case study: faltering growth
by Jacqui Lowdon
Specialist Paediatric Dietitian
Severe and prolonged faltering growth
Seven month old Baby M was presented to hospital
Increasing exposure to the bottle and even limiting
with faltering growth. Weight on presentation was
the time spent at each breast feed to 15 minutes in an
below the C0.4th. She had been born full term with a
attempt to make her hungry for the bottle feed made
birth weight on the C91st. However, by three months
no difference. After four days of trying and with a static
of age, weight had fallen to C9th and at five months
weight well below the C0.4th, the decision was made to
weight was on the C2nd.
pass a naso-gastric tube.
There was a history of chest infections with coughs
Initially, the aim was for 50 percent of fluid require-
and wheezing and decreasing feeding. One chest infec-
ment to be derived from the top up tube feeds i.e. 80mls
tion had been treated with antibiotics prescribed by
x 5, prior to every breast feed. Baby M however, vomited
the GP. A diagnosis of bronchiolitis was made. However,
on this amount and so it was reduced, firstly to 60mls
screening for faltering growth was also carried out – in-
then to 40mls, which was the amount eventually toler-
cluding a sweat test for CF, Coeliac Disease screening
ated. Throughout this time, solids were offered twice per
and a cardiology review. All tests were negative.
day. Solids made up with the formula milk were included
Baby M had been exclusively breast fed since birth
as part of the total amount of feed.
and mum had reported that she fed well, approximately
After one week with a weight gain of 100g, Baby M
six times per day, 3-4 hourly initially, decreasing to five
was discharged home on tube feeds. Within one month
times per day since introducing solids. Solids had been
weight had increased by 500g. Baby M was continu-
commenced at six months of age. As well as being in
ing with top-up tube feeds post breast feeds. Mum had
line with the guidelines, this was also hoped to help with
managed to slowly increase the total amount to 400mls
the weight gain. Mum reported that she had taken well
formula, although still no more than 60mls at any one
to the solids, despite being unwell. Mum herself had
time. Solids were being offered and taken well three
taken steps to help address the poor weight gain. She
times per day, which included mixed textures as well as
had begun to fortify solids with extra fat, adding in butter
finger foods.
where she could and had also begun to make up dried
Although weight remains below the C0.4th, there is
baby food with standard infant formula.
an upward trend. The plan will be to slowly reduce tube
On admission, once it was established that she was
feeds until we are confident that Baby M can continue
breast feeding well; i.e. that she was latching on appro-
to gain and maintain an adequate weight with her oral
priately, it was suggested that she be offered top-ups
intake alone.
after breast feeds. She was offered a nutrient dense
This is a good example of managing a severe and
infant formula from a bottle. Mum was to continue to of-
prolonged period of faltering growth through an acute
fer solids twice per day and to make these up using the
illness with top up tube feeds. As well as achieving a sus-
nutrient dense formula. However, Baby M did not do well
tained weight gain, it has also been possible to maintain
with the bottle, refusing it. She continued to breast feed an oral intake and actually progress with solids.
well and take solids.
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