Paediatric Dietetics

Who to refer

Faltering Growth

If all medical reasons for faltering growth have been explored, then refer to us.

Infants and children with faltering growth as defined by NICE Guideline 75. If there is concern about faltering growth:

• Weigh the infant or child
• Measure their length (from birth to 2 years old) or height (if aged over 2 years)
• Plot these measurements and available previous measurements on the UK WHO growth charts to assess weight change and linear growth over time.

Use the following as thresholds for referral for concern about faltering growth:

• Under 1 year of age 
• a fall across 1 or more weight centile spaces, if birthweight was below the 9th centile 
• a fall across 2 or more weight centile spaces, if birthweight was between the 9th and 91st centiles 
• current weight is <2nd centile 
• length and weight are greater than 2 centile spaces apart
• Over 1 year of age
• a fall across 1 or more weight centile spaces, if birthweight was below the 9th centile
• a fall across 2 or more weight centile spaces, if birthweight was between the 9th and 91st centiles
• a fall across 3 or more weight centile spaces, if birthweight was above the 91st centile
• BMI below the 2nd centile (over 2 years of age). Children’s BMI (between the ages of 2-18 years) can be calculated using the NHS website using the ‘child’ calculator tab, which adjusts for their age

All referrals for children with faltering growth and child protection concerns will be prioritised.

For advice where specific concerns, please contact tay.taysidepaediatricdietitians@nhs.scot

Selective eating/ Restricted Diets

Young people who present with longstanding restrictive eating associated with,

• Sensory aversion (taste, texture, smell, appearance)
• Lack of interest in food/eating (not recognising hunger, avoiding meals)
• Oral-motor skill delays (with SLT assessment)

Referral to our dietetic restricted eating clinic is appropriate when a child presents with malnutrition or risk of malnutrition (based on clinical concern, growth pattern, dietary restriction, or weight change) and meets one or more of the criteria below:

• Faltering growth or concerning downward trend in Weight-for-Height or growth centiles.

• Weight <0.4th centile, BMI <5th centile,
• Rapid or significant weight loss (e.g., >5-10% body-weight loss within 6 months).
• Suspected or identified nutritional risk with significant concerns about dietary adequacy, and vitamin/mineral supplements have been tried but are refused.
• <5 accepted foods in the diet (specify foods and quantities).

Exclusion criteria:

• Young people with trauma or perceived aversive consequences as driver for ARFID (e.g. following a choking, vomiting incident or severe anxiety around allergies) that leads to avoidance or restriction of food where intake is now insufficient quantity or variety - referral more appropriate with CAHMS.
• Young people who are under 3 years old. If faltering growth present refer to general paediatric dietetics.
• Young people with picky/selective eating (internally classified as young people consuming more than 5 foods and are not physically/nutritionally compromised) - consider signposting to community SLT/OT locality advice.
• The eating/feeding disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
• A manifestation of another medical condition (e.g. food allergies, hyperthyroidism) or mental disorder, and are not due to the effect of a substance or medication on the central nervous system including withdrawal effects - consult with paediatrician.
• Young people with restricted diets driven by body image concerns - refer to CAMHS. 

Pre-referral requirements

• Clinical History
• Are they under the care of a paediatrician (YES/NO)
• Any medical conditions/symptoms under investigation?
• Any medical conditions/symptoms being treated?
• Are you confident that there are no medical conditions impacting appetite or ability to eat, or causing pain/discomfort when/after eating?
• Failure to grow/gain weight as expected or significant weight loss
• If available, please provide details of growth history (e.g., weight/height in the first few years of life)
• Diet: Accepted foods, food group variety, allergies, dietary restrictions
• If patient meets referral criteria, detailed food diary will be sent out prior to initial appointment

Signposting - general fussy eating advice:

• Visit the following pages on the NHS Tayside website for signposting information and resources.
• NHS Tayside 'Fussy Eating' page. Fussy Eating Training Video

Coeliac Disease

Diagnosis Pathway:

Diagnosis in paediatrics is generally by serology or intestinal biopsy to detect villous abnormalities. Tayside adheres to the following ESPGHAN 2022 diagnosis criteria:

Initial serology tests:

• Nice recommends including gluten in at least two meals a day for at least six weeks prior to testing. There is no specific amount of gluten that should be recommended, but it is essential to ensure the patient is consuming sufficient gluten for the tests to be valid.
• Perform IgA anti-transglutaminase 2 antibodies (IgA-TGA) (also referred to as tTG) as the first-line screening test as this is the most accurate and cost-effective test.
• The laboratory automatically assesses the likelihood of IgA deficiency in all samples where IgA tTG antibodies are requested and will cascade likely IgA-deficient samples for further immunoglobulin analysis.
• For patients identified as IgA deficient:

• IgG-tTG antibodies will be measured instead.
• A factsheet on IgA deficiency will be included with the laboratory report.
• The patient will be flagged as IgA deficient in their records.
• All IgA deficient patients require a biopsy to diagnose coeliac disease

• EMA-IgA testing is conducted on the tTG test.

Second serology tests:

• If tTG is ≥10 times the upper limit of normal: Repeat tTG.
• If the repeated tTG is ≥10 times the upper limit of normal and EMA-IgA is positive from the initial test, no biopsy is needed for diagnosis. The patient should be referred directly to the paediatric dietetic department for further investigations.
• If tTG is <10 times the upper limit of normal: A biopsy is required to confirm the diagnosis and avoid false positives. Please refer to paediatrics for further investigation. Biopsy should only proceed if gluten challenge has been maintained as per NICE guidelines.
• According to the ESPGHAN 2022 guidelines, when coeliac disease is suspected, baseline screening should include a second sample of tTG alongside a complete blood cell count and micronutrient status (e.g., haemoglobin, iron, vitamin B12, and vitamin D levels). LFT’s should be measured after clinical evaluation at time of diagnosis. Additionally, TSH and thyroxine levels may be considered during follow-up, if clinically indicated.

Enteral Feeding

We will accept transfers of care from external health boards of children and young people who are enterally fed.