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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 as 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 cases will not have associated safeguarding concerns.

Faltering growth may be a safeguarding issue when:

  1. Where 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;
    • Parents/carers are hostile to professional concerns;
    • Children are exposed to parental domestic abuse, substance misuse, alcoholism, chaotic lifestyle);
    • Parents/carers show inappropriately 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 family.

In children under 5 years the first point of contact would be the health visitor. Over 5 years 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.

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 within 10 days and preterm infants within 3 weeks.

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. A range of medical causes 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 cases there is no underlying organic cause for the faltering growth.

When there are concerns about faltering growth, discuss the following, as individually appropriate with the infant or child’s parents or carers.

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 this is best tested by 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.

The role of the heath visitor (Appendix 1: HCT Policy for the Management of Faltering Growth (Failure to Thrive) in Babies and Young Children 0-5yrs) is to monitor and record the growth of children under 5 years in line with national and local parameters, using equipment and techniques specified by the Child Growth Foundation. Where appropriate use the Growth Faltering Protocols and in breast-fed babies the Best Practice Guidelines.

The GP/ Paediatrician should be asked to see the child to liaise on case management and if there is a rapid or persistent falling below the centiles. Weight and/or height below the 2nd centile for age should be investigated (NICE Guidance).

The Public Health 5-19 (School Nursing) Team in Hertfordshire see children that attend a mainstream, state funded school in Hertfordshire. Part of their role is to see children to measure their height and weight as part of the National Child Measurement Programme (NCMP). In addition, any child that is considered vulnerable or a child looked after is also seen for a health review which includes a height and weight assessment. Parents/ professionals can refer a child to the Public Health 5-19 (School Nursing) Team if they are concerned about a child’s growth using the Family Centre Service online Portal. Management of any child identified by these methods as underweight is covered by Standard Operating Guidance (Management of Underweight Children by the Public Health, School Nursing Service, SOG112) held by Hertfordshire Community NHS Trust.

Any child that is not covered by the Hertfordshire Public Health 5-19 (School Nursing) Team (e.g. Private school children, those educated at home, or those living in Hertfordshire but attending school in another county) can be seen by their GP For further advice and support.

If there is a concern about faltering growth:

  • Take a developmental, family and social history and carry out a physical examination to include height, weight and cardiovascular measurements;
  • Take a detailed feeding or eating history;
  • Consider requesting direct observation of feeding or mealtimes e.g., feeding assessment from speech therapists if possible unsafe swallow;
  • Consider investigating for urinary tract infection and coeliac disease if the diet has gluten containing food.

If an infant or child with faltering growth has any of the following, the primary care team should discuss with, or refer to the paediatrician:

  • Symptoms or signs that may indicate an underlying disorder;
  • A failure to respond to intervention delivered in primary care e.g., feeding advice;
  • Slow linear growth;
  • Rapid weight loss or severe undernutrition.

Any GPs seeking advice on such patients can contact the consultant advice line.

Refer to a paediatric dietician if it is felt that a formal nutritional assessment is indicated or for specific advice about allergy/intolerance. Feeding supplements may be required (usually guided by a dietitian).

If there is any concern about the child’s ability to swallow food safely a referral should be made to speech therapy for a feeding assessment.

Consult liaison psychiatric team support if suspected eating disorder.

The paediatrician's role is to diagnose and treat any organic disorder and to report coherently suspected neglect. Children are seen in the clinic setting and will have a comprehensive medical history, examination and assessment undertaken. Investigations are based on the clinical findings and in line with each acute trusts Faltering Growth guidelines.

Infants or children with faltering growth should not be admitted to hospital unless they are acutely unwell or there is a specific indication requiring inpatient care such as a plan to begin tube feeding.

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.

Last Updated: December 7, 2023