How can we best chart children's growth in the paperless age? The UK experience.

Growth charts have played an integral part in the monitoring and assessment of children's health for the past 50 years, but their use is now under threat as paperless electronic systems become more widely used. While the obvious solution is to adopt electronic charting systems, this can prove challenging in practice. This article describes the key issues to consider in planning this transition and the charting options available, ranging from bespoke local systems to commercial packages and a new initiative by the Royal College of Paediatrics and Child Health.

World variation in head circumference for children from birth to 5 years and a comparison with the WHO standards.

OBJECTIVE: A recent review reported that the WHO 2006 growth standards reflect a smaller head circumference at 24 months than seen in 18 countries. Whether this happens in early infancy and to what extent populations differ is not clear. This scooping review aimed to estimate the rates of children in different populations identified as macrocephalic or microcephalic by WHO standards. METHODS: We reviewed population-representative head circumference-for-age references. For each reference, we calculated the percentages of head circumferences that would be classified as microcephalic (<3rd WHO centile) or macrocephalic (>97th WHO centile) at selected ages. RESULTS: Twelve references from 11 countries/regions (Belgium, China, Ethiopia, Germany, Hong Kong, India, Japan, Norway, Saudi Arabia, UK and USA) were included. Median head circumference was larger than that for the Multicentre Growth Reference Study populations in both sexes in all these populations except for Japanese and Chinese children aged 1 month and Indians. Overall, at 12/24 months, 8%-9% children would be classified as macrocephalic and 2% would be classified as microcephalic, compared with the expected 3%. However at 1 month, there were geographic differences in the rate of macrocephaly (6%-10% in Europe vs 1%-2% in Japan and China) and microcephaly (1%-3% vs 6%-14%, respectively). CONCLUSIONS: Except for Indians and some Asian neonates, adopting the WHO head circumference standards would overdiagnose macrocephaly and underdiagnose microcephaly. Local population-specific cut-offs or references are more appropriate for many populations. There is a need to educate healthcare professionals about the limitations of the WHO head circumference standards.

Weight loss during ambulatory tube weaning: don't put the feeds back up.

OBJECTIVE: To describe the prevalence of weight loss during tube weaning and its impact on wean duration and growth. SETTING: Tertiary feeding clinic, UK. PATIENTS: All children seen for weaning from long-term enteral feeding between 2008 and 2016. INTERVENTIONS: Outpatient withdrawal of enteral feeding. DESIGN: Case series of children being weaned from tube feeding, documenting clinical details, periods of weight loss and timing of feed changes, as well as height and weight at baseline and within 1 year after feed cessation. MAIN OUTCOME MEASURES: Amount and frequency of weight loss, wean duration, change in body mass index (BMI) and height SD z score. RESULTS: Weaning was attempted in 58 children, median age 2.7 years, and 90% had stopped feeds after median (range) 5.9 (1-40) months. Weight loss was seen in 51 (88%) children and was more common and severe in children with initially higher BMI. Time to feed cessation reduced by median 4.9 months between 2008-2011 and 2012-2016, while having feeds increased prolonged the wean duration, by median 13 months. After feed cessation, mean (95% CI) BMI had dropped by 0.84 (0.5 to 1.2) z scores, but neither change in BMI, nor the amount and frequency of weight loss, related to growth. CONCLUSIONS: Short-term weight loss is to be expected during tube weaning and is not associated with compromised growth. It is important to avoid overfeeding enterally fed children and not to increase feeds again in response to weight loss.

Childhood stunting and micronutrient status unaffected by RCT of micronutrient fortified drink.

Micronutrient supplementation is widely used to prevent stunting in children under 5 years in low- and middle-income countries (LMIC), but the impact of treatment has been disappointing, possibly due to non-compliance. Our aim was to deliver long-term micronutrient supplementation via a novel, culturally acceptable liquid food to improve linear growth in a high stunting prevalence region. In a randomised control trial, 971 children aged 6-72 months received either 'Chispuditos®' (n = 681), a hot drink (atole) fortified with micronutrients (atole + MN) (9 mg/zinc, 12.5 mg/iron), or lactose-free milk (n = 290) for 18 months. Primary outcomes were changes in length/height-for-age (HAZ) score and the prevalence of stunting at 18-month follow-up. Adherence was monitored monthly, and 73% children in atole + MN group consumed at least half their daily zinc and iron requirement. At 18 months, there was no difference between the treatments in growth [mean change in HAZ -0.02 (95% CI -0.12, 0.08)] or stunting [atole + MN 41%, milk 41%; RR 0.99 (95% CI 0.84, 1.19)]. There were no differences in haemoglobin (HB), ferritin or zinc. No children had iron deficiency anaemia (IDA) at outcome, but zinc deficiency remained equally prevalent in both groups: atole + MN 35%, milk 35% [RR 1.02 (95% CI 0.83, 1.24)]. There was no difference in morbidity between the groups, and micronutrient status was unrelated to HAZ. Long-term micronutrient supplementation via a culturally acceptable food had no impact on stunting or morbidity, raising the question of whether large-scale micronutrient supplementation is worthwhile.

Assessing the optimal time interval between growth measurements using a combined data set of weights and heights from 5948 infants.

BACKGROUND: Current guidance on the optimum interval between measurements in infancy is not evidence based. We used routine data to explore how measurement error and short-term variation ('noise') might affect interpretation of infant weight and length gain ('signal') over different time intervals. METHOD: Using a database of weights and lengths from 5948 infants aged 0-12 months, all pairs of measurements per child 2, 4 and 8 weeks apart were extracted. Separately, 20 babies aged 2-10 months were weighed on six occasions over 3 days to estimate the SD of the weight difference between adjacent measurements (=116 g). Values of 116 g and 0.5 cm for 'noise' were then used to model its impact on (a) the estimated velocity centile and (b) the chance of seeing no growth during the interval, in individuals. RESULTS: The average gain in weight and length was much larger than the corresponding SD over 8-week and 4-week time intervals, but not over 2 weeks. Noise tended to make apparent velocity less extreme; after age 6 months, a 2-week velocity that appeared to be on to the ninth centile, would truly be on the second-third centile if measured with no noise. For 2-week intervals, there was a 16% risk of no apparent growth by age 10 months. CONCLUSIONS: Growth in infancy is so rapid that the change in measurements 4-8 weeks apart is unlikely ever to be obscured by noise, but after age 6 months, measurements 2 weeks or less apart should be treated with caution when assessing growth faltering.

Changes in the UK baby food market surveyed in 2013 and 2019: the rise of baby snacks and sweet/savoury foods.

OBJECTIVE: To assess how the baby food market in the UK has changed between 2013 and 2019. SETTING: United Kingdom. DESIGN: A cross-sectional survey of all infant food products available to buy in the UK online and in-store collected in 2019. Nutritional content and product descriptions were recorded and compared with an existing 2013 database. MAIN OUTCOME MEASURES: Change in the proportion of products marketed to infants aged 4 months, proportion classified as sweet versus savoury, spoonable versus dry (snacks) average sugar content. RESULTS: Fewer products were described as suitable for infants aged 4 months in 2019 (201, 23%) compared with 2013 (178, 43%; p<0.001), while the proportion for children in the 6-7-month age range increased (2013: 135, 33%; 2019: 369, 43%; p=0.001). The proportion of sweet and savoury products was unchanged; sweet spoonable products showed a small but significant decrease in sugar content (6%) between 2013 and 2019, but savoury spoonable products showed a 16% increase. Sweet snacks remained very sweet (~20 g/100 g median sugar at both time points). In the 2019 dataset, concentrated juice was added to 29% (n=253) of products and 18% (n=80) 'savoury' products comprised more than 50% sweet vegetables or fruit. The number and proportion of snacks increased markedly in 2019 (185, 21%) compared with 2013 (42, 10%; p=0.001) while the proportion of wet spoonable foods decreased (2013: 326, 79%; 2019: 611, 71%; p=0.001). CONCLUSIONS: Fewer foods are now marketed to infants aged 4 months, but there has been no overall reduction in the sweetness of products and the increase in snack foods and the sweetness of savoury foods is a concern.

Criteria for undernutrition screening in hospitalised infants under 6 months: a diagnostic accuracy study in a resource-poor setting.

PURPOSE: We aimed to describe the prevalence of undernutrition in hospitalised infants aged under 6 months and test the utility of simple index measures to detect undernutrition. DESIGN: Diagnostic accuracy study: weight, length, mid-upper arm circumference (MUAC), triceps and subscapular skinfolds were measured in infants aged 2 weeks to 6 months admitted to a Teaching Hospital in Enugu, Nigeria. Index criteria : low (<-2SD) weight-for-age Z-scores (WAZ), weight-for-length Z-scores (WLZ); MUAC <11 cm. Reference definition: weight faltering (conditional weight gain below fifth percentile for healthy Nigerian infants) or sum of skinfolds (SSF) <10 mm. RESULTS: Of 125 hospitalised infants, only 5% (6) were admitted specifically for undernutrition, but low SSF were found in 33% (41) and, 24% (25) with known birth weight had weight faltering, giving an undernutrition prevalence of 36%. Low WAZ was the most discriminating predictor of undernutrition (sensitivity 69%, positive predictive value 86%, likelihood ratio 5.5; area under receiver operator curves 0.90) followed by MUAC (73%, 73%, 4.9; 0.86), while WLZ performed least well (49%, 67%, 2.9; 0.84). Where both MUAC and WAZ were low, there was sensitivity 90%, positive predictive value 82% and likelihood ratio 8.7. CONCLUSIONS: Infants aged under 6 months admitted to hospital in Nigeria had a high prevalence of undernutrition. In young, high-risk population, a low WAZ alone was a valuable screening criterion, while combining weight with MUAC gave even higher discrimination. Measurement of length to calculate WLZ was a less useful predictor in this population.