Growth Problems

Growth problems are common in refugee children in Canada (Salehi et al., 2015; Lane et al. 2018). Family physicians seeing refugee children and teenagers should carefully monitor their weight, height/length and head circumference (birth-age 2) at every visit, and act promptly when their growth seems to be faltering. Overweight/obesity is also frequently encountered in the refugee population, but this topic is not covered in this section.

 

DEFINITIONS

Here are some definitions of common medical terms used to describe growth problems:

  • Underweight: Weight for age <3rd percentile.
  • Stunting: Height/length for age <3rd percentile.
  • Wasting: Weight for length <3rd percentile (birth-age 2). BMI for age <3rd percentile (age 2-19).
  • Faltering growth/poor weight gain: Decreased velocity* of weight gain that is disproportionate to growth in length.
  • Growth failure/retardation: Linear growth rate (height/length velocity*) below the expected growth velocity for age.
  • Constitutional growth delay: Usually presents as retarded linear growth in the first 2-3 years after which growth resumes at a low-normal rate. Delayed bone age and puberty are also hallmarks of constitutional growth delay. These children are expected to achieve their predicted height over time.
  • Severe acute malnutrition: Weight for height/length <-3 SD or mid-upper arm circumference <115 mm or edema of both feet.
* While crossing a percentile line on the growth chart is usually used as an indicator of decreased weight/height velocity, it does not always indicate a growth problem; children growing normally may change percentiles, especially in the first two or three years. However, crossing two major channels on the growth chart should not be considered normal.
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Canadian physicians should use the WHO Growth Charts for Canada to monitor the growth of children. For children two years of age and older, body mass index (BMI) should be used to assess weight relative to height and age.

 

MANAGEMENT

Here is a simplified approach for family physicians seeing refugee children with growth problems. This is a broad approach that can be applied to both weight and height issues in children of all ages:

  1. Complete the history

The following elements should be sought on history:

  • Confirm the child’s real age: The date of birth of refugee children will sometimes be different than the one written on their official papers.
  • Perinatal history: Birth weight, prematurity, maternal conditions during pregnancy.
  • Personal medical history: Food allergies, gastrointestinal parasites, chronic diseases such as celiac disease, recurrent acute illnesses (e.g. respiratory infections, malaria), history of major illnesses/hospitalizations (e.g. meningitis, tuberculosis).
  • Family history: Parental height (to assess genetic potential), growth of siblings, relevant medical conditions in the family such as inflammatory bowel disease or atopy.
  • Feeding and diet: Breastfeeding status, correct formula preparation, introduction of solids, feeding routine (frequency, quantity, quality), picky eating, excessive fruit juice/milk consumption, cultural/religious food restrictions.
  • Psychosocial (key element for refugee patients): History of poverty/refugee camp/war, food insecurity, parenting skills, child neglect.
  • Review of systems: Diarrhea (malabsorption, parasites), constipation (can decrease appetite), vomiting (gastroesophageal reflux), wheezing/cough (pulmonary disease), polyuria (diabetes), etc.​
  1. Complete the physical exam

In addition to accurate anthropometric measurements (weight, height/length, head circumference) plotted on the growth charts, physicians should look for these specific signs on physical exam:

Dysmorphic appearance, hair depigmentation (malnutrition), Bitot’s spots (vitamin A deficiency), poor dentition, goiter (iodine deficiency), heart murmur (anemia, cardiac defect), respiratory compromise (cystic fibrosis, tuberculosis), hepatosplenomegaly (infection), edema (protein deficiency, heart/renal failure, thiamine deficiency), rash (cow’s milk allergy, micronutrient deficiencies), signs of rickets (frontal bossing, rachitic rosary, bowing of legs, etc.)

  1. Investigations

If no obvious cause (e.g. poor diet) for the growth problem is identified on history and physical exam, the following tests can be considered:

CBC*, iron studies*, C-reactive protein, creatinine, urea, electrolytes, glucose, total protein, albumin, ALT, AST, GGT, alkaline phosphatase, calcium, phosphate, TSH, celiac disease screening, vitamin B12 levels, HIV serology*, schistosoma serology* (if from endemic country)

Stool Ova & Parasites and Protozoal Screen (PCR) - ideally 3 different stool samples

Urinalysis

* These tests are already included in our recommended initial screening tests.

If the initial tests do not reveal a cause for the growth problem, the following advanced tests can be considered based on the clinical picture (a Pediatrics referral should be considered at this point):

Serum immunoglobulins (allergies, immunodeficiency), sweat chloride test and stool elastase (cystic fibrosis, pancreatic exocrine dysfunction), vitamin D levels and parathyroid hormone (rickets), bone age study (stunting, growth failure), chest X-ray (cardiopulmonary disease)

  1. Treatment

If an underlying medical condition contributing to the growth problem is found, treatment should be initiated promptly.

The parents of all children with growth issues should be offered culturally appropriate dietary counselling. These children require more frequent follow-ups in order to track their growth.

Additionally, the following referrals should be considered:

  • Pediatrician: Children/teenagers with severe growth problems or complex comorbidities, growth problems not responding to dietary measures or medical interventions, or unexplained growth problems.
  • Dietician: Educate the parents to ensure adequate caloric intake. Refugee families might not be familiar with local food options when they arrive in Canada.
  • Lactation specialist: If breastfeeding is an issue.
  • Social worker: Ensure food security (food bank referral) and address psychosocial factors.

Growth problems are often associated with micronutrient deficiencies. All refugee children between the age of 6 months and 5 years should be prescribed an age-appropriate daily multivitamin, as well as adequate vitamin D supplementation. See Iron Deficiency Anemia and Vitamin D Deficiency for more information on these deficiencies.

 

>> Refer to the following resources for more practical approaches to children with growth problems: