Poor growth

  • Jack was born at term weighing 3.3 kg with a length of 49.9 cm and head circumference of 34.6 cm. He has been weighed and measured regularly since birth and at 3 months was considered to be typically developing with no known medical concerns.  In recent weeks Jack's mother has noticed that he is not feeding well.  Jack is now 5 months of age and mum has requested she have a review earlier than her scheduled review.  His growth details are shown in the table below.  Are you concerned about Jack's growth?  What recommendations do you make to Jack's mother?

    Age

    Weight (kg)

    Length(cm)

    Head Circumference (cm)

    Birth

    3.3

    49.9

    34.6

    1 month

    4.4

    54.7

    37.1

    3 months

    6.1

    61.4

    40.5

    5 months

    6.45

    65.9

    42.5


    Case study questions and activities

    1. Plot Jack's growth

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  • 2. How would you describe Jack’s growth pattern?

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    Jack’s weight initially tracked along the 50th percentile but it has now fallen below the 15th percentile.  He has gained very little weight in the last 2 months.  His length and head circumference have tracked along the 50th percentile.

    3. How would you interpret Jack’s growth pattern? Is there cause for concern?

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    A: Between 3 and 5 months Jack’s weight has flat lined.  The WHO charts display fewer centile lines than some other charts. Even although Jack’s weight has only crossed one centile line the flat line depicted on the growth chart over this short period of time represents a significant change that is cause for concern.  Regardless of the starting centile for weight, the crossing of centiles creating a flat line is cause for concern.

    4. What additional information would you take into consideration in advising Jack’s mother?

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    There are many reasons why Jack may not be feeding well.  While it is important to discuss the nature of the changes in his feeding other factors need to be considered in determining your advice.  These could include but are not limited to:
    1. Changes in general health and development.
    2. Social history.

    5. What advice do you give Jack’s mother?

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    While poor feeding was the initial cause for concern.   It is important to investigate the underlying cause.   Hence referral to a GP or Paediatrician for further investigation is recommended.  Attempting to modify Jack’s feeding to improve growth without investigating the underlying cause is not recommended. 
    In the interim advice on feeding will depend on the nature of the changes in Jack’s feeding and the additional information obtained.  If Jack is breast feeding care should be taken that recommendations do not inadvertently lead to weaning.  Introduction of solids is unlikely to provide a solution – first foods are generally low in energy and may displace breast milk or formula contributing further to slowed growth

    Key Learnings from this case study

    1. Abnormal growth patterns occur across a range of percentiles. Poor weight gains resulting in ‘flat lining’ at any percentile warrant further investigation. 
    2. WHO charts display fewer percentile lines than previous CDC charts hence the crossing of one percentile line represents a significant change.
    3. Regular growth assessment is helpful in the early detection of health conditions related to altered growth.
    4. Serial measurements are required for making growth assessment.
    5. Growth pattern is one indicator of health and well being.
    6. Attention to feeding practices alone may not identify the underlying cause of poor feeding and subsequent poor growth.