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Good morning, everyone. My name's Caroline Delahunty. I'm a consultant, pediatrician. I did a lot to lectures in the last semester, but this is my first lecture this semester. So, welcome to everyone. And if you've heard some of the talks before, I, there's some of this talk before I have changed it to include some more dietetic advice with nutrition and wean in and I'm very happy to take questions and have a general, a general discussion and please interrupt me. It's not a problem. I wanted to go back over failure to thrive and faltering growth in childhood is very generic topic. But it's something that any of you that come across um that practice pediatrics, you will come across nutrition, uh come across um Children and parents who are anxious about the nutritional status of their child and the nutritional intake of their child and growth is extremely important. We use it as a marker of well being and we're very focused. If a child is growing overall, this should not be an underlying significant pathology and you can support just with advice. If a child is failing to thrive, there is likely to be a pathology or lack of adequate nutritional intake. So it's an extremely important topic both from pathological, well, underlying significant organic pathology, but also socioeconomic deprivation and neglect as well. So it's something we like to think about very carefully. So there's different types of childhood malnutrition. And when you look at a child, every consultation, every opportunity you have with that child you should take, you should measure their height and weight. This is standard practice that we do. So every consultation, we will do a height and weight measurement. So you have a child who is growing normally for height and weight, you can have a child that has a low B M I that has a low weight for height. You can have a child that isn't achieving height growth. And that's really quite worrying actually because you're much further down the nutritional, the malnutrition line at that point or you can have a child that is just naturally low weight underweight for their age, but in proportion to their height. So their B M I will be normal, their height weight ratio. I'm not sure. I've said that very well, but okay, I thought we'd start with some case histories because I think it makes it easier to understand. So you're the pediatrician, you have a child that's coming into clinic being referred because their weight is falling, it's a baby, their weight is falling across the central chart. You take the history. You always start with the nutritional history. You ask, how are they feeding? So they're breastfeeding with frequent feeds, given top ups. So mom's given supplemental top ups because she obviously doesn't feel that her breast milk is satisfying the baby and the baby is feeding every two hours overnight. Now, feeding frequently, you do actually think what is it because the child is not getting enough and therefore always hungry but equally a lot of babies will cluster feed particularly in the first six weeks of life when they're trying to establish that lactation. And unfortunately, a lot of settling takes place overnight because that's when the prolactin levels are at their highest. So feeding overnight is is very common. Unfortunately, in the newborn and very exhausting for the mum, but the baby is developing eczema. Now, remember a lot of babies will have eczema but equally, it can make us think is there a cow's milk protein intolerance? But this is a breast fed baby. So cow's milk protein intolerance should be less common. The baby's neuro developmentally normal. So after the feeding history, you want a neuro developmental history. Although I think most people would ask about vomiting and stools first, the slides the wrong way round. But you want to know is that baby neuro developmentally is the brain growing normally. And you also want to know the head circumference actually because if you have micro carefully and that the head isn't growing, that is of more concern. Um There's no vomiting stool in four times a day. I think that is normal for a breast fed baby up to six times a day is normal in a breast fed baby, over six times a day would be abnormal. The stools are not pale. So there's nothing to suggest that you have obstructive jaundice, for example, cause in power of the stools or they're not offensive or abnormal in color. So, you know, there's no excessive mucus, there's nothing to suggest a malabsorption Syn syndrome. You're going to ask about the respiratory system because remembering conditions where you have an immune deficiency, you are more likely to have respiratory problems, particularly if you're getting repeated chest infections out with the normal viral infections of childhood. You're going to ask about recurrent infections. We would always ask whether the parents are, can sanguine us and does anybody want to shout out or say, why are we asking that? What, why are we concerned if the parents are related? What does it make us think about? But we uh you know, we have to make if it's not something irritable, you know. Oh, I didn't catch that. Sorry. Can you say that we have to make sure that their original parents then it's, it's not a condition to the heritable congenital condition. Yeah. And the fact that it was normally because it's a late child like uh the mature Beijing's of that. Uh Absolutely. So we're after things inherited conditions such as inborn errors of metabolism where, which can prevent present with failure to thrive. So, we're after because of the closer genetic pool, they're more likely to have an inherited pathology. And in particular, they're more likely to have an inborn error of metabolism which can present with failure to thrive and often quite difficult to diagnose because they are very rare. We're also going to ask about the social history and in that, I'm also going to ask about maternal depression and postnatal depression is this mom unsupported and more at risk of postnatal depression. So there's lots of things you can pick up in the history. This is a growth chart. So World Health Organization produces growth charts and to my knowledge, you are using these or you have access to these, their certainly available online across the world. We've tried to, the World Health Organization has tried to standardize them so that everyone is using the same growth charts and they recently reviewed them and updated the centre tiles to take into account breast fed babies because a breast fed baby grows at a formula fed baby will be bigger. Breast fed babies are naturally smaller. But that's actually a good thing because what you're doing in the first four years of life is you're setting your appetite center. So actually formula fed babies are more likely to become obese adults and have all the health problems of obesity. Um So a breast fed baby, it actually protects against adult and childhood obesity. So it is better to have, um, your lipid profiling and your appetite center set to grow along a lower center tile or certainly not to be above the average, but there's a huge range of normal. So if I look, I'm going to bring my pointer or I'm trying to bring my pointer onto the charts. So, at any age. Okay. So it's a four week baby. The majority of them, 50% of them will lie on the 50th Centre. I'll okay, which is that line marked 50 here, 25% of them will sit on this sent, I'll 250.4% of them will sit on the bottom sent, I'll okay. And 99% of babies should weigh below this line okay below this top line. So if you're above that, you're very large for gestational age. And even if you're above the 91st central, we would define you as large for gestational age, small for gestational age, we define as less than the 10th center. Although I appreciate the market here is the ninth. So when you're plotting, you want to plot a single line and you need to take in account, you plot against, you take the weight and then you plot against the age of the baby and you track, this baby has been referred by the health visitor by primary care because this baby is drop in centre tiles and they're concerned. Does this represent an underlying pathology, it may not, it can be, it can be normal. So you see the six month old baby, they have already been seen by a dietician and they've been put on a supplemental high energy formula in addition to their breast feeding. So they're receiving topic feeds. So in this case, the dietician is likely to have said breastfeed your baby first to keep that breastfeeding going because it's very important and then offer a additional formula top up and see how much the baby takes. So don't force it, don't give the formula first because the baby then won't breastfeed and you don't want to stop that breast milk. The baby's feeding every 2 to 3 hours at six months, you would expect a baby to have lengthened out to form every four hours, feeding every 4 to 6 hours. So that is very frequent feeding. So this baby looks like they've taken small, frequent feeds or they're not satisfied, satisfied. They're also taking up up to one hour to feed. That's too long. A baby should feed within 30 minutes. Most babies feed within 20 minutes actually. And if they stay on the breast after that, they're actually comfort stuck in and they're not actually taking more milk. They're just wanting to comfort themselves on the breast. Okay. So a breastfeed should take up to 30 minutes. 20 minutes is probably the standard. Actually, some babies will take only 10 minutes. They'll feed very quickly. But if you're taking an hour, you're feeding too long. Yeah. Hang on. Glides. Not moving. Right. Yeah, I always get this problem. Sorry about this. Try to press escape. Yeah, I'm gonna have to stop share ing I press escape. I'll stop sharing and then I'm going to come back in and share again. Sorry about that. Right. Let's go down. So you've taken the history the next, what are you going to do next? We're going to examine the baby and what you're after is does the baby look well or does it look undernourished? So you're looking at the general nutritional state and the alertness of the baby actually, but an undernourished baby can unfortunately hyper alerts, they're hungry, they're wanting to feed, you're looking to make sure the baby's not wasted. So you look at the skin folds, if the skin is folding, they're actually undernourished and if they've got distended belly, they're undernourished. Look at the buttocks, turn the baby over and look for buttock wasting. Okay. Why do we want to look for dysmorphic features? Is there anything in particular you would want to look out? So you're gonna interrupt, but you're not sharing full screen if that was the intentions in? Oh, sorry. Am I not showing? Right? It's not full screen. Okay. Okay. Yes, sorry. Oh, okay. Yeah. No, fair enough. Sorry about that. Yeah, sorry. So in dysmorphic features, is there anything in particular you would be thinking about the buttocks? You would see that there is, well, the G I track is not closed. Uh okay. The, you would say that there is no lesions uh scarring or the, whether their skin is dry or, or those distended belly would see whether it's malnourished in a manner like it's as a enlargement of the organs. Okay. Yep. No, I think that's a more of a general examination feature, distended abdomen, dry skin organa megaly with dysmorphism. I was after more of the genetic causes of failure to thrive. So for example, a baby with Down syndrome will have porch tone and can therefore have poor sock. So anna neurologically abnormal baby is likely to have a poor suck, swallow reflex. You also want to look at the chin and the jaw to make sure because to be able to suck your bottom and your top jaw need to be able to meet. So if you've got a small jaw, micrognathia or retrognathia with a receding jaw, that's going to affect the ability to breastfeed. So equally, if you have a cleft lip, a cleft palate as part of the genetic syndrome that will affect your ability to feed. So you need to very much think about the orofacial but any of the syndromes that are likely to cause low tone as well because low tone will go with low suck reflex. Um So that's why we're quite interested in dysmorphic features. As you've rightly said, look at the skin, make sure the skin is healthy. If the skin is chronically infected, you think about a, uh, you mean deficiency HIV, if they've got chronic, you know, chronic dermatitis with fungal infection, you start to think they're immune system's not right. If they've got Isma, you may think about cow's milk protein intolerance. But we've said this baby's breast breads are much less likely. You're going to look at the cardiovascular system. You don't want them to have a heart disease. Um You know, are they in cardiac failure? If they're in cardiac failure, they're breathless sucking. All your nutrition is hard work. If you were out of puff, you would not want to have to suck everything. Um You're going to look at the abdomen. Is it normal? Is the organomegaly? Like you've said a buttock wasting nappy rash palette always inspect the palate because you may have a pallet problem right at the very back, which is going to affect suck swallow and you're going to examine them neurologically that you must demonstrate normal tone, a good stock and that they're reaching their milestones. Okay. So change you. So that's how you're going to approach it. I'm just going to talk about the definitions a little bit because there is controversy. Not all babies, even if they start with in utero growth, that is good. Want to stay on that center aisle, particularly if you've been born large. If you're an infant of a diabetic mum, right? And you're large for gestational age and you came out being that poorly controlled infant of a diabetic man with the cherub faces start, I appreciate this growth chart doesn't show that. But starting on the 99th central, you're not going to stay there, you're gonna drift to normal. So a lot of babies drift, find the center aisle, they won't grow on. So unfortunately, we don't have a consensus on what is failure to thrive, but we use it as a trigger to consider the well being of the baby. It's a description of a growth pattern, not a diagnosis, okay. Um And crossing to central's should trigger the clinician to think about the well being of the baby. But remember that the majority will be normal and have no pathology. But your history taking should tell you you when you want to look further. So we need to be less judgmental because parents get very anxious about the baby not growing. And the clinicians saying, oh, your baby doesn't seem to be tracking the same line. We need to think about how we word that and our communication skills. Okay. I haven't showing lots of charts and lots of different lines here and remember to go back all these lines could normal. Okay. You could have a baby showing catch up growth. I'm not very good with this pointer. This baby is catching up and coming up to the 25th center aisle. It doesn't want to stay down low maybe had poor growth in the room from smoking, from placental insufficiency from a preeclamptic mum from um, um, that was unwell. Okay. And that baby is caught up equally. This baby may have been an infant of a diabetic and is coming down so babies can cross entitles and it can be normal. They can be self correcting themselves and go into where they want to be. And one of the things to look at is the height and weight of the parents, small adults are not going to produce tall Children. They should produce Children within the genetic range of their own genetic profiling. So most large babies will regress to the mean and catch down okay. And small babies are likely to catch up. It's not written there. There you go. So history is really important. I'm going to go over things about it. You're feeding history, your frequency of length. Remember we've just spoken about a child who's feeding too often. I've said that a breast fed baby should feed every, take 30 minutes to feed and feed initially at the beginning when they're establishing lactation, feeding every 2 to 3 hours is normal and cluster feeding in the evening and overnight is normal. But there's an age and stage by six weeks, I would expect the feeds to be lengthening out. And certainly by six months, I would expect that baby to have lengthened out. Most babies lengthen out, but they will have periods when they need to pull more milk down. They suddenly want to up their volumes and they will have feeding frenzy days when they just want to sit with mom all the time and feed. And it seems to happen every, every sort of 2 to 3 weeks because they're up in their volume. When you start at the beginning, you don't take as much as what you're going to take. Six months. You see it in a bottle feed. You got to think in a breast fed baby, they've got to change that volume and they change that volume by sucking mall. So there's an age and stage of feeding. You need to think about just this baby not want to feed as it got feed a version. Will it not go onto the breast? Will it fight against the bottle? You see it fight, see a baby fighting against the breast. You see a baby fighting against the bottle, that's because they have associated feeds with pain. They don't like it. Ok. Sophie diversion is a really concern. You need to think about the pregnancy, the social factors, the maternal well being. Do you could you possibly have depression or neglect here? You need to look at the systems, respiratory system, thinking about cough, cystic fibrosis, immunodeficiency, bronchio, bronchi, active ethicist aspiration pneumonias with an unsafe swallow. Okay. I'm throwing lots of facts out of you, but I've got lots slides. So a parral int cough is abnormal. A chronic cough is abnormal cough in the newborn period. Does abnormal newborn babies should knock off. They shouldn't come out with infection. And even if they do have a chest infection, the majority of them don't cough. If they've inhaled meconium, they do not cough. So cough is really pathological in the first three weeks of life unless they've gone in court to viral infection. But that first fortnight, they shouldn't have a cough. G I you think about vomiting. You think about bile because that would suggest g eye obstruction and a surgical problem such as a treasure of the duodenum mall rotation valve, Elice. You're going to think about stools, you don't want blood in the stool that would suggest you've got some kind of colitis. So, and that can be a cosmic protein colitis. It can be a Hirschprung's colitis. It is abnormal. You don't want to see a lot of mucus in the stool because that would say you're malabsorbing and you've got some kind of intestinal pathology going on. You need to think about the urine is that you're in normal. You don't want it to be pale in an obstructive jaundice because they won't thrive because they're not getting their bile salts down for fat absorption. But it's really important to think about the neurodevelopmental and the behavior of this baby. If a baby is not getting fed. First of all, they're hyper alert, then they go very sleepy. They almost switch off their feeding appetite and thinking well, I'll just sleep. So, a baby that's too drowsy is abnormal. It can be a neurological problem, but it can actually be an after effect of neglect as well. You look at the skin and you look at the parent child interaction in your consultation. Talk a little bit about food aversion. And initially it's, it's because the child thinks about pain, thinks about abnormal sensation. And if it's gastroesophageal reflux, which a lot of people talk about, which is very common in neurological Children. I think it's over treated in the well baby. So, um um that comes in to you to say my babies always vomiting, vomiting in the newborn period of milky vomits, what we call posits is actually normal and don't chase it to treat it. Just reassure the mum, the main may be much more a disease of the western world. Actually, I don't know if you're seeing it in Ukraine and from your respective countries. But we see a lot of moms coming in to say all my babies always bringing up mouthfuls of milk that is normal. It's only when reflux causes pain and food aversion. Should we be treating it with milk thickeners such as Gaviscon or Cara Bell is only then we should be thinking about treating it. We should allow our babies to have small, frequent milky, as long as they're not bile vomits and as long as it's not caught also in significant pain that it's stopping them thriving and stopping them feeding. You need to look for hand mouth, regard a baby naturally wants to suck in the room that baby has often brought. It's the foetus will take its hand to its mouth to suckle on their hand. Um And that is part of developing they're sucking reflex in utero and they will continue to do it uh when they come out. So baby should naturally ask the mom just a baby, bring your hand, baby, bring their hand up to its mouth in the older child in the infant that doesn't want to feed, which is very common. Actually, they have good days when they eat lots and bad days when they don't want to eat there too interested in play. But it's common. Think about Messi play, let them play with food. So if they've got true food, your version, the way you get them to start eating is to allow them to play. They were food so that they become comfortable with the textures with handling it. And then they should naturally start to take it to their mouth. And as they get older, if they're refusing food, they won't eat their broccoli, they won't eat this, they won't eat that. Let them take control. You can't force feed a child. If you force feed them, you make them worse. So I guess I'm talking more about toddlers in the latter bit. Actually, the messy play and letting them take control. Just give them plenty of opportunities to feed themselves. We say 10 times a day actually. Okay. You're some pictures anybody want to shout out what they can see here. What's wrong here? What are you seeing the jawline? It's retracted or retrograded the lower, lower jaw? Absolutely. Yeah. So this jaw is, uh, as you say, retracted, it's too small and it's receding. So this is, and if you look in the mouth, you're likely to see a cleft palate actually. And this baby is also being fed by a tube. So the picture tells you we've got a nasogastric tube in this baby can't suck and swallow. This is likely to be pure roll band sequence where they get retrognathia, they're often quite small and they get left palette problems. Um They can also get obstructive sleep apnea unfortunately, from that. So you have to think about their respiratory status because if they're hypoxic, it also affects their nutrition. Okay. It is probably repeating myself a little bit. But the things I'm going to highlight again in the abdomen, in an older child that is weaning. Look for a distended abdomen. If they've been exposed to gluten, we see a lot of celiac disease in the UK and to my knowledge in Europe and we would actually failure to thrive screen. Part of it would be to look for celiac disease and to do something called A T T G A tissue trans gluten. Amon is I'm going to say, I hope I've got that right. So we would look for their entire mesial antibodies and do their tissue transglutaminase is Cecily it disease. For those that don't know is when you have a sensitivity to gluten in the diet, which causes the ville i of the small intestine around the duodenum and the ileum to shrink and become a trophic and then that affects absorption. So you get villus atrophy in the small intestine. As a result of gluten sensitivity, it seems to be becoming more common and we're not quite sure why. That is everything else I think I've mentioned here. So how do we investigate a child that's failing to thrive if we think the child is healthy, remember to do nothing and to reassure is okay and very common thing to do. And to say, well, we think the baby has just been finding its own centre tile. Let's just accept where we are. And that baby should then track along the new center. They shouldn't keep on a downward trend, they should find their sent I'll and then grow normally along that. If you are concerned, you're going to look for. We tend to do a full blood count and a ferritin, we tend to look for anemia. If I think worldwide, I would think about intestinal infection with worms and parasites causing failure to thrive. I would think about malaria. I would think about lots of other conditions. We tend to do electrolytes and creatinine to make sure that we're not missing renal failure, diabetes, insipidus, or assault losing problem. All these should really present within the first few months of life. Although you can get it presenting later in childhood child, can a child to present chronic renal failure at any time. And I appreciate some of my colleagues have spoken about that. We would tend to do liver function tests and to do a split bilirubin to make sure that we don't have a conjugated bilirubin anemia or evidence of liver failure. We tend to do alkaline phosphatase actually, because if you've got a malabsorption syndrome, you're also going to have a problem with vitamin D and calcium. So we tend to look at calcium phosphate and alkaline phosphates. A blood gasses, something simple to do to make sure you haven't got a metabolic problem. Thyroid function tests. If you've got an underactive thyroid, you will fail to thrive and an overactive thyroid. It can go either way. Actually, Celia screen sweat test to think cystic fibrosis. We have an incidence one in 200 in the UK. So it's quite high. It's quite a common condition in Northern Europe. And we would think about chromosomes if we think we have any dysmorphic features. Okay. So this baby I mentioned earlier on looking at the skin folds and the skin subcutaneous fat. Can you see this baby has no subcutaneous fat, the eyes in the face almost look too big for the body, this malnourishment or, or a dehydration. Yeah. Yeah, definitely. The baby's malnourished and, or could be severe d it would be severe dehydration, isn't it? The abdomen is also distended. The fact that the abdomen is distended would take me more to malnutrition. But I don't know if I'm right on that. Um, but, yeah. Yeah, I think, I think this is chronic as well because you've got so many, you've got such poor skin turgor and skin folds there, but it's probably a combination of the two actually. Okay. I'm going to go on to the nutrition requirement. So you can all look up UNICEF and the World Health Organization and they are very clear on their recommendations and they're taking a very global picture. The World Health Organization recommends exclusive breastfeeding from birth up to six months of age and then continued breastfeeding up to two years and beyond. Alongside the introduction of safe and nutritious complementary foods. Winnin should start from six months. Uh Sorry, I'm doubling up here and I'm emphasizing because I think in the UK, we still have a problem with delaying the introduction of nuts. Okay. It's really interesting actually, we have a high instances of nut allergy. Okay. So does America. So just lots of Europe. And whereas if you look at Israeli Children, which there's a lot of data and Children from the Middle East that are weaned on ground peanuts, they never have nut allergy. So, you know, they don't understand why the West has such a problem. So there was a study called the Leak study, which is really revolutionize Wean in, in America, U K, parts of Europe to introduce nuts early. What they did? They took the siblings and Children of high risk nut ally allergy families where they had a history of anaphylaxis. And they showed that if you give them small regular amounts and nuts from six months of age, those Children do not develop nut allergy. So we have shown now that interest using nuts, early nut butters and groundnuts pureed nuts in weaning, you prevent nut allergy. So you know the Middle East and Israel has better weaning practices and prevented food allergy. Okay. I want to talk a little bit to let you know what your fluid requirements are in the formula fed baby, you calculate it out, you ask them how many mills they're taking a newborn should feed 100 and 5200 and 80 mils per kilogram of its weight. Ok. Appreciating a breast fed. You can't take that detail, but in a formula fed baby, you can take the detail by three months. That's dropping 220 mils per kilo of their weight by a year. They're down to 90 mils per kilo of their weight. Okay. So that's what they're fluid requirements are. When are you ready to start solids? So you're not ready. I'm going to start when you're not ready, first of all, actually. So the general rule is you should be starting around about six months and that's all down to head control actually. So you're not ready when you're just wanting more milk. When the baby just wants to feed a lot, feeding a lot can be that they're just pulling that lactation down. So higher demand for milk feeds, it's still normal up to about six months, putting their fists in their mouth. Remember all babies should be able to suck. They've put their fists in their mouth in the womb. They will obviously carry on doing it afterwards because they will be comfort sucking. So sucking your thumb is normal. So waking up more than usual during the night, it's not a sign that they need to go on to solids is sign to up their milk volume up. The breastfeeding allow them to have that feeding frenzy to pull more breast milk down when they're really ready is when they're reaching and grabbing toys, which normally comes in between 4 to 6 months and putting a toy in their mouth. So they reach for a toy, they put it in their mouth. They start chewing their toys and they start to sit up and show you some. Huh? Head control. They've got good head control support because you don't want to feed a baby that you have to support their head off. You want them to have good head control to feed them. So we recommend weaning really from six months. And that is all about reducing food intolerances as well. What you should wean on nutritionally, we want vegetables and fruits. We want baby rice, which is more of a ground rice is, it's a ground rice. As opposed to the large grain rice. We want potatoes, we want yam, we want pasta, we want bread, oats, cereals, meat, fish, lentils, beans, all food groups. I'm saying actually but for the UK because we have a problem with getting this knowledge out there, we actually want nuts in there as well. And nut butters mixed in food and you often with weaning, you will mix with some of the milk that the babies on. Um Don't you the food? Try it pyramid here. Now he said triangle showing you you should have lots of servings of fruit and veg at the bottom and you don't want at the top. You don't want high sugar and high salt food and drinks. Okay. So you need a healthy pyramid, fat spreads and oils are in reduced proportion of that pyramid at the top. OK. Shit I'm getting on in time. I'm just going to come to socioeconomic factors. I think they're really important. I think it's important to emphasize there's no link to maternal education. How well a child will thrive all parents want to feed their Children. Neglect is uncommon. It is a very high bond actually. So if you have a disabled child that you take over the nutrition of parents struggle with that because the one thing they want to do is diff feed their child. So getting a parent to stop feeding the home foods because of unsafe swallow is a really challenging consultation actually, because you're taking away that parental control, your medicalizing feeding. And that is a really difficulty in a child with an unsafe swallow or stopping um um breastfeeding when they wanted to breastfeed, their child is a difficult consultation with a lot of tears. Neglect is uncommon. You have to think about it. We do have to think about depression and the fact that the mom is really suffering and that has an effect. Then on the baby, you have, you must support the mom as well and get the mom the correct help. So mom's with high depression, we know that the babies will wait to falter in the first four months, but then they seem to catch up and I think it's as the baby is able to take more control, they catch up. So by 12 months, they seem to be okay, they're better. So this was a big study in Newcastle actually. So outcomes of failure to thrive. Does it affect developments? Now, I went on the UNICEF website actually this morning and they're really emphasizing the importance of global nutrition in the first two years of life affecting development. So I think worldwide there is more of an impact if you've got nutritional failure, some UK data has said that if you've got a failure to thrive, when you look at the outcomes at the age of 10, provided, they've shown some catch up. It doesn't seem the only positive relationship is weight gaining embassy with picture of a cavalry. So this is UK data. I'm not sure that's extrapolated. Looking at UNICEF around the world who are really trying to focus on comprehensive nutrition because one of the problems is we give our Children a multivitamin. They get free access to multivitamins for the first five years of life. There's a lot of data out there around about the importance of vitamin A and vitamin D with nutritional benefit. So I'm not sure this slide is worldwide. Actually, what I am going to emphasize is use your colleagues to support a baby who you don't think is nutritionally doing well. Use the health visitor that we have you speech and language. If you think you have a suck swallow, difficulty use are dietetic colleagues. Think about solid social work and obviously manage any pathology. Uh Have I got time, Hannah for a case or not? It's 12 47. Um If you need to go buy a few minutes, we have time because we have a bit of a break. Okay. Let's look at this case. This is a true case. Sorry. This handwritten photocopy, a nine month old comes in with fever, cough and vomiting GP referral accompanied by mom fever for four days. Um vomiting and poor oral intake for three days. No diarrhea sent in really because the lethargy and but really what was also of concern is there was this background, history of poor growth 25th to the fourth center aisle. But mom says that the baby normally feeds well. So, so despite adequate nutritional intake, this baby was failing to thrive and the health minister was actively involved in monitoring the weight. You can't, what are you gonna do? It would be better to consult a nutritionist expert or a pediatric nutritionist because uh even after giving a perfect that there is a decrease in the weight or the percentile weight, there must be under Ishan of the absorption of the food. Yeah, child is not absorbing the food properly. Uh There could be other many things which would be these right now. Is this, this is the only one coming to my head. Okay. So absolutely get a dietetic opinion. We go on to do some investigation. So we go down that list that I've said a full blood count using these LFTs blood gas. Um nine month old, you could think about celiac disease if they weaned and if they're on the gluten, um it's a little bit early to present. So it looks, well, you've got lower respiratory tract infections. So you would think about immunodeficiency. So, on your full blood count, you can look at your lymphocytes, your neutrophils. The baby gets oxygen and antibiotics and the baby gets some bloods. Oh, you see that? Can you write? So, at the top, I don't know if it's just the way my slide is showing. I'm sorry if you can't see it. So the sodium is 100 and 52. The potassium is Hemel ized. The chloride is 100 and 11 which is low for us. Such a li the bicarbonate is 27 the creatinine is 28 which is actually normal for us. What do people think about this? What do you think about the sodium and the chloride? There's a miss balance and the renal renal miss balance maybe. But the other thing which is bothering me is the creatinine as well. Yeah. So the creatinine is normal but the, as you say, the salt levels are not correct, this baby's losing. I'm going to go on to show you you're going to think about is this baby losing water may not re absorb water and they've got hypernatremia. Now, it could just be that you're in hyponatremic dehydration at that point. But with hyponatremic dehydration, you would naturally expect that your ear to be higher if this was an acute phase response. So what we show is that the osmolality of the plasma is very high, but the urine osmolality is also sort of is normal actually. But the odds morality of plasma is very high and the sodium in the urine is less than 20. So, what we've bought is we've actually got diabetes insipidus. So this baby is lacking these oppressing. Now, what we show though is that by doing are various phase of pressing tests. I won't go into that here is that it's actually the kidney doesn't respond to the vase oppressing. It's the receptors in the renal end that the problem as opposed to the pituitary production. But it could have been either. Um, you have to take further detail on that. Okay. I think I better stop. I'm going to go on briefly about fatty eaters. So my child doesn't eat common. I'm jumping here. Child doesn't eat common pediatric problem. Parents say they won't eat, they won't eat what I put in front of them. They're not eating all the good food I want them to eat. So being a fussy eater is often they're good. They grow well, actually. So you want to, if they're fussy eater, but they're growing normally you're not actually worried. It's just more the behavioral aspect. And remember it can be normal for a child to only eat limited number of foods. So if they're a milk drinker and you can't wean them, that's more of concern the milk drinkers because it's a high fat products are often a little bit overweight actually, but they become anemic because cows, milk does not have any iron in it. Formula, milk has iron, they need to get iron from, you know, meet lentils, pulses, other food products. So if they're not eating what you don't do is give them high energy foods. I am going to finish after this few slides. You don't say, well, you're only getting it. If you'll eat what I put in front of you, you just give them plenty of opportunities to try new foods. But we do say don't hide new foods inside foods that your child already likes. But try in a homemade blended soup is a really good way of getting a variety of vegetables into your child to try trying homemade soups is a good way of doing it. Homemade bolognese. If you're eating pasta, bolognese and blend the vegetables in that way. But I wouldn't sort of hide food underneath another food because they'll then start gagging on that food that they like that. You've put it that you've mashed it into only do it if it's a normal food that you could naturally blend like a soup. Okay. If they've got extreme refusal, encourage them to have messi play with food and let them start with dry food, dry bits of precooked pasta, then moving on to messy and wet substances like, you know, period ice cream. Anything let them meet with other Children encourage play groups, having their cousins, having their siblings sit them all down at the table. Don't have the meeting in front of the TV, or in front of a telephone, the mobile phone, watching programs because that distracts them. They need to focus on food. They need to focus on food as a family and give small frequent meals. We would say give the feed them six times a day, three meals, three snacks. But don't keep them sitting at the table until they finish 30 minutes and then what they haven't eaten, let them play but let them have access to snacks. But don't let them graze continuously have intervals. Okay. I am going to stop here any questions regarding the insipidus case, what would be the treatment uh to increase the sugary content? Or you need to increase the water content to bring the sodium down? So that baby requires water supplementation actually um to try to bring down normal because they're not going to respond to. So if it was pituitary diabetes, insipidus, just you literally give, they suppressing, you actually just give the hormone because the kidneys are going to respond because the kidneys aren't responding. You're having to compensate by giving them water and then given them energy because of the nutritional status as well. So we give Max Eagle, we would give a high calorie energy supplement for growth and give them extra water. It's quite difficult to manage actually. But there are cases where the Children are overfed and which leads to the obesity at a very young age. But uh it results in 222 things where I mean, depending on the social norms was in some countries, uh, feeding excessive is considered normal but it's not normal. The two ways of it about it where the child doesn't eat enough due to the old feeding. And the other is the child gets acute ID to more eating. Is this possible that, that two ways the child might, uh, suffer like one in my, in a psychological way where the, he has the habit, he or she has the habit to eat more and in another way where they fed more forcefully, but they're not uh more into like feeding of it like they want to restrain feeding. Yeah. No. What? I absolutely agree. We can, we have a big problem with that actually. Um So obesity and childhood is a major problem. And remember you set your appetite center and probably where you're gonna be in the first two years of life. So it's really important not to overfeed. Um So breast feeding, you self regulate. Um So the beauty of breastfeeding is you're not going to overfeed. You're actually self regulate yourself. Whereas parents will think, oh, I've made a six ounce bottle. I want them to finish it and they'll go back an hour later, but that baby has stopped. So baby at the beginning will stop themselves. It's only when they get into that pattern and they've set their leptin and they've set their Satiety center that they will then overfeed. So if mom comes in and you, she'll report vomiting cause they're often little vomit ear's, they're bringing up lots and you look at them and they're taking 200 mils per kilo. You'll actually say, well, that's too much. You know, we would expect a baby to feed 150. Can we start cutting back, please? And just letting your baby settle that way and just do play distraction, you know, comfort. Like if the baby cries, it doesn't need feeding every time a baby can cry just because it wants to be held. So there's other ways and to look at the feeding cues, not take crying just as a reason to feed. So you're absolutely right. We can overfeed then with plates. So one of the problems we have is I think people are very quick to go onto an adult plate. I'm probably talking more about 5 to 8 year olds here. Actually keep them on a child plate, right. They have small stomachs, they should eat small amounts and don't encourage them to absolutely complete everything. Let themselves regulate. There's a big drive in the UK at the moment to do something called baby led weaning. So as opposed to spoon feeding your baby with weaning, let them pick it up with their hands because they will control their appetite. Because spoon feeding, you may be giving them too much and you may be driving them towards obesity and a higher appetite desire because you all know if you start to eat more, you want more food if you cut back your actually less hungry. So if a baby weans itself by putting the finger foods in and finger food weaning. So move them to finger food weaning as quickly as you can. So by the age of one, you actually want them to finger wean and not be spoon furred by parents as much as possible. So there are some of the things that you can encourage to stop that obesity. But it's a real challenge. I showed you that healthy pyramid fruit and veg the biggest part of the diet. Then your cereals, then your proteins, your fish. You're so sorry being to, to feel your meat, you know, and you're higher fats, you need fat. But think about the amount of fat the fat is at the top of the healthy pyramids. So the healthy pyramid for weaning and for childhood nutrition is really important and balance in the diet. But it's a real problem actually and we need to tackle it in infancy. So it's right when everybody you have to eat your vegetables switched. Yeah. Yeah. Yeah, you need to eat your veg. You're absolutely right. Yeah. But don't force feed the broccoli. Is this child is getting force fed? It's not, that child is not doing that broccoli. Thank you. Okay. Thank you. Sorry, I've not actually opened the chat any other questions. Um, please doctor, can you uh we share these lights that, that presented the flu. The amount of amount of flutes taking the fluid side. Yeah. Absolutely. Okay. Oh. Right. I always get stuck. I think as soon as I stop scrolling, but I'm going to stop sharing again and I will find it. So a newborn is 100. I am. I'm getting you to the slide. It's okay. A newborn is 152 180 mils per kilo and a by three months that's dropped to 1 20. Oh, sorry. By three months that's dropped to 1 20 I'm not doing very well at sharing here and then by a year it's down to 90. I appreciate. I've not got it on full side. But can you see that? Yes, I can. Yes, I can, I can. And it would be the same if you're giving intravenous fluid that you need to. So if you're given total parenteral nutrition to a newborn, you would think about it. You would be working up to 100 and 50 mils per kilo. They take five days to get up to here. So this can take 52, a week, five days to a week to get 252 180 mils per kilo. But they don't need the formula make as long as they have been best Brekford right up to six months. Yeah. Yeah. So pure breastfeeding for the first six months, then introduce Wean in uh but breastfeed, if you can up to the age of two and I think in eastern Europe you are much better at breastfeeding. Um Up to the age of two, I don't think we're very good at it in the U K. A lot of parents will stop at the age of one. Okay. Really? Any more questions? Okay. I shall leave you here. Have a good, have a good day, everyone and keep safe.