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• To be aware of the link between malnutrition in children and faltering growth
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Malnutrition can be defined as ‘a state in which a deficiency of nutrients such as energy, protein, vitamins and minerals cause measurable adverse effects on body composition, function or clinical outcome’. Identification of malnutrition in children, therefore, requires an understanding of their growth. Faltering growth is the failure to achieve the expected rate of weight gain, linear and brain growth at a normal rate for age, which is a known consequence of inadequate nutrition. There are many medical, social and behavioural factors that can place a child at risk of malnutrition and faltering growth. This article examines malnutrition and faltering growth in children. It discusses monitoring and measurement of child growth, the aetiology and consequences of malnutrition, some risk factors and malnutrition screening. The article also considers some prevention strategies and the role of the nurse in the prevention of malnutrition.
Nursing Children and Young People. doi: 10.7748/ncyp.2022.e1436
Peer reviewThis article has been subject to open peer review and checked for plagiarism using automated software
Correspondence Conflict of interestThe author was previously an employee of Nutricia Ltd, UK
Atwal K (2022) Prevention of malnutrition and faltering growth in children and young people. Nursing Children and Young People. doi: 10.7748/ncyp.2022.e1436
Published online: 20 September 2022
• Faltering growth is the failure to achieve the expected weight gain, linear and brain growth at a normal rate for age at any time from birth to 18 years
• Prevention of faltering growth and malnutrition begins with routine growth monitoring in all children
• Growth charts can provide the most reliable method of assessing growth, but signs and symptoms are also used in diagnosis of malnutrition
• Regular surveillance of child growth offers a gateway to preventing or identifying malnutrition
• Nurses have a vital role in the delivery of prevention strategies against malnutrition and faltering growth
The aim of this article is to raise awareness of malnutrition and faltering growth in children by discussing the monitoring and measuring of child growth, the aetiology and consequences of malnutrition and faltering growth, prevention strategies and the role of the nurse. After reading this article and completing the time-out activities you should be able to:
• Define malnutrition and faltering growth and describe the signs and symptoms, aetiology and consequences.
• Understand the monitoring and assessment of child growth.
• Discuss the medical, social and behavioural risk factors of malnutrition and faltering growth.
• Be aware of the referral criteria for children with malnutrition and faltering growth and consequent management by specialist services.
• Identify aspects of the nursing role in prevention of malnutrition and faltering growth in children.
Malnutrition is defined by the National Institute for Health and Care Excellence (NICE) (2017a) as ‘a state in which a deficiency of nutrients such as energy, protein, vitamins and minerals cause measurable adverse effects on body composition, function or clinical outcome’. Identification of malnutrition in children, therefore, requires an understanding of growth. Poor growth in children, termed faltering growth, is the failure to achieve the expected linear growth (measured by length or height), weight gain and brain growth (measured by head circumference) at a normal rate for age at any time from birth to 18 years (Shaw 2020). In the UK, child growth is assessed using the UK-World Health Organization (WHO) gender and age-specific growth charts (Royal College of Paediatrics and Child Health (RCPCH) 2022a).
It is difficult to estimate the prevalence of childhood malnutrition and/or faltering growth in the UK because there are variations in the definition of these terms (NICE 2017b). Studies in other developed countries have suggested that malnutrition affects approximately 6-40% of hospitalised children (Joosten and Hulst 2008, Pawellek et al 2008, Marino et al 2018). This wide variation may reflect the use of different definitions or variation in malnutrition management.
Faltering weight is measured relative to birthweight and will occur as a consequence of inadequate nutrition, particularly in infancy when energy requirements are high. Faltering weight can be identified as follows (NICE 2017b):
• A fall across ≥1 weight centile spaces if birthweight was < 9th centile.
• A fall across ≥2 weight centile spaces if birthweight was between the 9th and 91st centiles.
• A fall across ≥3 weight centile spaces if birthweight was >91st centile.
• When current weight is < 2nd centile for age whatever the birthweight.
If there are concerns about a child’s weight based on these thresholds, their length (in children aged <2 years) or height (in children aged >2 years) should be compared. If there is discrepancy between the length and/or height and weight centile, the mid-parental centile for height should be calculated using the accompanying ‘parent height comparator’ on the UK-WHO 2-18 years growth chart (RCPCH 2012). If the child’s length and/or height is more than two centile spaces below the mid-parental centile, this could suggest undernutrition or a growth disorder (NICE 2017b, Shaw 2020).
In a child aged over two years the body mass index (BMI) centile should be determined using the accompanying ‘BMI centile look-up chart’ on the UK-WHO growth chart to identify whether their weight is appropriate for their length and/or height (RCPCH 2012). The accretion of weight and length and/or height varies between different stages of development and in relation to body fatness, for example during puberty. Consequently, a child’s BMI must be interpreted relative to the average child of the same gender and age from the ‘BMI centile look-up chart’. If the child’s BMI is below the 2nd centile, this may reflect undernutrition or a small build, but if it is below the 0.4th centile this suggests probable undernutrition (RCPCH 2012, NICE 2017b).
In the UK, child growth is commonly measured from birth to 18 years (RCPCH 2022a). It is important to use gender and age-specific growth charts to plot measurements against age accurately; these measurements are often inappropriately plotted by healthcare professionals (Shaw 2020). The RCPCH (2009) provides advice on plotting and interpretation of results for all healthcare professionals involved in the routine care of children.
The most recent UK-WHO growth charts (RCPCH 2022a) are based on standards published by WHO (2006) and are suitable for children from various ethnic backgrounds - data were compiled from Ghana, India, Brazil, Norway, Oman and the US and combined with existing British data from 1990. Patterns of weight gain differ between breast and formula-fed infants and previous UK growth charts were based on data from formula-fed infants who generally gain weight at a faster rate than breast-fed infants (Wright et al 2010).
Certain medical conditions can affect child growth. Where sufficient data are available, specific charts have been developed to monitor growth accurately in, for example, preterm infants and in children with conditions such as Down’s syndrome, Williams syndrome and sickle cell disease (Shaw 2020). All UK-WHO growth charts and supporting materials are available at www.rcpch.ac.uk/resources/growth-charts Other condition-specific growth charts are available to purchase online from Harlow Healthcare at www.healthforallchildren.com
Download the RCPCH guidelines on measuring and plotting child growth at www.rcpch.ac.uk/sites/default/files/Measuring_and_plotting_advice.pdf
What are the important factors to consider in relation to accurate plotting and calculation of child growth? How can you ensure these are considered in your workplace?
In children with neurodisabilities, such as cerebral palsy, measurement of weight and length and/or height may be challenging due to their inability to weight-bear, scoliosis, or lack of access to appropriate measuring equipment such as a hoist or to trained personnel who can perform proxy measurements.
One alternative method for determining weight is measuring mid-upper arm circumference, which is closely linked to nutritional status and is a relatively simple procedure requiring only a measuring tape (Figure 1). Results can be interpreted using the WHO (2013) guideline on managing severe acute malnutrition in infants and children. In infants and pre-school children (aged 6 months to 60 months) with a mid-upper arm circumference of <115mm there is a high risk of death (Shaw 2020). The British Dietetic Association (BDA) Paediatric Specialist Group has produced guidance on how to measure mid-upper arm circumference at www.bda.uk.com/uploads/assets/7e50d27d-6135-457a-941f7cc30cff2324/Information-sheet-on-measuring-mid-upper-arm-circumference.pdf
Where linear growth cannot be measured, there is a lack of consensus on appropriate proxy measurements – such as knee-heel height, ulna length and arm span – as there are no reference standards based on large enough populations to confirm reliability of or to validate these proxy measurements (Shaw 2020).
Although growth charts provide the most reliable method of assessing growth, the following signs and symptoms are suggestive of, and commonly reported in, children with malnutrition (Shaw 2020):
• Muscle and fat wasting, low skinfold thickness.
• Thin, frail hair.
• Visible or prominent bones (for example, protruding chin in infants).
• Pale complexion (suggestive of iron deficiency).
• Poor sleep pattern.
• Developmental delay (particularly communication skills).
• Emotional and behavioural issues (ranging from withdrawal to passive, active to chaotic, and with poor concentration).
These signs and symptoms provide an additional layer of assessment and should be used to support identification of malnutrition in conjunction with growth measurements, particularly if faltering growth is detected.
Malnutrition and faltering growth in children are a result of inadequate nutritional intake in relation to their nutrient requirements, whether these requirements are ‘normal’ or elevated due to illness. The aetiology of malnutrition and/or faltering growth is multifactorial and can be disease or non-disease related or both (Shaw 2020). Box 1 shows examples of the nutrition-related effects of some acute and chronic illnesses in children (Shaw 2020).
• Impaired nutrient absorption, for example in cystic fibrosis
• Maldigestion, for example in coeliac disease
• Impaired use of particular nutrients, for example in inherited metabolic disease
• High nutrient loss, for example in chronic diarrhoea
• Impaired nutritional intake, for example in cardiac disease
• Increased nutrient requirements, for example in the presence of inflammation during critical illness
(Adapted from Shaw 2020)
Children with acute or chronic conditions, such as those in Box 1, may have higher nutritional requirements than those who are healthy (Shaw 2020). Further, medical interventions such as surgery or fluid restriction, or the side effects of chemotherapy or prolonged antibiotic use can exacerbate malnutrition and/or faltering growth (Shaw 2020). Other physical risk factors include preterm birth and neurodisabilities (NICE 2017b). In a survey of European paediatric gastroenterologists and dietitians, ongoing weight loss, increased fluid loss, increased nutritional requirements, low dietary intake and high-risk medical conditions were ranked as the most important clinical indicators of children with disease-associated malnutrition (Huysentruyt et al 2019).
There is a range of non-disease-related social and behavioural factors which can affect a child’s nutritional intake and subsequent development of malnutrition and faltering growth, although these may co-exist with disease. These social and behavioural factors include: lack of parental or caregiver knowledge about dietary needs; behavioural issues which may be linked to neglect and/or abuse; poor feeding practices which may be linked to poverty; maternal postnatal depression or anxiety; and social/cultural influences and beliefs (NICE 2017b, Shaw 2020).
Nutrition has a major role in the neurological and behavioural development of a child which, in turn, influences their future health risks (Rosales et al 2009). Inadequate weight gain in the first six to eight weeks of life has been linked to a stronger predictor of developmental delay than inadequate weight gain during the rest of the first year of life (Drewett et al 2005).
Some studies have suggested that growth outcomes in children with faltering growth are reversible and that physiological dysfunction of the respiratory, immune and gastrointestinal systems can be resolved by correcting malnutrition, however cognitive and behavioural impairments caused by malnutrition are permanent (Rudolf and Logan 2005, Shields et al 2012).
Malnutrition in infancy and childhood can result in increased ill-health in childhood and in the future, increased risk of infection due to inadequate immunity, increased complications such as pressure wounds, increased hospital admissions and associated healthcare costs, and longer recovery time following illness (Guest et al 2011).
Recognising children at risk of malnutrition and faltering growth from disadvantaged backgrounds, for example families seeking asylum, families who do not speak English, members of the Traveller community, families with disabilities or families who are homeless, is essential (Taylor 2005). Inadequate access to healthcare services is higher among these groups. Therefore, it is important to recognise and address the associated barriers to ensure that children and families receive appropriate support. Access to high-quality, family-centred care is crucial to manage and prevent malnutrition and faltering growth effectively (Taylor 2005).
Some evidence has suggested that between 5% and 10% of children known to social care services in the UK are identified as having faltering growth (Shaw 2020). Children identified as a ‘child in need’ (Department for Education 2018) will undergo an assessment of their family dynamics and physical, emotional and health needs so that a care plan of support from a wide range of services can be provided. This should include growth monitoring to identify the risk or presence of faltering growth and malnutrition and instigate management (Shaw 2020).
Gaining access to children in such ‘at risk’ groups largely depends on the ability to provide services that engage with these groups to support adherence to standards of growth monitoring, the frequency with which children and families interact with healthcare services, whether growth is considered part of each assessment during these healthcare interactions and collaboration between multiple healthcare disciplines (Shaw 2020).
Screening children for malnutrition is based on a holistic assessment, which generally includes current growth measurements and growth history, chronicity and aetiology, dietary and nutrient intake and the effects of these on their functional status (Joosten and Meyer 2010). The European Society of Enteral and Parenteral Nutrition (Hartman et al 2012) and the Royal College of Nursing (RCN) (2017a, 2017b) recommend nutritional screening of all hospitalised children. However, there is no universally accepted or recommended tool for malnutrition screening in children in the UK since there is a lack of consensus on the clinical indicators and components of assessment for disease-related malnutrition (Shaw 2020). For example, the Paediatric Yorkhill Malnutrition Score (Gerasimidis et al 2010) and the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) (McCarthy et al 2008) are validated but use different clinical indicators and assessment components to detect malnutrition.
Some settings may choose to implement a screening tool, but they are not widely adopted in practice. All nurses who work with children and young people should be aware of general risk factors with growth and the clinical features of malnutrition, such as the signs and symptoms described earlier. They should also follow local escalation procedures, for example referral to dietetics or medical review, if there is concern about a risk or presence of faltering growth or malnutrition (Marino et al 2018, Huysentruyt et al 2019, Shaw 2020).
In the UK there are guidelines for the management of children with faltering growth (NICE 2017b). Children identified as having faltering growth who are suspected of having an underlying medical condition or have failed to respond to first-line intervention(s), or have slow linear growth, unexplained short stature, rapid weight loss or severe undernutrition, or where there is a safeguarding concern, should be referred to specialist paediatric services (NICE 2017b). This may be a paediatric dietitian or a multidisciplinary team which includes a paediatrician, clinical psychologist, speech and language therapist, occupational therapist and a paediatric dietitian.
These specialist teams have the skills required to identify and assess malnutrition and implement appropriate strategies. These strategies may include medical, nutritional and, where appropriate, play-based therapies that address fear-based food phobias, food aversion and delayed feeding skills (NICE 2017b, Shaw 2020). A range of nutrition support strategies can be used to increase nutrient intake and promote ‘catch-up’ growth, including tailored dietary and behavioural advice (NICE 2017b, Shaw 2020). The BDA Paediatric Specialist Group has designed a range of patient resources, which are available for healthcare professionals to purchase at www.bda.uk.com/specialist-groups-and-branches/paediatric-specialist-group/patient-resources.html
Where dietary intake alone is insufficient, oral nutritional supplements, typically available as 200mL servings (which provide 1kcal -1.5kcal per mL), can assist in meeting children’s nutritional deficits and are available on prescription (Hubbard et al 2020). Compliance with oral nutritional supplements is variable, but evidence suggests that using higher energy density (2.4kcal per mL), low volume (125mL serving) supplements can result in enhanced compliance, as well as improved energy and micronutrient provision and ‘catch up’ growth compared with standard paediatric oral nutritional supplements (Hubbard et al 2020).
Enteral tube feeding is reserved for children whose growth is concerning and who have a history of failed interventions. Input from a specialist multidisciplinary team is required to provide an enteral feeding treatment strategy (NICE 2017b).
Prevention of faltering growth and malnutrition begins with routine growth monitoring in all children. Every infant in the UK is given a Personal Child Health Record (the ‘red book’) (RCPCH 2022b) at birth to record important information such as growth as part of child health screening, which is led by health visitors. The aim of child health screening is to monitor children’s health and development and detect early warning signs such as faltering growth. All healthcare professionals, including nurses, have a responsibility to record growth when measured in the red book and review changes over time. For best practice, weight is measured at the following intervals, which are more frequent in early life owing to rapid growth and development in infancy (RCPCH 2022b):
• At birth and in the first week of life.
• Monthly between two weeks and six months.
• Every two months between six and 12 months.
• Every three months over one year of age.
Infants and pre-school children do not require weighing as frequently as this, apart from those at risk of malnutrition and/or faltering growth. NICE (2014) guidelines on maternal and child nutrition recommend weight measuring of all children at least in the first week of life, then at eight, 12 and 16 weeks, at one year and every three months over the age of one year until school entry (aged 4-5 years). Apart from at birth and at the eight-week review for measuring head circumference, length or height and head circumference, measurements are only recommended if there are concerns about a child’s weight gain or development (Hall and Elliman 2013, NICE 2014). Recommendations for weighing school-aged children and young people are sparse, but the Child Growth Foundation (2020) recommends annual growth monitoring for all children from two years onwards.
In England, national surveillance programmes such as the National Child Measurement Programme largely focus on trends in overweight and obesity, but also provide an opportunity to capture data on children at the other end of the spectrum, which should prompt dietetic referral for those identified as underweight as well as those who are overweight or obese. Data from the 2019 National Child Measurement Programme identified 0.9% of children aged 4-5 years and 1.4% of those aged 10-11 years as underweight (BMI centile ≤2nd centile) (NHS Digital 2020).
If there are concerns about malnutrition and/or faltering growth, or these have been identified, local pathways for monitoring and management should be followed. Growth measurements should be compared with previous measurements and frequency should be indicated by medical need (RCN 2017a, 2017b). Weight monitoring in these circumstances is recommended in infants and pre-school children as follows: (NICE 2017b, Shaw 2020)
• Daily (if aged <one month).
• Weekly (between one and six months).
• Fortnightly (between six and 12 months).
• Monthly (from one year until four years).
The Child Growth Foundation (2020) recommends growth monitoring for all children at every point of contact with any healthcare professional to detect faltering growth early and to ensure interventions have optimum effect in preventing malnutrition.
Measuring children forms part of the care provided by nurses and is one of the standards that underpin the Nursing and Midwifery Council Code (NMC 2010). The RCN (2017a) standards on assessing, measuring and monitoring vital signs in infants, children and young people, summarised in Table 1, recognise the need to take appropriate action where necessary. The standards emphasise the importance of using appropriate age-based procedures when collecting growth measurements and consider the equipment required for each index. Further, the RCN (2017b) competencies for weighing children working in acute care can be used as a framework for those in primary care as no other guidelines are available.
(Adapted from Royal College of Nursing 2017a)
Based on the RCN standards on assessing, measuring and monitoring growth in infants, children and young people, summarised in Table 1, discuss with a colleague how you would measure the height and weight of a child aged four years
Inadequate awareness of nutrition and risk of malnutrition, lack of local policies or guidelines to identify malnutrition and lack of time have been reported by healthcare professionals as common barriers to routine nutritional screening and/or assessment in children (Huysentruyt et al 2019). A lack of equipment has also been identified as a barrier to prevention and management of childhood malnutrition. Therefore there is a need for investment in resources such as anthropometry equipment (Huysentruyt et al 2019).
Professional groups and experts have described the components required for healthcare professionals to deliver effective services for children in the context of preventing malnutrition, including the following (Griffiths et al 1996, Marino et al 2018):
• Well-organised services with clear objectives about the purpose of growth monitoring and nutritional assessment in each service (policy, pathway and/or guideline(s) in place).
• Access to, and maintenance of, resources and equipment for services that support growth monitoring, such as growth charts, scales, stadiometers and measuring tapes.
• Integration of growth monitoring and nutritional assessment in preventive and curative health services for children.
• Integration of nutrition and growth education into all services and induction of new healthcare professionals (to create awareness of policies, pathways and/or guidelines).
• Priority monitoring of children at high risk of malnutrition and/or faltering growth.
• Healthcare professionals trained and skilled in standard operating procedures, such as anthropometric measurements, and with good communication skills and knowledge about how to start a conversation with parents and caregivers about the importance of growth and nutrition in children (with support from dietetics).
• Adequate time for healthcare professionals to offer nutrition counselling to parents and caregivers.
• Education for healthcare professionals on the skills and techniques required to promote behavioural change.
• Regular supervision of healthcare professionals to maintain performance over time (including service audit against growth standards).
• Healthcare services delivered locally, with good accessibility, at convenient times or with home visits.
• Development of important messages that are actionable, feasible, memorable and used at all points of contact – that is, weighing and measuring a child at every contact.
Although these are general recommendations, these components of prevention of malnutrition and faltering growth are relevant to nursing teams delivering care to children alongside aspects of the RCN (2017b) competencies for measuring growth in children.
Participation in regular training and education on nutrition, growth monitoring and malnutrition prevention and management in children aligns with professional standards of practice (NMC 2010, RCN 2017a).
Compliance with growth standards (Table 1) will enable the provision of universal best care, especially for those at high risk of malnutrition and faltering growth. Regular audit against standards for growth measuring and management is essential to underpin performance of nursing services and to ensure best care. The RCN (2017b) standards for the weighing of infants, children and young people includes a growth audit tool which can be readily adopted by nurses in primary care. However, it does not include linear and brain growth (head circumference).
Local dietetics teams, which have expertise in feeding, nutrition and growth management, should provide nurses with evidence-based advice. Advice may include management of parents’ and caregivers’ concerns about feeding – for example, what to feed and how, which may influence how a child reacts to food – and identifying underlying issues such as food aversion, which can contribute to the risk of malnutrition or faltering growth, and how these can be managed with support from the multidisciplinary team (NICE 2017b, Shaw 2020).
Robust local pathways for faltering growth and malnutrition should be developed in collaboration with dietetics teams to enable appropriate monitoring and management. Pathways should be regularly reviewed, updated and communicated to all nurses. Nurses’ engagement with all other healthcare disciplines involved with children, including midwives, health visitors and GPs, social and education services, is essential to ensure that those at risk are adequately monitored and receive coordinated care (Taylor 2005).
Some authors have suggested using a similar approach to Making Every Contact Count (Health Education England 2022) in delivering malnutrition prevention strategies; for example, Marino et al (2018) proposed including nutritional screening as part of routine clinical practice for all healthcare professionals at every point of contact to prevent malnutrition. Developing a ‘making every contact count’ culture may underpin effective faltering growth and childhood malnutrition prevention strategies.
In March 2020, in response to the COVID-19 pandemic, healthcare teams in the UK faced challenging decisions about how to operate due to national lockdowns and diversion of healthcare resources. Some routine services were interrupted, but new ways of working emerged as services adapted to remote delivery. The BDA published best-practice insights for paediatric dietitians on how to operate during the pandemic at www.bda.uk.com/resource/covid-19-best-practice-sharing-to-support-paediatric-dietitians.html Guidance on remote growth measuring produced by the BDA Paediatric Specialist Group, which aims to support parents to undertake children’s height and weight measurement at home, is available at www.bda.uk.com/uploads/assets/59f0da07-63bd-4fe1-a110300642bc55b9/Information-sheet-on-measuring-height-remotely.pdf and www.bda.uk.com/uploads/assets/dd66200d-1539-4d1e-a163692da77c863b/Information-sheet-on-measuring-weight-remotely.pdf
Prevention of malnutrition in children requires an understanding of faltering growth and associated medical, social and behavioural risk factors. Paediatric malnutrition screening tools are poorly adopted because of a lack of consensus on their clinical features. It is therefore important to ensure that growth monitoring and assessment is an integral part of nursing care. Regular surveillance of child growth offers a gateway to preventing or identifying malnutrition. Education on the role of nutrition and growth in childhood, alongside integrated and high-quality services with robust local policies that support vulnerable at-risk groups, are vital to deliver effective prevention strategies. Nurses have a vital role in the delivery of these preventive strategies against malnutrition and faltering growth.
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