According to the WHO, malnutrition is by far the biggest contributor to child mortality Under-weight births and IUGR (intra-uterine growth restrictions) cause 3 million child deaths a year. According to the Lancet, consequences of malnutrition in the first two years is irreversible. Malnourished children grow up with worse health and lower educational achievements. Malnutrition can exacerbate the problem of diseases such as measles, pneumonia and diarrhoea. But malnutrition can actually cause diseases itself , and can be fatal in its own right The term 'faltering growth' is widely used in relation to infants and young children whose weight gain occurs more slowly than expected for their age and sex. In the past, this was often described as a ‘failure to thrive’ but this is no longer the preferred term :- partly because ‘failure’ could be perceived as negative, but also because lesser degrees of faltering growth may not necessarily indicate a significant problem but merely represent variation from the usual pattern when measured against the standardized growth charts (WHO Growth Charts

1. By
Dr.Osama Arafa Abd EL Hameed
Consultant
of
Pediatrics & Neonatology
Head of Pediatrics Department
Port-Fouad Hospital
Faltering Growth
in infants…..Can we Help?!

2. Outline – Faltering Growth
 Introduction
 Definition of Faltering Growth
 Classification by birth weight
and gestation
 Useful Terminology
 Prevalence
 Causes
 Consequences
 Nutritional management
 Feeds for Faltering Growth

3. INTRODUCTION
“Severe malnutrition is one of the most
common causes of morbidity and mortality
among children under the age of 5 years
worldwide. Many severely malnourished
children die at home without care, but even
when hospital care is provided, case fatality
rates may be high, as high as 30-50% in
some hospitals.”
(WHO, Training course on the management of severe malnutrition,
2002)
A great many of the world’s children are
underweight i.e. 23% under age 5 according to
the UNICEF report in 2006.

4. INTRODUCTION
 Faltering Growth – can occur in both infants
(below one year of age) and in the children (> 1
year of age).
 Faltering Growth – can occur for many reasons
& it has severe consequences on the growth and
development of the infant/child.
 Faltering Growth (FG)– needs to be identified
early & nutritionally treated/managed.
Nutritional management of FG often requires long
term intervention.

5. INTRODUCTION
 According to the WHO, malnutrition is by far the
biggest contributor to child mortality
 Under-weight births and IUGR (intra-uterine
growth restrictions) cause 3 million child deaths
a year.
 According to the Lancet, consequences of
malnutrition in the first two years is
irreversible.
 Malnourished children grow up with worse
health and lower educational achievements.
 Malnutrition can exacerbate the problem of
diseases such as measles, pneumonia and
diarrhoea.
 But malnutrition can actually cause diseases
itself , and can be fatal in its own right

6. Definition of Faltering Growth
 The term 'faltering growth' is widely used in
relation to infants and young children whose weight
gain occurs more slowly than expected for
their age and sex.
 In the past, this was often described as a ‘failure to
thrive’ but this is no longer the preferred term :-
 partly because ‘failure’ could be perceived as
negative,
 but also because lesser degrees of faltering
growth may not necessarily indicate a significant
problem but merely represent variation from the
usual pattern when measured against the
standardized growth charts (WHO Growth
Charts).

7. Interchangeable terms used to describe
Faltering Growth :
 Failure to thrive (FTT)
 Growth Retardation
 Malnutrition/Undernutrition
 Wasted / Stunted
 Slow weight gain
Bottom line :
These infants are NOT growing well
malnutrition

8.  The World Health Organization (WHO) has produced growth
standard charts.
 A child’s weight, length or height, and head circumference can be
plotted on the chart to provide a visual representation of their
growth over time.

9.  Looking at only one point on a
growth chart may not be very
helpful as it is more important to
see what the trend has been like,
rather than one point in time.
 Monitoring the trend “pattern”
across the centiles can give an
indication of how the child is
growing.
 ‘Weight falling through centile spaces,
low weight for height or no catch up
from a low birth weight’
 Height (length) for weight <2 centiles
 A drop from usual centile by 2 centile
lines (for height/length or weight)

10. Infants
Faltering
Growth

11. Classification by weight and gestation
 Preterm (premature)  born at 37 weeks' gestation or
less
 Term  born between the
beginning of week 38
and the end of week 41 of
gestation
 Post-term (postmature) born at 42 weeks' gestation or
more
Newborn classification based on gestational age
 Low birth weight (LBW)  < 2500 g
 Very low birth weight (VLBW)  < 1500 g
 Extremely low birth weight (ELBW)  < 1000 g
Newborn classification based on birth weight
 Appropriate for gestational age (AGA)  weight is appropriate
for the
gestational age
 Small for gestational age (SGA)  smaller than
expected, the
weight falls bellow
the 5th
percentile for the
Newborn classification based on birth weight and gestation is
valuable in predicting the outcome.

12. Terminology
Newborn or
Neonate
An infant in the first 28 days after birth
Infant Is typically applied to young children between the ages of 1 - 12
months
Gestational age A baby that is delivered at 38-42 weeks.
“Conceptual age” and “postconceptual age” should be avoided.
Chronological age Refers to days, weeks, months, or years. It is the time elapsed from
birth. It is the postnatal age of the infant.
Corrected Age Also referred to as “adjusted age” , “corrected gestational age”
Chronological age reduced by the number of weeks born before 40
weeks of gestation ( measured in weeks or months)
Prematurity An infant born before 37 weeks
Perinatal period perinatal period starts at 22 completed weeks (154 days) of gestation
and ends 7 completed days after birth (WHO)
IUGR The most common definition of intrauterine growth restriction (IUGR)
is a fetal weight that is below the 10th
percentile for gestational age as
determined through an ultrasound. This can also be called small-for
gestational age (SGA) or fetal growth restriction.AAP, 2004

13. Prevalence - FG
Incidence
1–5% hospital admission (UK)
3–21% in primary care – depending on criteria used1
France – 26–40% of children were mild/moderately undernourished2
Netherlands– 31% of hospitalised children were malnourished
(10% severely)3
Germany – 31% of Dutch children screened in hospital were malnourished
(9% severely)4
Middle East - ?
SEA - ?
1) Sullivan P 2004 (In Blair et al 2004); 2) Sermet-Gaudelus et al 2000; 3) Pawellik I et al (abst) –
ESPGHAN 2006; 4) Schweizer J et al (abst) – ESPGHAN 2006

14. Causes of Malnutritionis multifactorial....
Disease/illness related
• Cardiac disease
• Cystic fibrosis
• Cerebral palsy
• Congenital heart disease (high risk of
FTT)
• Respiratory disease
• Surgery/transplants
• Burns
• Head injury
• Cancer, e.g. leukaemia
• Inflammatory bowel disease
Non-disease related
 Caloric deprivation – intentional
or unintentional (poor feeding
practices)
– e.g. parent isolation (immigrant),
poverty, feeding inaccuracies, etc.
 Emotional deprivation
e.g. loss of parent, postnatal
depression, chronic medical
problems of parent, substance
abuse by parent, etc.

15. Causes relating to Nutritional Factors
1
.
2
.
3.
Nutritional
imbalance

16.  Short- term:
• Lethargy, irritability/distressed child
• Limited /No growth (start to see falling through
the centiles
 Long- term:
• Growth Faltering with muscle-wasting and
• Stunting
• Delayed neuro-development
• Behavioral and cognitive deficiencies
• Increased risk for infections
• High morbidity and mortality rates

17. The United Nations Standing Committee on
Nutrition recently stated that
‘‘while under nutrition kills in early life, it also
leads
to a high risk of disease and death later in life”
“Optimal nutrition is one of the fundamental
components for infants to reach their full
growth potential and neurodevelopment“
Tuthill, 2007

18. Energy and Protein
 Requirements for energy and protein for healthy children are
generally calculated using the Dietary Reference Values (DRV).
 Many paediatric dietitians refer to a publication entitled
‘Nutritional requirements for Children in Health and
Disease’ produced by the Dietetics Department at Great
Ormond Street Hospital NHS Trust, 2002 (GOSH
Guidelines,2002).
 This document provides a summary of the DRV’s plus guidelines
for the nutritional management of sick infants and children.
 The guidelines for high and very high energy and protein intakes
in sick infants aged 0 – 1 year are presented below, compared to
those of healthy infants:

19. Protein & Energy requirements of infants – health & illness
Age Healthy infants* Infants with illness**
0–3 months Energy
100–115kcal/kg/d
Protein
2.1g/kg/d
Energy
120–200kcal/kg/d
Protein
3–4.5g/kg/d
4–6 months 95 kcal/kg/d 1.6g/kg/d 120–200kcal/kg/d 3–4.5g/kg/d
7–12
months
95 kcal/kg/d 1.5g/kg/d 120–200kcal/kg/d 3–4g/kg/d
(to max
10g/kg/d to
1yr)
* DRV UK
** GOSH data
Geukers et al
2005

20. Nutritional requirements for catch-up growth – protein
What is the protein/protein % energy (PE%) needed for catch-up
growth?
 >10-14% recommended by Deweys1
 9-11% suggested by Waterloo related to kcal load2
(Jackson confirmed
this5
)
 9% suggested by Shaw & Lawson3
 WHO Guidelines – severe acute malnutrition
1) Deweys et al 1996; 2) Waterloo et al 1961; 3) Shaw & Lawson 2001; 5) Jackson A 1990;
>9–14% needed – depending on condition

21. Energy and Protein
 Most children are prescribed high-energy feeds to meet their
basic requirements and to allow for catch-up growth.
 Healthy infants generally require between 7.5 - 12% of energy to
be derived from protein to allow for growth.
 Dietitians may refer to the guidelines mentioned in the ‘Clinical
Paediatric Dietetic Manual’ by Shaw & Lawson (3rd Ed, 2007),
which state that for ‘catch up’ growth it is necessary to provide
about 9% energy from protein.
Two principles that hold true irrespective of the etiology,
that all children with Faltering Growth need :
 High-calorie diet for catch-up growth,
 Close follow - up.

22. (WHO ,Guidelines for the inpatient treatment of severely malnourished Children, 2003 )

24. Fortification with supplements
Concentrate formula
Increase volume
High energy/protein formula
Current treatment practice may include…

25. Issues:
Unbalanced feed –  PE% = ~5.5PE%
Dilute nutrient composition –
micronutrients and vitamins are
approximately 50% lower1
Mixing feeds -  risk feed
contamination2,3
Preparation errors1
  osmolality4
 Difficult to make up to 100kcal/100ml –
protein up to 2.3g/kg but osmolality can
reach close to 500mOsmol/kg
(recommended <400mOmol/kg for sick
infants 5
)
 electrolyte & *pRSL –
>400mOsmol/100kcal risks hypertonic
dehydration in some sick infants 6
(unable
to tell level in concentrated formula)
Time consuming and costly
Prof. Koletzko ESPGHAN 2006
Fortification

26. Mixing of feeds causes contamination and therefore is a risk of
infectious complications!
nfection Control Nurse Association – www.icna.co.uk; Mathus-Vliegen 2006
Main sources and routes of microbial contamination in enteral feeding
systems
….…….…

27. Post-Discharge PhaseNICU Phase
Premature Infants
> 37 weeks 0 month
Term Infants
12
months

28. 0 month
Term Infants
Premature Infants
> 37 weeks
Premature Formula
NICU Phase
12
months
 Premature formula has been developed for preterm
and NOT for term FG/FTT infants. Both patient groups
have different needs and need different nutritional
treatment.
 Not intended for feeding LBW infants after , highly
probably mainly because of its high protein content
and very high levels of fat soluble vitamins.
 There is a clear risk of overdosing both protein and
vitamins and minerals when giving premature formula

29.  Designed to be used as a post-discharge formula
for preterm infants for use up to 12 months
gestational age .
 (0.7-0.8 Kcal/ml)
Premature Infants
> 37 weeks 42 - 52
Weeks
(gestational age)
0 month
Term Infants
12
months
Post Discharge Formula

30. ESPGHAN
 “Infants discharged with a subnormal weight for corrected age
(post-conceptional age) and thus with an increased risk of long-term
growth failure, if fed on human milk should be supplemented to provide
an adequate nutrient intake.
 If such infants are fed formula, they should receive special post-discharge
formula with high contents of protein, minerals and trace elements as
well as LCPUFA, at least until a corrected age (post-conceptional age ) of
40 weeks, but possibly until about 52 weeks”.

31. “The use of post-discharge formulas, has been
shown to result in greater :-
linear growth,
weight gain, and
bone mineralization
when compared with the use of term formula. In
addition, small, preterm infants… may benefit from
the use of such formulas for up to 9 months after
hospital discharge”.
(Guidelines for Perinatal Care (Aap/Acog)) by American
Academy of Pediatrics - 2007
AAP & ACOG Recommendations
AAP American Academy of Pediatrics
ACOG American College of Obstetrics and Gynecology

32. 0 month
Term Infants
Premature Infants
> 37 weeks
Infatrini
12
months
18
months
or 9 kg
 Designed to be used for
 Infant with chronic diseases and highly risk of faltering growth
 Low birth weight Infant (full term < 2,500g)
 Infant post preterm phase (SGA)
INFATRINI can only be recommended for a LBW or
premature infant where the paediatrian has done a corrected
gestational age.
Note : A corrected gestational age recommended by AAP is 40 weeks
(some regions may use 38 weeks)
INFATRINI can only be recommended for a LBW or
premature infant where the paediatrian has done a corrected
gestational age.
Note : A corrected gestational age recommended by AAP is 40 weeks
(some regions may use 38 weeks)

33. a rapid feeding approach is required for catch-up growth i.e. high
energy and high protein to encourage a weight gain of > 10g
gain/kg/day,i.e. 100 kcal/100 ml and 2.9 g protein/100 ml.
WHO Guidelines

34. Summary of Infatrini
Feature Benefit
Higher energy in a smaller
volume
• To support optimal catch-up growth in
infants with/at risk of growth failure
Low osmolality • For better tolerance
Improved ratio of LCPs &
Nucleotides
• For brain & cognitive development
• To support immune function
Ready to use • For convenience and safety
Nutritionally complete • For use as a sole source of nutrition from 0-
18 months or upto 9 kg body weight
Clinically evaluated • Trusted for over 10 years, +++ evidence vs
competitor products

35. INFATRINI
per L
Energy (kJ) 4200kJ
Energy (kcal) 1000 kcal
Protein (g) 26
Fat (g) 54 [LCP’s]
CHO (g) 103
Calcium 800mg
Phosphorous 400 mg
Sodium 250 mg
Iron 10 mg
Zinc 9 mg
Vitamin A 810 µg RE
Vitamin D 17 µg
Potassium 930 mg
GOS/FOS 8 g
Osmolality
mOsm/kg/H2O
345
Osmolarity
mOsmol/L
295
Duggan C, et al. Nutrition in Pediatrics. 4th ed. Hamilton, Ontario, Canada: BC Decker Inc; 2008.

36. Standard
Formula
~/100ml
Energy dense
Formula
/100ml
Energy 66kcal 100kcal
Protein
Protein % energy
1.5g
8%
2.6g
10.4%
Fats
EFA n6:n3
3.5g 5.4g
Iron 0.5–0.8mg 1mg
Comparison INFATRINI vs STD
Formula…

37.  Faltering Growth is not a disease, but rather a description of a relatively
common growth pattern
 It is most commonly caused by undernutrition relative to a child’s
specific energy requirements
 Causes tend to be multifactorial and often involve problems with diet
and feeding behaviour
 More rarely, faltering growth may be associated with neglect or
maternal mental health problems or addiction
 Organic disease is often a contributing factor – due to
 Inadequate nutritional requirements.
 Increased nutritional needs
 Increased nutritional losses

38. Thank