Pediatric presentation
Poor weight gain in children
Faltering growth is a trajectory, not a point; most of it is intake, and the history of a feed tells you more than the blood tests.
What are you worried about?
- Neglect or food insecurity
- A feeding problem in the newborn: latch, supply, a cleft, a tongue that does not work
- Cardiac disease (sweating and breathlessness with feeds), chronic infection, celiac disease, cystic fibrosis
- A metabolic or endocrine disease
Differential, by age
Newborn birth to 28 days
- Breastfeeding difficulty or insufficient supply
- Formula preparation errors
- Cleft palate, ankyloglossia
- Congenital heart disease
- Sepsis or urinary tract infection
Infant 1 to 12 months
- Inadequate intake
- Gastro-esophageal reflux with feeding aversion
- Cow's milk protein allergy
- Cystic fibrosis
- Congenital heart disease
- Neglect
Toddler 1 to 3 years
- Grazing, juice, milk excess
- Celiac disease
- Iron deficiency
- Chronic diarrhea
- Neglect, food insecurity
Preschool 3 to 5 years
- Selective eating
- Celiac disease
- Inflammatory bowel disease
- Chronic disease
School age 6 to 11 years
- Inflammatory bowel disease
- Celiac disease
- Hyperthyroidism
- Diabetes
- Eating disorder in the older child
Adolescent 12 to 17 years
- Eating disorder
- Inflammatory bowel disease
- Hyperthyroidism
- Diabetes
- Depression
- Substance use
Key history
- A 24-hour feeding recall: what, how much, how long, who feeds, how it goes
- Formula preparation, the number of scoops and the water; breastfeeding frequency and supply
- Vomiting, stools (frequency, fat, blood), sweating or breathlessness with feeds
- Birth weight, gestation, previous weights plotted
- Development, the family's food security, who lives at home, parental mental health
- Family heights and weights; parental size explains many small children
Key examination
- Weight, length or height and head circumference, plotted and compared with previous points
- Subcutaneous fat, muscle bulk, the skin and hair
- A murmur, hepatomegaly, the respiratory effort during a feed
- Dysmorphic features, the palate, the tone
- Signs of neglect: hygiene, interaction, unexplained injuries
Red flags
- Weight crossing two major centile lines downward, or falling below the 2nd centile
- Weight loss rather than slowed gain after the first two weeks of life
- Head circumference falling with the weight
- Signs of cardiac or respiratory disease, chronic diarrhea, or developmental regression
- Concerns about neglect or the caregiver's capacity
Initial investigations
- Often none beyond a careful history and a feeding observation
- Blood count, ferritin, celiac serology, urinalysis and culture, electrolytes and creatinine, thyroid function, as a targeted first line
- Sweat test if the story suggests cystic fibrosis; echocardiogram for a murmur or feeding-related breathlessness
How to interpret them
- Weight falling with a preserved length points to intake or absorption; weight and length falling together with a preserved head points to a longer or more systemic problem; all three falling is severe or prenatal
- Correct for prematurity when plotting until 2 years
- A normal set of screening tests does not end the assessment; a documented feeding observation often does
When the child is deteriorating
- Severe malnutrition is admitted, refed slowly, and watched for refeeding syndrome (phosphate, potassium, magnesium)
- Safeguarding concerns are raised with the team, never held by one clinician
Cases and practice
No longitudinal case yet for this presentation; the conditions below and the practice drills cover it.
Conditions under this presentation
The adult frame, for contrast