ObJECTIVES
Definitions
Recognition and diagnosis
Assessment of severity
Summery of managment
INTRODUCTION
 poor weight gain "faltering growth,“
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Faliure to thrive
 failure to gain weight appropriately , is a sign that describes a particular problem rather
than a diagnosis.
 The underlying cause of poor weight gain is "always insufficient usable nutrition,"
although a wide variety of medical and psychosocial stressors can contribute .
 If it results in severe malnutrition can cause persistent short stature, secondary immune
deficiency, and permanent damage to the brain and central nervous system .
 Early identification and expeditious treatment may help to prevent long-term
developmental deficits.
DEFINITIONS
 There is no consensus definition
 1- weight less than the 2nd percentile for gestation-corrected age and sex when plotted on
an appropriate growth chart and decreased velocity of weight gain that is
disproportionate to growth in length .
 Weight below the 2nd percentile is approximately equivalent to a Z-score of -2;
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the Z-score is a value that represents the number of standard deviations from the mean
value.
 We do not consider weight gain to be poor among children growing along a curve with a
normal interval growth rate, even if their weight is <2nd percentile ,
 We also do not consider weight gain to be poor among infants and young children with
genetic short stature, constitutional growth delay, prematurity, or intrauterine growth
restriction who have appropriate weight-for-length and normal growth velocity.
What else
 Weight below the 2nd percentile for gestation-corrected age and sex on
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more than one occasion .
special growth charts for prematurity and selected genetic syndromes
should be used when indicated (eg, for children with achondroplasia,
Turner syndrome, etc).
Weight <80 percent of ideal weight-for-age, using a standard growth
chart.
Depressed weight-for-length (ie, weight age less than length age,
weight-for-length <10th percentile
A rate of weight change that causes a decrease of two or more major
percentile lines (90th, 75th, 50th, 25th, 10th, and 5th) over time (eg, from
75th to 25th).
A rate of daily weight gain less than that expected for age.
Growth charts
calculatores
calculatores
EPIDEMIOLOGY
 Poor weight gain is common.
 It occurs in approximately 5 to 10 percent of children in primary care settings and 3 to 5
percent of those in the referral setting.
 Medical risk factors for poor weight gain include:
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prematurity (particularly when associated with intrauterine growth restriction),
developmental delay,
congenital anomalies
intrauterine exposures (eg, alcohol, anticonvulsants, infection), lead poisoning, anemia,
any medical condition that results in inadequate intake, increased metabolic rate,
maldigestion, or malabsorption.
Virtually every organic disease process may contribute to poor weigh gain.
EPIDEMIOLOGY
 Psychosocial risk factors for poor weight gain include
 poverty
 certain health and nutrition beliefs (eg, fear of obesity or cardiovascular
disease, prolonged exclusive breastfeeding),
 social isolation, life stresses, poor parenting skills,
 disordered feeding techniques,
 substance abuse or other psychopathology, violence, and abuse.
ETIOLOGY
 insufficient usable nutrition secondary to
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inadequate nutrient intake,
inadequate nutrient absorption,
increased urinary or intestinal losses,
increased nutrient requirements, or
ineffective metabolic utilization .
Medical, nutritional, developmental/behavioral, and psychosocial factors may all
contribute .
 The majority of cases in primary care practice are secondary to inadequate dietary intake,
usually related to psychosocial factors or disturbance in feeding behavior . Insufficient
dietary intake is also a common cause of poor weight gain among infants referred to
specialty clinics .
 traditionally been classified as "organic" or "nonorganic.“
causes
Assessment of severity
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The Waterlow method
is based on the ratio of the child's weight to the median weight-for-height (ie, percentage of
the median weight-for-height) for children with acute undernutrition
and the ratio of the child's height to the median height-for-age (ie, percentage of the median
height-for-age) for children with chronic undernutrition.
Other methods
Gomez method
McLaren-Read method
Some children classified as severely malnourished by one method were classified as normal
or only mildly malnourished by another. In clinical practice, if there is uncertainty about the
appropriate categorization, referral to a dietitian may be warranted.
Assessment of severity
EVALUATION
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Measurement of growth
use the World Health Organization (WHO) growth standards to assess the growth of children
younger than two years, as recommended by the Centers for Disease Control and Prevention
(CDC)
Boys: Weight-for-age, length-for-age, head circumference-for-age, and weight-for-length
Girls: Weight-for-age, length-for-age, head circumference-for-age, and weight-for-length
The WHO growth standards are appropriate for children of all races and ethnicities.
Specific genetic disorders (eg, achondroplasia, Williams-Beuren syndrome) may have
individualized growth charts.
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Correcting for prematurity
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it is important to correct growth parameters for gestational age (by subtracting the number
of weeks the child was premature from the child's postnatal age at the time of evaluation
However, there is no consensus about how long to continue such correction. Studies that
provide definitive guidance are lacking .
The rate and duration of "catch-up growth" may vary depending upon gestational age, birth
weight, race/ethnicity, and other factors.
generally follow the traditional approach of correcting for weight through 24 months of age,
for stature through 40 months of age, and for head circumference through 18 months of age.
However, the 2009 United Kingdom-WHO growth charts suggest correction of all three
parameters until age two years for children born before 32 weeks' gestation and at least until
age 12 months for children born between 32 and 36 weeks' gestation.
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EVALUATION
• The goal of the evaluation of a child with poor weight gain is to identify
the potential contributing factors (medical, nutritional, psychosocial, and
developmental/behavioral) that can be addressed in the management .
• Ancillary providers (eg, dietitian, occupational or speech therapist, social
worker, developmental and behavioral pediatrician) can facilitate
information gathering and formulation of the management plan.
• Throughout the evaluation, it is important to work in partnership with and
to support the family, who may feel guilty about the child's poor weight
gain.
• The evaluation involves a thorough history and physical examination and
basic laboratory tests. Additional laboratory testing and diagnostic
imaging are guided by the findings from the initial evaluation.
Growth trajectory and proportionality
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The growth trajectory should be plotted from birth.
The timing of changes in the slopes of the weight, length, or head circumference trajectories
is particularly important .
What happened at that point in the child's life? Initiation of complementary foods? Onset of
diarrhea? Parental stressor (eg, divorce, loss of job, etc)?.
Proportionality is assessed by determining
the weight-for-length percentile
or the median age for the child's weight (weight age),
length (length age), and head circumference (head circumference age).
Growth trajectory and proportionality
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Growth trajectory and proportionality may provide clues to the etiology of
diminished weight:
Decreased weight in proportion to length ("wasting") reflects inadequate
nutritional intake.
Normal growth parameters at birth with subsequent deceleration in weight,
followed (weeks to months later) by deceleration in stature (referred to as
"stunting") and finally deceleration in head circumference, is characteristic of
inadequate nutritional intake , As stunting develops, the weight-for-length may
return toward normal
Decreased length with a proportionate weight may be nutritional (if longstanding), genetic, or endocrine in origin
Information from the family history, growth trajectory, and calculation of the midparental height may help to distinguish between these possibilities
Growth trajectory and proportionality
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Normal growth parameters at birth with simultaneous deceleration in length and weight
before two years of age and normal growth velocity after two years of age is suggestive of
genetic short stature or constitutional growth delay. These normal growth patterns are often
confused with poor weight gain.
When head circumference is impaired as much as, or more than, weight or length,
intrauterine infection, teratogenic exposures, congenital syndromes, and other causes of
microcephaly should be considered.
Deceleration of head circumference before deceleration in weight or length is suggestive of a
neurologic disorder (eg, neonatal encephalopathy)
Premature and SGA infants have increased risk for subsequent undernutrition, but many
infants with these conditions have catch-up growth and subsequent normal growth velocity.
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Ensure that the primary care team has access to the following healthcare
professionals:
infant feeding specialist consultant
paediatrician
paediatric dietitian
speech and language therapist with expertise in feeding and eating difficulties
clinical psychologist
occupational therapist.
EVALUATION
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In children with mild to moderate malnutrition The initial evaluation focuses on
the age of onset , associated symptoms , and possible feeding problems .
In children with moderate to severe malnutrition they will require
more intensive investigation of medical and , nutritional , and social factors.
EVALUATION
Medical history — Important aspects of the medical history include :
Pre- and perinatal history – Low birth weight, intrauterine growth restriction, perinatal
stress, and prematurity are important predisposing factors to poor weight gain.
Prenatal exposures (eg, anticonvulsants, alcohol) may compromise growth and/or
affect parent-child interactions.
Past medical history – Chronic diseases of any type (eg, celiac disease, cystic fibrosis,
giardiasis) may affect nutritional intake, absorption, or needs; frequent recurrent
illnesses may indicate immunodeficiency; frequent injuries may indicate
inadequate supervision.
Report of problems in ≥5 organ systems, ≥5 food allergies, and absence of serious
congenital anomaly or confirmed genetic disorder suggest the possibility of
medical child abuse
EVALUATION
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Family history – Family history should include the height and weight of parents and
siblings and history of developmental delay, constitutional delay of growth and
puberty, and any illnesses that may contribute to slow growth. Shorter parental
height and higher parity may be associated with slow weight gain in infants.
Review of systems – The review of systems should include symptoms of medical
conditions that could contribute to poor weight gain .
EVALUATION
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Dietary restrictions related to perceived food allergies or dietary beliefs and practices (eg,
fear of cardiovascular disease, vegetarianism)
In children with moderate to severe malnutrition quantitative assessment of intake (eg, 24hour food recall, three-day food record) may be helpful.
Psychosocial — The psychosocial history is critical in the evaluation of children with poor
weight gain; poor weight gain can be an indicator of serious social or psychologic problems in
the family .
Psychosocial stressors are the predominant cause of insufficient intake in children of all ages.
The material and emotional resources of the caregiver(s) may not be available for the care of
the child for a variety of reasons (eg, poverty, parental depression, substance abuse, family
discord, maladaptive parenting style, etc) .
Many parents of children with poor weight gain lack self-esteem; the health care provider
should work to identify the strengths of the family that will encourage development of a
nurturing environment, rather than focus blame
EVALUATION
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Examination
he goal of the physical examination of a child with poor weight gain is to identify
signs of genetic disorders or medical conditions contributing to undernutrition,
malnutrition (eg, vitamin deficiencies), and child abuse or neglect.
Caregiver-child interaction
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Important aspects of the feeding observation include :
s the child adaptively positioned to eat (eg, in a high chair)?
●For bottle-fed infants, does the caregiver cuddle the infant or merely "prop" the bottle?
●Are the child's cues of hunger and satiety clear? Does the caregiver respond appropriately?
●Is there sufficient time for feeding?
●Does the child have oral motor or swallowing difficulties (eg, does the child have difficulty
with foods of certain textures? Is feeding prolonged?)
●Does the caregiver permit age-appropriate autonomy and messiness?
●What is the tone of the feeding interaction for the child? For the caregiver (eg, pleasant?
relaxed? stressful? hurried?)?
●Is the child easily distracted during feeding?
●Is the child fed while he or she is watching television or the television is on in the
background?
●Is the caregiver irritable, punitive, depressed, disengaged, or intrusive?
●Is the child apathetic, irritable, noncompliant, or provocative
Development and behavior
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Children with poor weight gain should undergo formal developmental and behavioral testing
for a number of reasons
Developmental and behavioral problems may contribute to undernutrition and vice versa (eg,
it can be difficult to feed a child with "difficult temperament"; malnutrition may cause
irritability).
●Children with poor weight gain are at increased risk for developmental and behavioral
problems .
Insufficient intake of nutrients during the vulnerable periods of most rapid development may
have a persistent effect on the nervous system.
Poor weight gain also appears to heighten developmental vulnerability to other adverse
psychosocial factors that contribute to undernutrition (eg, poverty, maternal depression). The
earlier these problems are identified, the sooner they can be addressed.
Development and behavior
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Subtle neurologic deficits may interfere with the normal progression of feeding skills, limiting
with the child's ability to consume adequate nutrients (eg, fine motor deficits may affect the
ability to self-feed) .
The feeding skills of a child with such deficits may be consistent with his or her
developmental, rather than chronologic, age.
●Evaluation of the child's behavior can provide clues to an underlying problem. Children who
fail to interact appropriately with their environment and caregivers (eg, avoidance of eye
contact, absence of smiling or vocalization, lack of interest in the environment, or lack of
response to cuddling) may have developmental delay, hearing or vision impairment, ASD, or
psychosocial or environmental deprivation.
Behavioral rigidity or sensory aversions may result in self-imposed feeding restrictions
Diagnostic evaluation
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Laboratory tests and imaging studies are unlikely to lead to the diagnosis of an underlying
medical disorder in the absence of findings from the medical history or physical examination
The initial (baseline) tests in the children <2 years with poor weight gain may include:
Complete blood count, C-reactive protein, and erythrocyte sedimentation rate as a screen for
anemia, chronic infection, inflammation, and malignancy.
●Urinalysis and culture as a screen for protein or carbohydrate loss (eg, glucosuria in type 1
diabetes mellitus) and indolent renal disease, such as chronic urinary tract infection or renal
tubular acidosis
These routine tests may identify consequences of malnutrition (eg, anemia) or medical
conditions that may contribute to undernutrition (eg, infection, renal disease).
Additional tests
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Additional laboratory tests or imaging studies may be necessary in the initial
evaluation if the history and/or examination suggest particular conditions. For
example:
●Electrolytes, blood urea nitrogen, creatinine, glucose, calcium, phosphorus,
magnesium, albumin, total protein, liver enzymes, amylase, lipase to evaluate
kidney, liver, or pancreatic disease; these tests also provide an indication of
nutritional status
Stool studies, including guaiac, leukocytes, routine culture, ova and parasite
smears, and/or Giardia antigen to evaluate gastrointestinal infection.
Chest radiograph to evaluate cardiac pulmonary disease
Advanced tests
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Specialized testing may be warranted if certain diagnoses are suspected or if an
etiology has not been found and the child has not responded to dietary or
behavior modification. Specialized testing may include:
Serum immunoglobulin (Ig) E, radioallergosorbent tests (RAST), and skin tests to
selected food antigens.
Tissue transglutaminase and serum IgA as a screen for celiac disease.
Stool tests for malabsorption
Carbohydrates – Stool-reducing substances
•Protein – Stool alpha-1 antitrypsin
•Fat malabsorption or pancreatic insufficiency – Stool elastase
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Sweat chloride test
Testing for inborn errors of metabolism, storage diseases, or chromosomal
abnormalities (eg, serum amino acids, urine organic acids, urine-reducing
substances, serum carnitine profile, chromosomes).
Thyroid studies
Advanced endocrine evaluation, particularly growth hormone
Tuberculin skin testing if tuberculosis is suspected.
HIV test
Cytomegalovirus and Epstein-Barr virus IgM and IgG.
Stool or 13C-urea breath test for Helicobacter pylori if H. pylori is suspected.
Hepatitis (A, B, C) panel if hepatitis is suspected
Serum antinuclear antibodies (ANA), anti-liver-kidney microsomal (anti-LKM), antidouble-stranded (ds)DNA antibodies as markers for autoimmune disease (eg,
autoimmune hepatitis).
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Stool studies including guaiac, leukocytes, and calprotectin if inflammatory bowel
disease (IBD) is suspected.
IBD panel for anti-Saccharomyces cerevisiae antibodies (ASCA), perinuclear
antineutrophil cytoplasmic antibodies (p-ANCA), and anti-outer membrane protein
C (anti-OmpC) antibodies.
Upper gastrointestinal series with small bowel follow through if IBD is suspected.
Swallowing function study if swallowing dysfunction or aspiration is suspected.
Advanced diagnostic imaging studies, such as abdominal ultrasound, radionuclide
scans for gastric and biliary tract emptying, and abdominal and head computed
tomography scans to evaluate the presence of intra-abdominal and intracranial
processes that may affect appetite or cause vomiting.
Advanced endoscopic studies with biopsies, including duodenoscopy, colonoscopy,
and small bowel capsule enteroscopy.
Summery of managment
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Management of children with poor weight gain is individualized according to severity and
chronicity of undernutrition, underlying medical disorders, and the needs of the child and
family .
Successful management requires a plan to address contributing nutritional, medical,
developmental/behavioral, and psychosocial factors.
The involvement of a dietitian, occupational or speech therapist, social worker, and/or
developmental and behavioral pediatrician can be helpful in formulating a management plan.
Mild malnutrition
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provision of dietary advice by the primary care clinician or a pediatric dietitian, focusing on
ways to increase oral intake
Changes to the feeding environmen
Home-based support (eg, visiting nurse or other appropriately trained home visitor).
'Psychosocial support.
Children with mild malnutrition should have regular follow-up visits to reinforce the feeding
plan and monitor weight gain.
Moderate malnutrition
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interdisciplinary management in the outpatient setting
Involvement of a dietitian is helpful in formulating the nutrition plan and strategies to
increase intake. For children with moderate malnutrition, the target energy and protein
intake should be achieved over 7 to 10 days to avoid complications associated with rapid
refeeding.
Severe malnutrition
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body mass index (BMI) <12 kg/m2
hospitalization for initial management by an interdisciplinary team .
Indications for hospitalization include :
●Severe malnutrition or body mass index ≤12 kg/m2
●Significant dehydration
●Serious intercurrent illness or significant medical problems
●Psychosocial circumstances that put the child at risk for harm
●Failure to respond to several months of outpatient management
●Precise documentation of energy intake
●Extreme parental impairment or anxiety
●Extremely problematic parent-child interaction
●Practicality of distance, transportation, or family psychosocial problems preclude outpatient
management
Nutritional therapy
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The goal of nutritional therapy is to enable "catch-up" weight gain to overcome the weight
deficit .
Catch-up weight gain typically is two to three times the expected weight gain for age or
approximately 45 to 60 g/day.
Catch-up growth will not occur unless energy intake is greater than the Estimated Energy
Requirement (EER) for age.
0 through 2 months – 100 to 110 kcal/kg per day
●3 through 5 months – 85 to 95 kcal/kg per day
●6 through 8 months – 80 to 85 kcal/kg per day
●9 through 11 months – 80 kcal/kg per day
●12 through 24 months – 80 to 83 kcal/kg per day
Catch up growth
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To estimate the daily energy requirement for catch-up growth, we usually multiply the EER
for age by the median weight for the child's current length and divide by the child's actual
weight .
As an example, in a 15-month-old boy whose weight is 9 kg and length is 78 cm, the median
weight for length is 10.4 kg and estimated energy intake for catch-up growth is 96 kcal/kg
per day ([83 kcal/kg per day x 10.4 kg] ÷ 9 kg).
The sufficiency of intake is proven by subsequent weight and, eventually, height gain . Infants
with severe malnutrition may require >200 kcal/kg for catch-up growth.
The need for a multivitamin preparation that includes iron and zinc is determined by
laboratory evaluation.
Strategies to increase intake
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Infants younger than four months require frequent feedings, typically 8 to 12 per day; infants
older than four months typically require between four and six feedings per day.
Breast fed babies
In the inpatient setting, the caloric density of human milk is generally increased with human
milk fortifiers. In the outpatient setting, the caloric density of human milk for term infants
can be increased by adding infant formula powder to pumped breast milk.
For breast milk with 22 kcal per ounce (30 mL), add one-half teaspoon (2.5 mL) of infant
formula powder to 3 ounces (89 mL) of pumped breast milk.
-For breast milk with 24 kcal per ounce (30 mL), add one teaspoon (5 mL) of regular formula
powder to 3 ounces (90 mL) of pumped breast milk.
The caloric density of human milk should not be increased by the addition of carbohydrate
or fat (eg, medium chain triglyceride) because the protein concentrate of such a mixture is
inadequate for optimum growth.
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Formula fed babies
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he caloric density of infant formula can be increased by adding less water to powder or
concentrated formula or by adding modular supplements such as glucose polymers (eg,
maltodextrin) or fat (eg, medium chain triglycerides, corn oil).
Increasing the caloric density of commercial infant formula through concentration or the
addition of glucose polymers and medium chain triglycerides increases the osmolality of the
formula, which can cause diarrhea or malabsorption.
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Feeding environment
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guidelines for optimizing the feeding environment include
Infants should be positioned so that the head is up and the child is comfortable. Older infants
and toddlers should sit upright in a highchair or on a booster seat at the table. Children
should be allowed to feed themselves as is developmentally appropriate with parents
gradually decreasing the amount offered through direct spoon-feeding as the child's selffeeding skills improve.
●Mealtime distractions should be minimized.
●Mealtime should be relaxed and social; eating with other family members and pleasant
conversation not related to food should be encouraged.
●Mealtime should be free of battles over eating; caregivers should encourage, but not force,
the child to eat; food should not be withheld as punishment.
●The child should be praised when he or she eats well but not punished when he or she does
not.
Additional tips for caregivers are provided in the table
Nutritional recovery syndrome (refeeding syndrome)
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In severely malnourished children, refeeding may be complicated by a nutritional recovery
syndrome.
Symptoms and signs include
sweatiness,
increased body temperature,
hepatomegaly (caused by increased deposition in the liver),
widening of the sutures (the brain growth is greater than the growth of the skull in infants with
open sutures),
increased periods of sleep, and fidgetiness or mild hyperactivity
Rapid changes in tissue mineral content during the first week of refeeding may cause
hypophosphatemia and hypokalemia
Hypophosphatemia or hypokalemia can be treated orally with sodium phosphate or potassium
phosphate in two divided doses to correct deficits.
The estimated daily requirement for phosphorous approximates the dietary reference intake for
age (ie, 100 mg/day [3.2 mmol/day] for infants 0 to 6 months, 275 mg/day for infants 6 to 12
months, and 460 mg/day for children 1 to 2 years .
Conversion from mg to mmol varies with the source of the supplement; consultation with a
pharmacist is recommended.
The estimated daily requirement for potassium is 1 to 2 meq/kg. Phosphate and potassium
supplements should be discontinued once serum levels have returned to normal
Adjunctive management
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includes intervention as indicated for medical and developmental/behavioral
conditions contributing to undernutrition and anticipation and prevention of
medical, developmental, and behavioral consequences. Psychosocial support of
the caregivers is critical.
The frequency of follow-up depends upon the child's age and the severity of
undernutrition, but usually ranges from weekly to monthly. Frequent follow-up
should continue until catch-up growth is demonstrated and a positive trend is
maintained.
Response
• Response to therapy is defined by achievement of catch-up
growth (ie, a rate of weight gain that is two to three times the
normal rate for age) .
• With adequate nutritional intake, catch-up growth is generally
initiated within two days to two weeks, depending upon the
severity of the initial deficit.
Prognosis
• Between 25 and 60 percent of infants with poor weight gain
remain small for age (weight or height <20th percentile for age
and sex). Cognitive function is below normal in one-half of the
children with undernutrition, and behavior and learning
problems are common. Whether these findings are a direct
result of undernutrition or are the result of continued adverse
social circumstances is not known