Growth and Nutrition
Assessment of growth is a basic element of the routine physical examination of children. Routine care in a typical child becomes a challenge when dealing with a child with a disability.
Length, weight, and head circumference should be obtained at each health maintenance visit in the very young child, and length and weight should be obtained for the older child. Obtaining a weight on a child who is unable to stand on the office scale is often accomplished by having parents hold the child while stepping on the scale themselves. This is more effective in a smaller child, but is more difficult in a larger child or one with severe spasticity or hypotonia. It is recommended that an office who cares for large numbers of children who are nonambulatory obtain a wheelchair scale, which allows the child to be weighed easily in his or her own wheelchair. Assessment of the length of a child is also problematic when the ability to stand is limited. Use of arm span as a substitution for height may be an acceptable option. Alternatives to standing height also include individual measurements of lower extremity segments when significant joint contractures are present. To obtain segmental measurements, the child is placed in the supine position on the examination table and the assessment is done by adding all of the measurements obtained from the head to pelvis, the pelvis to knees, and knees to feet. Use of knee height has also been used as another means of monitoring a child's growth (6-8).Plotting a child's anthropometric data on a growth chart will allow the PCP to track a child's nutritional status. A weight-to-length ratio below the fifth percentile may represent failure to thrive. However, growth velocity is the more important piece of information. Many children with disabilities will be below the fifth percentile for their age, but as long as their weight and length increase in parallel to a normal curve, growth may be appropriate. A child's age should be corrected for prematurity until 2 years of age.
One must remember that some children with special health care needs have short stature as part of their disease process or syndrome. Special growth charts are available for children with Down's syndrome and Turner syndrome (9,10).A nutritional assessment should be completed during routine health maintenance visits. When there is concern about a child's growth, a more careful investigation into the food intake is necessary. The amount, variety, and consistency of food eaten may provide the examiner with information regarding the caloric intake of the child. The amount of food eaten is important, but the amount of time it takes a child to complete a meal also is essential. It is not unusual for a child with severe cerebral palsy or an infant with spinal muscular atrophy to eat a meal over a prolonged period. The amount of energy that is expended during this lengthy meal may cost more in energy expenditure than is actually gained in caloric intake. Additional information that is important to obtain includes how safe the child appears while eating. This is best achieved by watching an infant or child eat or drink during their routine visit. Signs and symptoms of feeding problems include coughing or choking while eating, a wet vocal quality during or after the meal, poor sucking, gagging easily, and vomiting after a meal. A referral to a comprehensive feeding clinic should be considered if there is a concern about the weight of the child or his or her safety while eating. An interdisciplinary clinic may include an occupational and speech therapist, nutritionist, physiatrist, gastroenterologist, and/ or developmental or rehabilitation physician.