Faltering Growth (previously known as Failure to Thrive)

Faltering growth is a term widely used to refer to a slower rate of weight gain in childhood than expected for age and sex. It is not possible to make a spot diagnosis based on a single weight. It is based on a fall across centiles (a centile is the space between adjacent centile lines on UK WHO Growth charts). These charts allow a visual representation of growth over time with healthy children growing relatively consistently along a growth centile.

Thresholds for concerns are determined by NICE:

• A fall across 1 or more weight centile spaces if birth weight was below 9th centile;
• A fall across 2 or more weight centile spaces if birth weight was between 9th and 91st centiles;
• A fall across 3 or more weight centile spaces if birth weight above 91st centile;
• Weight below 2nd centile;
• Over 2 years the use of BMI centile charts are also recommended with BMI below 0.4th centile requiring assessment and intervention.

The reason for having practice guidance on this subject is that faltering growth can be a feature of neglect. It can also be present in other forms of abuse and should be considered as part of the overall picture. There are however, a wide variety of causes for growth to falter and it is important to be mindful that many situations will not have associated safeguarding concerns.

Faltering growth may be a safeguarding issue when:

1. The infant or child fails to gain weight and:
   • There is evidence of neglect abuse - the carers are not providing or preventing the child accessing a proper diet, which includes young children not being fed and teenagers who may present as undernourished;
   • Parents/carers are hostile to professional concerns;
   • Children are exposed to parental domestic abuse, substance misuse, alcoholism, chaotic lifestyle);
   • Parents/carers show inappropriate apathy or in denial;
   • Parents/carers have possible, or diagnosed learning disabilities or are suffering an active mental health problem (e.g. chronic self-harm, poorly treated depression or psychosis);
   • A parent/carer claims to follow professional advice but may be giving diluted feeds etc. (see Fabricated or Induced Illness and Perplexing Presentation);
   • When hunger and starvation has an impact on the child – affecting school performance, scavenging for, stealing food The infant has a chronic illness or disability, and the parent is uncooperative with medical treatment, exhibits some of the above problems or may not be feeding the child.
2. Children with faltering growth may be identified by routine growth monitoring or by parental or professional concerns. If a professional is worried about a child's growth, they should discuss the concerns with the parents and direct them towards health for assessment and any further support or any onward referral that may be indicated. This may include an Early Help Assessment and support for the child and their family.

In children under 5 years old, the first point of contact would be the health visitor. In children over 5 years old, either the school nurse (for children in state funded school), or the GP would be appropriate.

All children with confirmed faltering growth should have:

1. An initial careful clinical assessment, most appropriately by the GP; and
2. Referral to a paediatrician and paediatric dietitian if the faltering growth is severe, is associated with a medical condition or there is no progress.

If there are other features that are suggestive of neglect/abuse, then investigating this should commence promptly and should not be delayed whilst waiting for a medical opinion.

See Working Together to Safeguard Children 2023 - Page 7.

Safeguarding and promoting the welfare of children is defined for the purposes of this guidance as:

• providing help and support to meet the needs of children as soon as problems emerge;
• protecting children from maltreatment, whether that is within or outside the home, including online;
• preventing impairment of children's mental and physical health or development;
• ensuring that children grow up in circumstances consistent with the provision of safe and effective care;
• promoting the upbringing of children with their birth parents, or otherwise their family network through a kinship care arrangement, whenever possible and where this is in the best interests of the children;
• taking action to enable all children to have the best outcomes in line with the outcomes set out in the Children's Social Care National Framework.

See Working Together to Safeguard Children 2023 - Page 161.

Safeguarding and promoting the welfare of children - Defined for the purposes of this guidance as:

• protecting children from maltreatment, whether the risk of harm comes from within the child's family and/or outside (from the wider community), including online;
• preventing impairment of children's mental and physical health or development;
• ensuring that children are growing up in circumstances consistent with the provision of safe and effective care;
• taking action to enable all children to have the best outcomes.

See Children's Social Care National Framework - page 161.

Throughout the National Framework, the term 'children's social care' refers to the local authority services that exist to:

• safeguard and promote the welfare of children in their area who, without the provision of services, are unlikely to achieve or maintain a reasonable standard of health or development, or their health or development will be significantly or further impaired, or is disabled (section 17, Children Act 1989).

At present, we screen for faltering growth routinely by measuring weight in all young children at specified ages. In general, babies will regain their birth weight by day 14. It is considered faltering growth if they are not back to their birth weight by day 21.

The ultimate cause of faltering growth is an imbalance between calorie intake and usage. This can be due to failure to take in enough calories e.g. insufficient access to food, physical difficulties with eating, behavioural or psychological issues with food or malabsorption. Professionals should have an awareness of teenagers who may present as undernourished. 

There are a  range of medical causes which can result in the body's energy requirement being increased. This is why a health assessment is needed for all children.

In the majority of children, there is no underlying organic cause for the faltering growth.

When there are concerns about faltering growth, the following should be discussed, as individually appropriate, with the infant or child's parents or carers. If the mother is breastfeeding or bottle feeding, a full feeding assessment must be completed. 

Encourage relaxed and enjoyable feeding and mealtimes:

• Eating together as a family or with other children;
• Encouraging young children to feed themselves;
• Allowing young children to be “messy” with their food;
• Making sure that feeds and mealtimes are not too brief or too long;
• Setting reasonable boundaries for mealtime behaviour while avoiding punitive approaches;
• Avoid force feeding;
• Establishing regular eating schedules;
• Advise parents/carers that drinking too many energy-dense drinks, including milk, can reduce a child’s appetite for other foods.

If the concern is that the child is not being presented with sufficient calories, the best way forward would be to hold a discussion with parents/carers to agree arrangements to establish if the child receives a normal amount of calories at home. If the child thrives with normal calorie intake this demonstrates that their poor growth was likely due to inadequate intake. If they need extra calories to grow, then a cause for the excess calorie requirement needs to be discovered.

In infants or children who need a further increase in the nutrient density of their diet, a referral to the paediatric dietician should be considered. They can advise on food choices appropriate to the child’s developmental stage in terms of quantity, type and texture as well as optimising energy and nutrient density.

If faltering growth is identified and is linked to neglect, professionals should seek advice from their designated safeguarding lead and refer to the Continuum of Need. This will support identifying the most appropriate service for the child.

Usual referral procedures should be followed, see Hertfordshire County Council - Report concerns about a child or request support.

Child Protection Concerns: Flowcharts (see Appendix 1: HCT Policy for the Management of Faltering Growth (Failure to Thrive) in Babies and Young Children 0-5yrs).

Should concerns for a child reach threshold for a statutory social care response, information sharing involving all key health professionals will be key - full, understandable health chronologies and analysis will be needed to support this.

• UK-WHO Growth Charts, Royal College of Paediatrics and Children Health (RCPCH);
• PHE National Child Measurement Programme – Operational Guidance.

Click here to view Appendix 1: HCT Policy for the Management of Faltering Growth (Failure to Thrive) in Babies and Young Children 0-5yrs.

Click here to view Appendix 2: Faltering Growth Flowchart.