| Insufficient nutrient intake | Comments |
| Food insecurity |
- Lack of access to sufficient quantity or quality of food to meet basic needs
| - Routinely screen with questions about whether the family has been unable to buy enough food or varied food due to lack of money or other resources
|
| Behavioral contributors |
- Feeding aversions
- Selective eating
- Pediatric feeding disorder
- Avoidant/restrictive food intake disorder
- Disorders of gut-brain interaction (functional abdominal pain)
- Hyperactivity and attention problems
| - Review any trauma and/or fear that might be associated with eating such as choking or aspiration
- In some cases, caregiver-child feeding interactions cause or contribute to the maladaptive behaviors
|
| Decreased appetite |
- Excessive juice or other nonnutritious liquid
- Chronic disease that causes anorexia, vomiting, or early satiety (a variety of gastrointestinal, kidney, cardiac, or pulmonary disorders)
- Medications (eg, anticonvulsant drugs or stimulants for ADHD)
- Lactose intolerance (untreated)
- Stressful psychosocial conditions
| |
| Dietary restriction |
- Dieting for weight loss (including disordered eating, eg, anorexia nervosa)
- Perceived food intolerance or allergy
- Diets for cultural or personal beliefs (kosher, halal)
- Other specific diets (dairy free, vegetarian, vegan, low fat, low carbohydrate, gluten free)
| - Anorexia nervosa is characterized by body image disturbance
- Most specific diets can provide sufficient nutrients if appropriately designed and implemented; however, diets that are more restrictive (eg, vegan) can be associated with poor weight gain, especially if the child also has limited food preferences
|
| Medical issues |
- Discomfort or pain associated with eating (eg, peptic disease, esophagitis, dental caries, constipation)
- Oromotor dysfunction
| |
| Child neglect or maltreatment |
- Food withholding (eg, as punishment)
- Poor caregiver-child feeding interactions
| |
| Increased nutrient requirements | Comments |
| Increased metabolic rate |
- Congenital heart disease
- Chronic lung disease (eg, bronchopulmonary dysplasia)
- Spasticity
- Hyperthyroidism
- Obstructive sleep apnea
- Diencephalic syndrome
| - Children with neurologic conditions that cause spasticity also may have feeding issues that contribute to poor weight gain
|
| Inflammation |
- IBD
- Cystic fibrosis
- Malignancy
| |
| Increased physical activity |
- Sports with very high energy expenditure (eg, long-distance running)
- Hyperactivity (uncertain effects on weight)
| |
| Increased nutrient losses | Comments |
| Disorders that may cause nutrient loss in stool, urine, or vomitus |
- IBD
- Celiac disease
- Bulimia nervosa
- Short bowel syndrome
- Eosinophilic gastrointestinal disorders
- Pancreatic exocrine insufficiency (cystic fibrosis, Schwachman-Diamond syndrome)
- Chronic liver disease
- Diabetes mellitus (with glucosuria)
- Chronic kidney disease
- Inborn errors of metabolism (many types)
- Renal tubular acidosis
- Food protein sensitivity (eg, FPIES)
| - Refer to relevant UpToDate content on each of these disorders
|
| Energy cost of growth |
- Increased total energy requirements for catch-up growth after a period of undernutrition
| - Approximately 85 kcal/kg/day more than normal energy requirements to achieve catch-up weight gain of 20 g/kg/day
|
