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and everyone. Good morning, everyone. My name is Caroline Delahunty. I'm a consultant pediatrician. If people would have joined last week, I had spent Tuesday and Thursday sessions talking about growth in childhood, and I wanted to continue the theme this week talking about faltering growth or failure to thrive. We are a small number, so please feel free to interrupt. Just shout out. I'm happy to stop and take discussion as we go along. Um, for once, I don't think I've got too many slides. So I'm hoping this is going to be more relaxed and more time for discussion. So growth in childhood is incredibly important. We take it as a marker of childhood health and well being. So when it falters, you need to stop and think is one of the messages that I want to get across today. But it's not always abnormal. Okay, I'm going to try and get my slides to move. Oh, no. It's typical, isn't it? Uh, my slides won't move. Right. Hang on. I'm going to pause share in a minute. And, uh, in fact, I'm going to stop sharing, and I'm going to re share, if that's okay. Let's see how we get on. Okay, I'm going to go to here. Okay? Right. Sorry about that. So this is a pictorial diagram to although it says malnutrition at the top. I think that's a bit strong, but I want to show you that Children come in different shapes and sizes. We always take height and weight, and obviously, in the first two years of life were very much concentrate on acceptable head circumference as well, because a lot of the head growth and brain growth takes place from a mass point of view in the first two years of life. So this slide is taking you through a child that is normal. That's in proportion, then a child that has a low weight for height. A child that has the low height for age, but a normal weight and then a low weight for age and height. So there's different shapes and sizes of Children to start with the case history just as an illustration. And then we'll start to talk about some of the detail. Um, do you know, I think we may have missed the No, We haven't missed the objectives. Right. Okay, so this child presents to the pediatric department, with the weight having fallen across five cent aisles. I will take you to growth charts in the middle in a minute. But if you remember your growth charts, we have definitions in Caen tiles, and it's when they drops more than two sent aisles that should trigger a careful history and examination. The history is that the child breastfeeds frequently with frequent feeds, and Mom has been given expressed breastmilk top ups. So what we want the mom to do is, uh, actually express her milk, and we give that as a top up so that child, if possible, still remains purely breast fit fed. I'm not going to go into cow's milk allergy and intolerance. But the ideal scenario, if you can, is to breastfeed your child purely for the first six months of life. Because we know if that happens, that they are less likely to develop various childhood health conditions such as asthma, such as allergies such as cosmic protein intolerance, the child's of frequent feeder. It's feeding every two hours overnight. That's a lot you want to try in an eye lease scenario for rest, for the mother, for rest, for the baby, because growth takes place during rest as well that you're feeding every three hours. But every baby is different. The child's developing eczema is what's written in the history. Now that would make me think. Is there a histiocyte reaction going on? And although this is a breast fed baby, were not told what the top ups are, they could be cow's milk. Um, is this a sign of cosmic protein intolerance? But what's important is that this child is neuro developmentally normal. It's reaching milestones. If you were told the child was neuro developmentally abnormal, you'd be worried that this child has an abnormal brain and has an abnormal suck and swallow. There's no vomiting, baby stooling four times per day. That is normal for a breast fed baby. They stool frequently. The stools are normal in color. They're not pale, so you've got no sign of malabsorption. So you've got bile salts coming through into that stool, and they're not offensive in color. We sometimes say with a lot of the diarrheal type illnesses, that they will be offensive and there's no respiratory tract or recurrent infection. So there's no red flags in this history. The parents are not consanguine iss. If they were consanguineous, we'd be thinking about inborn era of metabolism. In certain parts of the UK, we have a lot of consanguine Ooh, itty. And the pregnancy was normal. So this wasn't an infant for diabetic mom who could have started off with a large for gestational age baby sitting on the center aisle that genetically that baby doesn't want to sit on. And it's not a baby that's failed to thrive. If it's crossed five centers down, I suppose it could have. The pregnancy was normal, and there's no concerns in the social history. So with us, this would actually not be labeled as an urgent case. And it would probably go to a dietician, first of all, and health visitor involvement showing you the growth chart here. And I will try to get a marker. We talked about growth charts last week, so this baby starts on the 50th percentile. This is the World Health Organization growth chart, so they leave a gap in the first two weeks of life accepting that we know babies lose weight in the first two weeks of life. By day to 3 to 5 majority lose 10% of their birth weight, and they regain 2 to 3 weeks. So that's why we have a gap, because degree of weight loss is common. We then have the baby on the 50th percentile. But over the weeks it starts to cross down to the 25th, then crosses down to the ninth tracks along the ninth and then hovers just below between the second and the ninth center aisle. So what that means is a, uh the weight is faltered. We don't know anything about the parents. We don't know if these parents are small and that this baby wants to be genetically small. We don't know anything of that, but any point that we have plotted, what we're saying is if we plot 100 babies, if we plot 100 babies, 50% of them fall below the 50th percentile. And you know, if they plot on the 99th percentile, 99% of babies at that age will weigh less than that. Sen. Tile. And remember, it's a normally distributed curve. It's a Gaussian Sinus rhythm Sinus sinusoidal wave form, so it's six months old. You're seeing the baby. It's been supported by dietetics, and they've not been too concerned. They've given high energy topper in addition to the breastfeeding, but the feeding pattern has now normalized. This baby is feeding every 2 to 3 hours, and it will take up to an hour to feed. That's quite a long feed, but it's always difficult to know how much is comfort feeding on the breast. But we do say that a baby should be on the breast anywhere from 10 minutes to 40 minutes, so it is actually a long feed, Um, but if that's the pattern and it's working, we just accept it. Clinical examination. So we've gone through some history factors right at the beginning. The clinical examination is important. Baby looks well, it's not looking under nourished you're not seeing wasting now. We don't routinely start to measure mid arms circumference to get a feel for subcutaneous fat around the triceps. If we were doing a detailed assessment if we were worried, there are calipers that we can pinch between the scapular blades to get a feel for skin subcutaneous fat, and we'll also measure mid thigh circumference to get a feel for fat. But you just look, you eyeball in your eyes with your eyes. You're looking particularly for wasting around the buttocks. That can be quite an obvious wasting. Last week I showed you a picture of someone with celiac disease, Um, a baby with celiac's disease with a lot of buttock wasting, and you're not seeing excessive skin folds that are not filling out. The baby's not dysmorphic. So we do look for abnormal features, which may take you to a syndrome and take you to a baby being genetically small or neurologically abnormal. The skins healthy. Remember, there was an X men mentioned, but what we're seeing is just one scaly south scalp plaque. Remember, separate dermatitis is very common in babies around about 6 to 12 weeks of age and then tends to naturally get better. But you have a normal cardiovascular system, chest, abdomen. You've got no buttock waste, and you've got no nappy rash. I mentioned nappy rash because if you're immunocompromised, if that baby had HIV, for example, quite often we get really very severe dermatitis for superimposed infection. Also in cosmic protein intolerance, we often talk about the buttocks, been very excoriated. They're burnt because of um, acid factors in the stool, but the baby has good suck normal tone milestones met, and we're happy with the head circumference being on the 25th. It's not on the third. It seems to be in proportion to where the weight is currently sitting. What this shows is this baby has now stabilized on this center tile, and you'll actually argue that there's a little bit of catch up growth going. Are we heading back up across entire? So have we just faltered and come back up and remember everyone's breast milk. Calorie content is different, and so is this just faltering and we're now coming back up. Or is this a baby that just wants to sit on that sent tile? I think what it does demonstrate. There's a lot of measurements here. Actually, I would almost wonder if we measure too much because sometimes you don't want to measure every week. You want to leave gaps between your measurements to get a feel for what's happening. Because two measurements close together don't give you a trend per se. So let's talk about the definition. Do you know, I think when I Reese shared these slides, I do wonder if I've actually shared a different set. So if I suddenly stop and switch sides, that will be what's going to happen. Okay, so we talk about these two terms in use, this failure to thrive, which is becoming less acceptable as a term because of the guilt that imposes on parents. And there's weight faltering, which is probably a better description. But there's no consensus on the definition. Remember, it's a description of growth pattern. It's not a diagnosis. You are looking for the diagnosis. All you've done is describe growth. Crossing to centre miles is what's labeled as triggering assessments and thought I've put and there's a spectrum of normal to underlying pathology. But the majority actually have no pathology, and we don't understand growth, particularly in the first year of life. On this slide, I'm showing you a growth chart where you can see this bait. This is a child that's tracked. It's sent tiles throughout. So everyone's happy. This is one that you can see. The child is crossing centre tiles. Uh, right. OK, okay. So I'm showing you here various centers and what I'm trying to show you is that there is such a variety of patterns growth of growth. There are Children that may show Patrick Growth and go on to a higher center aisle. And there are Children that may go down center aisle. So there's a huge spectrum. So a lot of people regress to the mean. We are in that curve where we have 95% of babies that are going to fall on the 50th percentile. Two standard deviations. Either side, too, where their growth may fall. So most large babies don't. Particularly if they've got genetically shorter parents or average parents, they will regress to the mean. And you do need to think about parental height and parental height is a marker not necessarily weight, because weight is so variable. You know, I am just looking here, actually. Right, OK, I've lost a slide. Never mind in your history. These so I want to give you a framework. So there was an objective slide where I said that I wanted to give you a framework for practice. So here are some pointers in the history that I would be interested in asking. You're obviously gonna ask about food and the feeding history. You want to ask about the frequency of feeds so if a baby was sleepy all day and didn't want to wake for a feed and would have six hours between a feed that would concern me unless they were taken a particularly high volume. So I've not given a slide on the classic noon Nutritional infant feeding, but by six weeks of age, or certainly even by three weeks of age in a non breast fed baby, we would be expecting them to take 100 and 50 mils per kilo by three months because their waiters got higher and they don't want to keep accelerating like that. We would expect them to be dropping down to about between 115 120 mils per kilo, and then wean in normally starts between 6 to 9 months. On average, you expect a baby to feed every 3 to 4 hours. There may be a five hour interval in there, but you expect them to take 6 to 8 feeds a day, so frequency is 6 to 8 feeds a day. The length of feed is hugely variable. You would want them on the breast, though for 10 minutes if they were only on the breast. for five minutes. They're not establishing that sucking and drawing down of that hind milk. They're probably only taking the four milk. The dieticians will sometimes talk about the hind milk of as having a higher fat content, a higher calorie content, so you want them on the breast for 10 minutes. A lot of babies will stay on the breast for half an hour. Some babies will finish at 12 20 minutes. It's variable, but 10 minutes just probably your minimum. And you want to think about the type of nutrition, the age and stage of the child. So is the faltering weight coming with inability to get weaning established when the calorie requirements change And it's not purely met by milk or, you know, where are you? So the age and stage of a child I'm going to talk a little bit about feed version. I should have a separate slide on it if these slides are correct, but otherwise we'll come back to it. Um, think about the pregnancy. Did that Did that Mom have maternal diabetes? Is probably one question I would always ask, because that that baby will be born abnormally, abnormally large insulin, a stimulated insulin like growth factor, which has caused excessive growth in utero. And then the baby's natural insulin like growth factor, which controls life weight gain in the first year of life. Growth Woman comes in in childhood phase of growth in infancy It's insulin like growth Fighter will have fallen down to normal. And that baby is likely to regress to the mean. Think about the social factors. We'll talk a little bit about it. Um, probably doesn't have a huge significance, actually, but we'll come to that and maternal well being. The one factor that we know can affect growth in the first year of life is maternal depression and the ability of that mum as a result of the challenges of that depression, to engage with her baby and to deliver everything she's expected to do when she's really struggling with her maternal health, you're you're going to do a systemic review, a systematic review. Sorry, not systemic. That's a spelling mistake. A systematic review. You're going to ask about the respiratory system. If you've got peril int cough you're going to be thinking about. Does this child have cystic fibrosis? In the UK? We There is a national screening process On day five, they have, uh um, you know, trips in measured on a heel prick. And so most Children with cystic fibrosis are picked up in the newborn period. But that is only, uh, there's still a miss of about 3%. So you would think about a sweat test If you have that sort of history you'd also think about could this child have bronchiectasis iss? Is there an underlying immunodeficiency? So I'm throwing a lot of words out at you. But don't worry. Think ask about the gastrointestinal system. Does this child vomit excessively and ask about bio? Actually, we often think forget about it. Are the vomits green? Because we always think it's milky vomits positive. I have had one case of failure to thrive faltering growth. And I'm using that terrible term. Uh, actually, there was a mile rotation in there, and it really surprised me. Actually. Ask about stools. Is there any sign of malabsorption pale color in those stools and ask about the possibility of urine sex? ISS really focus on the neurodevelopmental attainment of this baby and the behavior of the child. You want to think about the parent child interaction. Does this baby wake for feeds? Does it behave hungrily, Does it? Is it satisfied after a feed? Look at the skin. You're looking for chronic infection and you're looking obviously the skin turgor for the hydration, Stace of the child. And we do like to think about the parent child interaction. Were we concerned about that in clinic? Could there be neglect here? Buy food aversion. Difficult one and difficult to manage, actually. So they're your nightmare in clinic. Actually, when you've got a trial that is refusing to feed and I am talking about babies here, we will come on to Children at the end, and the food aversion and the fussy eaters. And how do you manage them in a baby is very challenging because that baby is learnt that feeding is associated with pain or an abnormal sensation. Some of the biggest challenging some of the most challenging group are actually the premature babies who have had a lot of oral sensitization. They've had entered turkey. He'll tubes into their lungs. They've had nasogastric tubes through their nose into their stomach. So they've had a lot of oral sensitization. They've been sucked out uh, they've had laryngoscope down there. They develop abnormal sensory signaling of pain around around, feeding a child with significant gastroesophageal reflux. Interesting topic over. Treated. Certainly in the UK, there's too much Gaviscon and antacids handed out. But where it is significant treat is if you've got faltering weight so we don't treat vomits and posits we treat weight and behavior. So if you've got a baby that's got a lot of gastroesophageal reflux with arching and vomiting, that it leads to food refusal. That is the one case where I would advocate absolutely advocate treatment. Failure to thrive is an indication under the European guidelines with gastroesophageal reflux to treat, remember, the child will naturally start to help itself because there is a neuro developmental stage, four months of age where they have hand mouth regard. They want to bring their hand up and put it in their mouth. They are getting ready to feed themselves with a spoon so you do have a window of the brain, and development is going to help you with food aversion. Because this child's brain is going to kick in and say, I've got to learn to feed. I've got to bring my hand to my mouth and be able to put things in my mouth, and you want to encourage that. So, actually, one of the ways we would tackle this with the baby is that we would put different textures on the hand, encourage Messi, play in a young child, put milk on the finger, let it bring it into its mouth so it starts to maybe stimulate or this taste nice. I'm going to start to suck, so you know you can't keep putting plastic in with the dummy. Or obviously, if it's the breast, you'd want to express some milk around. So once that nipple goes in this and milk there for the child to lick and to get the idea of a positive taste sensation, we encourage Messi play. We want Children to play with the textures. Parents are always horrified when we say no, just put the food on the floor, let them play with it and let them cover their hair. But let's see if they start to get some in their mouth and enjoy it and let them take control of their feeding as they get older so that you're not forcing plastic into their mouth or food into their mouth. Let them finger feed. Baby led weaning has a lot of evidence behind it that you don't get this food aversion that they start to enjoy it. Maybe this slide is slightly out of sync. Can anyone shout out what they think is the problem here and why this baby could have a feeding problem? What am I looking at when I've looked at this baby? The jaw, lower jaw. Is it the lower jaw? Yeah, absolutely. The baby's lower jaw is too small. So this is micrognathia is the medical term, so you can see this lower jaw is small and it's set back now when you want to suck, you need your bottom and your top jaws, or I'm not a breastfeeding specialist or but or a speech and language therapist. But you basically need both aspects of your jaw to be able to form that seal. So if you can't seal, you can't suck and coordinate. And if the lower jaw is small, remember that tongue may be too big for the oral cavity. It's propulsion to bring the food back and to stimulate the sac swallow reflex can be difficult. So micrognathia often don't feed. And this baby is tube fed. So the jaw is small and set back. We will naturally watch for growth we will think about Is there another syndrome? So if you've got micrognathia really have a look at that palette, the pallets probably abnormal as well. There's something called peer Roberts sequence. I don't want to throw chromosome abnormalities at you where you get cleft palate and a lower jaw problem. Um, eventually, that baby may come to reconstructive surgery, but you allow growth, first of all, and you support nutrition. Okay, that slide was I just think it should have come on the next bit, but never mind. Right? So on your examination, you're going to look for dysmorphic features and you're going to look at the jaw. Just move. It features a child with down syndrome because of the tone may not suck and swallow. So trisomy 21 a very common chromosomal problem. Russell Silver syndrome are Children that are genetically small, very difficult to pick up. But they have little pixie faces, and they are small. So if you've got a child that you think is small but in proportion and has a small chin small face. You may want to do some genetics if we're really struggling. We normally end up doing some genetics, but we don't do it. First line. We wait and we watch. Look for pallor. Look for anemia that may cause fatigue. We're feeding. Look for skin problems. As I've already said, Chronic infection examine the heart. Is this baby got a murmur in in heart failure and therefore breathless and just as exhausted to feed can't breathe and suck and swallow. So if you're out of puff and all your nutrition was coming from suck in and you have to suck 150 mils per kilo, it must be horrendous. Um, so think about your respiratory in your cardiac system. Respiratory system of mentioned cardiac. Um, sorry. Chronic infection bronchiectasis, cystic fibrosis, immunocompromised, HIV, abdomen in a child who was weaned and you're faltering. Growth starts post the introduction of gluten. We do actually always screen for celiac disease, but it's because we have a high rate of celiac disease in this country. Um, think about obstruction. Think about cow's milk protein intolerance. But I appreciate one of my colleagues has given a lecture on that cleft palate micrognathia palette problems, and then an abnormal neurological child who can't suck and swallow or it doesn't still can't smile, can't fix and follow. All these problems will lead to feeding difficulties. A child who's got a seizure disorder won't feed investigations to consider, and I want to emphasize Don't investigate every child. Follow your clinical impression. Sometimes a period of monitoring is more appropriate to see if you've got a child that is regress into the mean or is going to show some catch up if we are going to investigate. This is what we tend to think about. Full blood count and ferritin looking for anemia, electrolytes and creatinine. And remember, faltering growth can happen over any age and stage of the child. So electrolytes and creatinine looking for a child that maybe in renal failure, often quite difficult to diagnose because it can present with lethargy, poor appetite, insidious weight loss. So I guess I'm talking a little bit more about the older child here, so we would think about electrolytes and creatinine. Salt losing problems, water losing problems. It can give failure to thrive, faltering growth, diabetes, insipidus, liver function, tests, liver failure, autoimmune disease, bone and blood tests we would actually do as part of our work up. Most of us will do a blood gas. Or, if we don't do a blood gas, we'll do a lactate were after metabolic problems to make, particularly in the first year of life. Is there an inborn error of metabolism, particularly if you've got consanguine ISS? Asian parents always do a thyroid function test because it's the hidden abnormality, isn't it? Um, if you've got an underactive or an overactive thyroid, you may have problems with your weight. Do a celiac screen. If gluten is in the picture and think about sweat test and chromosomes. Sweat test has sort of gone out for us because we've got national screening. But think about chromosomes if you're concerned. So that would be where I would start naturally or thinking down a list. This is a picture of a baby that is absolutely got faltering weight and poor growth profile. The baby is looking wasted. You're looking not just at the eyes are almost too big for that baby's face, aren't they? But you're just looking at that body. That body has got let me see if I can get a probe. Look at these skin folds like that body that this little one isn't filling out with subcutaneous fat. And I suspect that abdomen is distended if we could see it fully down the way. So I want to talk about socioeconomic factors. If you read the old textbooks, I'm going to give you a reference at the end, actually, but if you read the old textbooks, there's always concern about social deprivation and faltering weight. But actually, when we look at the epidemiological data and there has been work done on this, there's no link to maternal education. There is a link with breast feeding, whether you breastfeed or not in some countries, but there's no link to maternal education. Neglect is very uncommon, but what we do know is if we've got infants of a mom with high postnatal depression and depression symptom scores, they show slower weight gain and increased rates of weight full treatment up to four months of age, and especially if you add that onto a deprived factor where you deprivation deprived family where you won't necessarily have the support around the mom to support the baby the relative risk is 2.5 fold, but by 12 months there is no different from the remainder of the cohort. They seem to have caught up now, whether that's because the baby starts to self feed, will hold the bottle and put the bottle in its mouth. Itself starts to wean, can finger for food in. But also, you know, the maternal depression. And people are starting to kick in and support that mum to by 12 months. The problem seems to be settling. The weight falls through in catches up that mum need. That family needs support. Does faltering weight failure to thrive? Is it important? Does it do any harm? Um, like you do want obviously you do want growth, but I guess we always thought that brain growth was really important and it is important. But actually, the data out there isn't, uh, says that maybe we should normalize some faltering weight support, but not be too heavy handed. So there was a Newcastle cohort. They looked at quite a lot of Children, actually, so I have not put the numbers in, but it it was about 800 they tested for four development outcomes. Age of 10. And the only thing they found was weight gain in infancy. The link was with picture vocabulary. So, uh, you know, is there some cognitive importance of getting nutrition? Right. Um, they do say that birth weight is important, and the problem with birth weight is birth weights can represent whether you've had in utero growth compromise. So if you've had central insufficiency and smoking, you have compromised your development in in utero, so it almost feels that you're in utero. Growth is actually more important than your ex utero faltering, um, provided that faltering get support. So even if you've had a period of faltering growth, it doesn't seem to affect your developmental outcome except the picture vocabulary. I think the important thing with management is a team effort. We have health visitors who are nurses out in the community who are just there to support mom and baby and to support with monitoring and well being. Our national screening program of growth was has been significantly reduced. So the healthiest, uh, really only sees targeted families that she feels may be at risk or is seeing the child and weigh in them at the time of immunization or and then there is a two year assessment. It may be slightly different across different regions In the UK speech and language, Uh, colleagues are very good at oral aversion and assessing, suck and swallow a dietician. We need to get them involved early. They will look at the calorie requirement of that child, baby, and look if it's been met by the intake by a food diary. They'll also give Mom advice on optimizing her nutrition. If she is breastfeeding, social work may require to be involved. If you're concerned, this is a vulnerable family that requires support, and they'll often put in a requirement that this bit that this family do require more partnership with health is to for more support. And obviously we're going to manage any pathology. So the medical side is management of the pathology go through some case histories. Gosh, I've not as much time as I thought. I'm gonna miss that one. Okay, so this is a baby that came in. Gosh, can you see, sodium? At the top is 152. So came in wheezy but was noted to have faltering growth. And when we looked at the electrolytes. We saw that the sodium was too high. And in fact, we go on to show that this baby has diabetes insipidus and is water losing? Um, I'm going to skip quickly to give you some more examples. This, uh, faltering growth for you to thrive, child with a murmur. Breathless after one ounce, you can't feed when you listen. There's a gallop, rhythm and a murmur. Uh, and then when you echo, you see that there's a ventricular septal defect in an interrupted heart art. So I'm just giving you an example of pathology that may cause your failure to thrive the cardiac condition. Here, let's talk about high energy supplements. One of the problems is they. If you give a piled high energy supplement, you're going to suppress their appetite. So if you fill them up with a high fat product, um, the risk is you suppress their appetite. So you want to first of all, encourage normal diet so you don't need jerk into supplements you need jerk. And I guess here I'm talking about maybe a child that's not growing properly. You need jerk into normal diet and trying to optimize the calories in something that Mum can do. You empower the family to take control. So adding butter and milk to your potatoes, adding dairy and making sure there's adequate dairy. If they don't like milk, they've got to, and they're refusing milk. Make sure they're getting yogurts. Make sure they're getting custards and puddings. Just make sure they're getting a balance of food. But think about the calorie content of that food. I thought we'd spend a little bit of time. If you do become a pediatrician or end up in general, you know, as a general practitioner, you are going to get families coming to you to say my child doesn't eat properly. Okay, that's but what we know is a fussy fatty eater. Maybe that's an English term. A fussy eater is only weakly associated with poor growth. Most Children grow even if they're on a restricted diet. So if you re eat a limited variety of food and refuse your parents meals, you will still likely to grow the milk drinkers that won't wean. In fact, what happens is they have. They fill themselves up on milk. It's high fat. High volume fills up their small stomachs because they don't. Children don't have a big stomach. They haven't stretched, particularly if they've not got used to big meals. They've still got that small stomach, and then once their stomach feels it's full, you get appetite suppressant going on to stop you eating. So high milk feeders tend to have a lower appetite, but they don't have poor growth. In fact, because it's high calories, sometimes they're actually try quite heavy Children. They get anemia because they're not getting enough iron, so they get anemia, and sometimes they'll develop peka. I've had a child that believe it or not, bars of soap. But what? Because they had peka from severe iron deficiency anemia. They were a pure milk drinker at the age of four. But what I really couldn't believe is that this mom used to buy lots of bars of soap in the shopping trolley and let the child eat it. It was just beyond belief. So what not to do? So the advice you give is you don't want to refuse to give high energy foods such as often things they will want to eat ice cream cakes, biscuits and chocolate. What the parents are labeling as junk food in their hope that your child will eat proper meals and healthy food. You can't insist your child finishes your food, you're going to get into a cycle of conflict, and it just ends in tears. You don't want them. You don't want to starve them to let them get hungry. What? And you don't want to hide foods, so inch of foods they already like, because you'll put them off that food if they develop. Think all that food doesn't taste nice anymore, so don't mix foods in things. So what to do is again encourage Messi play if they are not feeding at all. Normally we say Start with little bit, sir. Pasta. Let them feel touch it. Start with little bits of cooked lentils and cooked rice. Let them feel touch it. You know little pieces of apple and mash. Messy, wet substances encourage touch and see if they will start to play with it. Let them make faces out of the food. Make it fun. Encourage them to eat with other Children because that peer pressure of eating at nursery and playgroup, all with friends, make sure they're sitting at a table altogether. You eat as a family they see you eat. If they eat on their own in front of the TV, the TV is too stimulating. There won't focus on their plate. They'll focus on the cartoon on the TV, and you want to give them small, frequent meals. So what we say is give them three meals and three snacks, so you're feeding your child 56 times a day. So breakfast, lunch, dinner. Then offer them something mid morning, mid afternoon, even if it's just a few grapes. Raisins, something little a breadstick, whatever you can and limit them 30 minutes a meal. Don't need them sitting there for an hour because they haven't finished. So there's a time limit on meals. Okay, so the classic picture the child doesn't want broccoli to stick to routines. Make it sociable. Avoid distractions. I'm probably repeating myself here, aren't they? Don't offer the sweet dessert as a reward. Let them have their sweet dessert because you want to expand their stomach food. Stimulate appetite. If you stop eating food, your appetite falls right. So if you're on a low food intake, you don't actually have much appetite. You've got to up it to get your appetite up, make positive comments, let them prepare it, let get them involved in cooking. I'm talking about the older child here off for at least 10 times. I've just said six. I think tens may be a bit much. You must be preparing meals all the time and keep calm. Don't get into a temper with it. It's so frustrating, though. Sometimes Children eat better at lunchtime. They're less tired. If you've got a tired child after school or after nursery, all they want is the foods they like their bath bed. So make their main meal lunchtime, which may not be your family pattern. So think about the pattern in the day. Hey, it's quarter to so I'm going to stop here. So I think growth patterns are very variable. A lot of crossing centre aisles can be normal for that child as long as the child is clinically well and you have no red flags in your history and you are monitoring or someone is monitoring. Defining poor growth is hard. There are lots of controversies. Multiple measurements get. Trends are good, but don't measure too often. Don't start wearing a baby every week, um, you know, it's It's too much. You need to distinguish the well versus the unwell. Remember, a lot of variants are normal, but always remember, there it can be pathology there. Think about your rare conditions as well. Get help if this child really doesn't feel right when you're looking at it and do think about neglect and abuse because although I've said it's rare, we don't want to miss it either. Maternal depression and the requirement for support worries me more. I'm going to end there and stop chairing. Thank you, Doctor. If anybody has any questions, please feel free to our mute and ask. Now, since we have 10 minutes left also posted the food back form in the chat. It was very informative. Thank you, Doctor. Ah, there's a hand up. Hello, Doctor. Good afternoon. Can I please have a look at that PowerPoint slide where you had some sort of, um uh, laboratory results for the baby regards? Absolutely. I'm happy. I'll put that back up. Thank you. Uh, you can tell I'm not the best technology. Don't worry about it. The other thing. Oh, hang on. I may have sled a different side. I'm just going to put this slide up minute because it has a reference. I think I've gone back to my original discussion. Okay, this reference. Nice dot org dot UK. So nice is the UK National Institute of Clinical Excellence they have, Even if you just google nice and failure to thrive this guidance guidance number 75. So it's number 75. That's all you need to know. Comes up. And that gives you, um, information as well. Right. But let's get to the slide that you wanted. Okay? Can you see that? Yeah, I think it was another one with some numbers on it. I think it was all right. OK, the one with that. I skipped over because the time Okay. Oh, thank you. Uh huh. Yep. That's the 1. 24. Yeah. Okay. So basically, this baby came in with an inter current infection, but was noted to have faltering weight and weight loss, actually, and just didn't look well when they did the basic bloods. Um, and we wouldn't normally bleed a baby with wheeze. So this was the easy babies. It was investigated because of the weight. The sodium was found to be 100 and 52 the chloride 111 with normal creatinine. Um, so we thought we had a child that was showing dehydration, but it appeared to be chronic, just from where they were showing water loss. If that makes sense, because the urea is 4.3, so it's not too bad. And they went on to think about diabetes insipidus and gave supplemental water and sodium normalized. They did a visa pressing test, and there was no response because it was a nephrogenic diabetes insipidus, which so it's basically the kidneys weren't responding to Visa pressing to re absorb water at the loop of Henley and the distal nephron. Um, so it was nephrogenic diabetes. Insipidus was actually the diagnosis. There was just very rare. Actually, that's the only case. As a general pediatrician, I've come across. I think that's very much something for our renal colleagues. I'm going to stop sharing again. Any other questions? Yes, please feel free time you and ask any questions. You have the means normal end in eight minutes. So now is your chance. Have also posted the feedback form as well, and the certificate will follow after Thank you guys. And thank you, doctor, for your time. Not at all. Does anybody want to shout out some topics they would like covered? I've sort of ended up doing a lot of lectures because of Well, basically, I broke my hip. So I've got time is how I've ended up doing this. But if anyone's got topics, they would particularly like covered that you haven't been able to get covered. You know, back at your own base. Maybe the most common conditions that will be dealing as, um foundation, Year one. Doctors one day, for example, In pediatrics. Okay, I can do that on Thursday. Common pediatric problems. I have got a talk semi prepared on that. Actually, I was going to come to. So why don't I do that on Thursday? I think we've probably spent a week and a half on growth. So we'll move on to common pediatric conditions this Thursday. Communication skills for pediatrics. Oh, well, that's quite difficult. I love that. That's quite difficult, because basically, it's play. You play with the child and talk to the child. Don't always talk to the parent. Okay? I'm going to take notes. Yes, please put any comments you have now, so doctor can be prepared in the future. Mm. That's, uh,