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A case of Faltering Growth

Anna had a small appetite/oral intake and poor compliance to a range of ONS. She struggled to take the required volume and had minimal catch up growth in 7 years.

Background

Anna is an 11 year old girl who has been under the care of the hospital dietitian for over seven years for poor weight gain. She is a carrier of the thalassemia trait but has not experienced any health problems except for anaemia in the past. In some forms of thalassemia, growth can be retarded. It is unclear however if Anna’s difficulty to gain weight is related to this blood disorder.

From the age of four, Anna’s weight consistently tracked along the 9th centile whilst her height followed the 75th centile. A greater than two centile difference and low Body Mass Index (BMI) which followed the 0.4th centile indicated that Anna’s growth was faltering.

Barriers to weight gain included a low appetite and difficulty managing age appropriate portion sizes at mealtimes. Unfortunately food fortification techniques to increase the energy density of Anna’s diet were, rendered unsuccessful and consequently a range of supplements of various styles and flavours were prescribed following each review at the dietetic clinic. Anna’s compliance to the supplements prescribed was poor as she struggled to take in the required volume. Additionally, her mum felt that these drinks were counterproductive as they increased satiety at mealtimes, which further reduced her daily nutritional intake. Consequently, in seven years there has been minimal catch up growth.

Assessment

Anna was reviewed by my predecessor. Her weight at 28.32kg followed the 9th centile whilst her height measured at 146.5cm tracked between the 50-75th centile. Her BMI was plotted below the 0.4th centile and her weight for height was calculated as 75.5% (Grade 2 acute malnutrition Waterlow). 

It was a concern for mum that Anna was starting to develop anxiety and body image. A nutritional diagnosis of faltering growth and stunting due to low dietary intake as evidenced by anthropometry and dietetic assessment was formed. 

The opportunity to be involved in a 28 day randomised controlled nutrition trial was discussed with and accepted by both Anna and her mum and Anna was randomised to receive the trial product which was the high energy density, low volume oral nutritional supplement for children, known as Fortini Compact Multi Fibre. All previous supplements were discontinued and Anna was advised to take the trial product once each day to provide her with 300kcal and 7g of protein.

Review

After just one month on Fortini Compact Multi Fibre, Anna experienced a significant weight gain of 1.5kg (5% body weight). For the first time, her weight increased to the 25th centile and her BMI tracked upwards to the 2nd centile. When compared to previous interventions, Fortini Compact Multi Fibre provided Anna with more nutrients in less volume. 

Anna found the smaller volume more manageable and the oral nutritional supplement in general is more palatable despite the higher energy density. Her compliance increased and her weight subsequently improved. Additionally mum reported that her appetite slowly increased at mealtimes and overall her diet became healthier as she was less reliant on sugary snacks to meet her nutritional needs. Anna continued on Fortini Compact Multi Fibre following the end of the trial.

Two Month Review

Anna‘s weight continued to track along the 25th centile, while her height tracked slightly upwards towards the 75th centile. Considering her parents’ tall stature, and likely genetic disposition, the dietetic goal agreed was to maintain her weight and height along current centiles (within two centiles). Overall it was reported that Anna had developed a more positive body image since gaining weight and it was agreed that she would continue on Fortini Compact Multi Fibre until her 12th birthday with a view to discontinuing nutritional supplements at this stage.

Conclusion

As a dietitian, having access to a product which is high in energy yet low in volume without compromising on taste is essential, particularly for patients like Anna who struggled with compliance to nutritional supplements in the past. Her increased appetite at mealtimes and healthier snack choices improved the nutritional adequacy of her diet, which was a reassurance to her mum. After seven years of trialling a range of supplements, Fortini Compact Multi Fibre has enabled Anna to achieve the desired weight gain. For the first time, the dietetic team are considering taking her off supplements as the dietetic goal has been reached. 

Sarah O’Toole 

Paediatric Dietitian, Lewisham and Greenwich NHS Trust

IMPORTANT NOTICE: The Fortini Range are Foods for Special Medical Purposes for the dietary management of disease related malnutrition and growth failure in children from one year onwards, and must be used under medical supervision. Refer to product labels for details.

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