One guideline for the Kimberley region recommends even more frequent monitoring of weight, height and head circumference.¹⁸ Some guidelines recommend against such regular monitoring.¹⁹ Irrespective of frequency, growth monitoring in situations of malnutrition should be accompanied by history gathering and counselling, including food intake patterns and the caregiver’s perspectives of what they feel about their child’s development and growth. In many growth-monitoring programs, often carried out by low-skilled staff or volunteers, it has been noted that the skill and experience necessary for such counselling may not be available. Health professionals do not often engage in counselling because they have not received adequate training and supervision/support in counselling, or because of the increased workloads associated with counselling.²¹

Growth charts need to be interpreted with a knowledge of the health context of the community within which a health professional works. 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.²⁶ There is no such description used among Aboriginal and Torres Strait Islander peoples. We would therefore recommend focusing on the progress and cross-sectional observations of the growth profiles with the growth charts while considering the health and psychological context of the child and family.

FTT has been associated with depressed developmental test scores.¹⁴ There is strong evidence to support publicly funded, centre-based, comprehensive early childhood development programs for children aged 3–5 years of low-income families 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.²⁷ However, such programs may be useful as secondary prevention 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.²⁵ Other Australian guidelines also recommend developmental surveillance be tied in with routine child checks rather than singled out.¹⁹ 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. Parent-reported developmental assessment tools, such as the Ages and Stages Questionnaire (ASQ) or Parents’ Evaluation of Developmental Status (PEDS), or objective tools such as the Denver Developmental Screening Test (DDST), may be used.^19,28

Although 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.²⁹ There is some evidence that neglect may be more common in communities which experience poverty. It is useful to consider the constraints on the parents’ or carers’ ability to meet their children’s needs within a framework of understanding how other people in similar circumstances have been able to meet those needs.^25,30,31 The effects of many programs to prevent neglect is not known^32,33 and outcome evaluations of child maltreatment prevention interventions are exceedingly rare in low-income and middle-income countries.³⁴ A Cochrane review showed insufficient evidence to support parenting programs as an intervention in child abuse, including neglect.³⁵ 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 Aboriginal and Torres Strait Islander child health workers.¹⁹

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.³³ Home visiting programs have been found to be most cost effective when they involve a multidiciplinary team and target high risk populations.^36,37 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.³⁸

There is evidence that FAS (refer to Chapter 3: Child health, ‘Fetal alcohol spectrum disorder’), independent of the effects of poor nutrition, is associated with growth deficits in children. Not drinking during pregnancy is the safest option.^39,40 Brief interventions have been shown to be effective in reducing alcohol use during pregnancy and in the postnatal period.⁴¹

There is evidence that providing multiple micronutrients (MMNs) to pregnant women improves birthweight, and may have other beneficial effects on pregnancy outcomes. Supplementation with single nutrients, however, does not appear to have the same effect on birthweight. Single micronutrient (MN) zinc supplementation given during pregnancy may decrease prematurity of infants but does not increase birthweight.⁴²

In contrast, there is a lack of consistent evidence whether MMNs given to children in the first two 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.^22,23 Study variability is large, in terms of what was given, what dose, what duration, baseline characteristics of children, and whether MMNs were combined with other strategies to enhance growth. Some studies show that MMNs do not improve growth,^43–47 and others show that MMNs do improve growth.^{10,17,48–50} 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, especially respiratory infections or chronic diarrhoea when given to children in the first year of life.^45,51–53 There are mixed data as to whether zinc supplements improved weight, but there are no data demonstrating that they prevent stunting or underweight. There is further evidence that zinc supplementation is of no benefit in preventing growth faltering.^22,23 There is evidence of benefit from vitamin A supplementation in populations with moderate to severe vitamin A deficiency.^22,23 Chemoprophylaxis using deworming regimes has also been shown to confer benefit to children living in areas known to have high rates of infestation.^18,22,23 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.⁵⁴ However, nutrition education has been noted to be very context specific,⁴⁶ 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 involve²⁴ ‘hands-on’ skills development; be tailored to the educational level and needs of the mothers and families, and include strategies for behaviour change; and be ongoing and delivered by nutrition paraprofessionals and/or peer supporters. One important systematic review^22,23 found evidence that effective nutrition counselling was often part of a multifaceted intervention and involved education to not only carers, but also community health workers and community representatives. Parenting in Aboriginal and Torres Strait Islander communities often includes 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.¹⁹ 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.²⁴ In the context of Aboriginal and Torres Strait Islander health, home visits to relay nutritional information are recommended.¹⁰ There is evidence that improving doctors’ knowledge and counselling skills around nutrition may be helpful in prevention of FTT.^10,22,25,41 There is also evidence that encouraging certain eating behaviours may be helpful in improving nutrition for children in low-income households. These include 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.²⁴

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 lactosecontaining formula in the re-feeding period following rehydration in studies continued for up to seven days. Guidelines recommend confirmation of lactose intolerance with Clinitest^TM tablets before treatment.^18,55

There are similarities and differences in scientific versus lay perspectives on growth. Scientific perspectives generally focus on the extreme ends of poor health and look forward to adult outcomes, but lay perspectives tend to be 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 compromised and that their idea of a ‘norm’ may not reflect a healthy nutritional status.^10,56,57

Food insecurity is a major problem in many remote and urban Aboriginal and Torres Strait Islander communities (refer to Chapter 1: Lifestyle, ‘Overweight and 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 fridge, lack of transport to get to the shop, and excess expenditure on substances such as cigarettes, alcohol and other substances. Such problems need to be addressed by long-term cooperation and commitment of intersectorial bodies, working with local communities so that appropriate action plans can be enacted. Additionally, household sanitation is strongly associated with growth in children, and programs addressing issues of sanitation have shown a reduction in rates of stunting.⁵⁸

Community feeding programs supply supplementary foods to children at risk of FTT, often on a population basis, although children can be individually targeted if there are risk factors for FTT. Food may be distributed for no cost through childcare centres and schools, over and above what is normally provided in such places or provided through health services. Such programs have been used to overcome food insecurity barriers, without the need to alter community infrastructure. Evidence for using community feeding programs is mixed. While one systematic review^22,23 states such programs should only be relatively short term and must be supported by the community, another review shows support for this approach.¹⁷