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Nutrition in children - growth faltering, food allergy and other common problems

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Assessing growth and referral guidelines, and a guide to common nutritional problems in young children, including growth faltering, iron deficiency anaemia, rickets, constipation, and food allergy

Bridget L. Wardley, MS, RD (UK and USA), is a freelance paediatric dietitian, adjunct instructor, New York University, New York and director of nutrition, Applied Nutrition Corp, New Jersey, US.

Children’s nutritional needs differ from those of adults primarily because they are growing. Accurate assessment of growth and weight is therefore vital in determining nutritional status, as a screening tool and for monitoring a child’s progress.

This section includes:

  • Some pointers for assessing growth and referral guidelines;
  • Common nutritional problems in young children in the UK, including:
    • growth faltering (failure to thrive), iron deficiency anaemia,
    • rickets, constipation,
    • food allergy.

Many parents and carers have concerns about feeding and some of the common problems are listed with suggested solutions.

Guidelines for basic growth assessment

  • Weigh the child naked if under two years or in light clothing, using regularly calibrated scales.
  • Measure length in infants using an infant stadiometer (measures standing or sitting height) or suitable measure mat; in older children use a stadiometer, with the child barefoot.
  • Measure head circumference at largest point around mid-forehead and occipital prominence using a non-stretch tape measure.
  • Plot weight, height and head circumference on age-appropriate growth chart. Correct for gestational age (until 2 years) if the child was born prematurely.
  • Refer for further investigation in following circumstances:
    • Height and/or weight below 0.4 centile,
    • Height and/or weight above 99.6 centile,
    • Crossing of two or more centiles between two measurements,
    • Weight and height differ from each other by two major centiles.

Common nutritional problems

Growth faltering (failure to thrive)

Characteristics: There is no universally accepted definition, but the problem involves failure to meet expected potential in growth and other aspects of wellbeing.

Possible causes: Dietary, organic and social factors can all lead to under nutrition.

Investigations:

  • Weight/ height measurement and history;
  • Feeding history;
  • Observation of feeding to assess for feeding difficulties, abnormal feeding behaviour or interaction between carer and child;
  • Biochemical/haematological/microbiological screening. 

Treatment: will depend on cause but may include:

  • Advice on feeding;
  • Increasing nutrient density of foods. Increase the nutrient content of food by choosing more nutrient dense foods or by adding one food to another, for example, milk and cheese to mashed potato;
  • Reassurance and support to parents/carers;
  • Referral to specialists.

Iron deficiency anaemia

Characteristics: Often asymptomatic unless severe and then symptoms include pallor, tiredness and poor appetite.

Diagnosis: anaemia (haemoglobin <10g/L), microcytic red cells, low plasma ferritin (<10µg/L). Exclude other causes of anaemia.

Preventive measures include

  • Introduction of solids by six months of age including iron-fortified cereal and other iron containing foods;
  • Avoid whole cow’s milk before 12 months, use iron fortified infant formula if not breast fed;
  • Encourage iron-rich foods with foods containing vitamin C to improve absorption
  • Iron fortified follow-on formula may be useful after 1 year if ‘at risk’.

Treatment: supplemental iron (may cause nausea and constipation), encourage health diet including iron rich foods.

Vitamin D-deficient rickets

Characteristics:

  • Softened skull bones;
  • Epiphyseal swelling (especially at wrists);
  • Enlarged costochondral junction where the ribs articulate with sternum (rickety rosary);
  • Tibial bowing (bow legs);
  • Delayed dentition.

Diagnosis:

  • Raised plasma alkaline phosphatase;
  • Low phosphate/calcium;
  • Cupping, fraying, splaying at end of long bones on X-ray.

Prevention: Vitamin D-fortified formula milk or 7.5–10µg/day supplement in children’s vitamin drops.

Treatment:

  • 25–125µg/day Vitamin D until alkaline phosphatase is normal, then 10µg/day;
  • Exposure to sunlight;
  • Good intake of calcium.

Constipation

Characteristics:

  • Difficulty/delay in passage of stools;
  • Motions are usually hard;
  • The child is often fearful of pain associated with constipation.

Management:

  • Encourage the child to sit on toilet/potty after meals – give positive reinforcement;
  • Laxatives are often needed to clear bowel and establish a regular bowel pattern;
  • Increase fluid;
  • Promote a healthy diet;
  • Consider behaviour modification/star charts.

Diet:

  • Encourage foods that contain fibre (high fibre breakfast cereal;wholemeal/granary bread, jacket potato with skin, wholemeal pasta, five servings of fruit/vegetables a day, beans, pulses);
  • Increase fluid intake.

Food allergy/intolerance

Common foods implicated in food allergy/intolerance:

  • Milk;
  • Egg;
  • Nut;
  • Wheat;
  • Shellfish;
  • Soya.

Some allergies may resolve over first three years of life, others are lifelong.

Diagnosis:

  • Skin prick test, involving the introduction of a small amount of allergen under the skin to identify allergy;
  • Radioallergosorbent test (RAST) tests for the amount of specific IgE antibodies in the blood to specific allergens (or antigens);
  • Food challenge test.

Treatment: Exclusion of food from diet (obvious and hidden sources).

Complications: Nutrient deficiency and growth faltering due to inadequate intake of food is possible. The child should be referred to paediatric dietitian if this is suspected.

Common feeding problems and suggested solutions

Refusal of food

  • Structured family meal pattern (three meals, 2–3 nutritious snacks);
  • Small portions, variety of foods, include some favourites;
  • Happy, relaxed environment;
  • Do not offer sweets or other foods as rewards;
  • Do not ‘force feed’.

Excessive milk drinking

  • Limit intake to 500–600ml/day and give after meals/with snacks;
  • Give water between meals if thirsty;
  • Use a cup rather than bottle.

Excessive juice drinking

  • Limit to one cup/day;
  • Give plain water if thirsty and give drinks after meals;
  • Encourage milk;
  • Use a cup, not a bottle.

Refusal of milk

  • Offer in ‘fun’ cup, with coloured straw;
  • Mix milk/cheese/yoghurt into foods;
  • Try flavoured milk – warm, cold or frozen.

Refusal of fruits/vegetables

  • Include small amounts at each meal;
  • Mix grated or pureed vegetables/fruits with other foods;
  • Try raw vegetables/fruits with dips, for example, hummus or yoghurt;
  • Make blended fruit drinks/milkshakes;
  • The family should set good example by eating/enjoying fruit and vegetables.

Further reading

Holden, C., MacDonald, A. (2000) Nutrition and Child Health. London: Balli貥 Tindall.

Thomas, B., Bishop, J. (eds) (2007) Manual of Dietetic Practice. 2007. Oxford: Blackwell.

Thompson, J.M. (1998) Nutritional Requirements of Infants and Young Children. Practical Guidelines. Oxford: Blackwell.

Wardley, B.L. et al (1997) Handbook of Child Nutrition. Oxford: Oxford University Press.

Useful websites/resources

Allergy UK

British Dietetic Association

British Nutrition Foundation has an information booklet for parents My Child Still Won’t Eat

Child Growth Foundation provides education, advice and support and promotes and funds research on growth disorders.

The Children’s Society

Foods Standard Agency

Child Nutrition Panel algorithms on: feeding the healthy term infant; the infant and young child with faltering growth; the infant with possible food intolerance; the preterm infant; the infant with gastroesophageal reflux/regurgitation (available free of charge from SMA: 0845 776 2900).

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