Faltering Growth (Failure to Thrive)

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Faltering growth\: failure to thrive, re
Normal growth phases\: rapid in the
life.
Red ≥2 centile spaces) or weight below 2nd centile may indicate faltering growth.
Common cause\: inadequate dietary intake (e.g. neglect, fussy eating, poor diet understanding).
Other causes\: malabsorption (e.g. CF, coeliac), chronic illness (e.g. congenital heart disease, malignancy), metabolic
disorders.
Assessment\: thorough paediatric history, systemic exam, dietary history, use appropriate growth charts.
Investigations\: guided by history, consider FBC, iron studies, vitamin D, U&Es, LFT, tTG, and malabsorption screening.
Management\: dietary advice, mealtime routines, dietitian referral if needed; consider secondary care referral if unresolved.
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Introduction

Routine assessments of height and weight should occur throughout childhood and should be plotted on appropriate
centile charts. It is important to understand what is a normal growth pattern, when to be concerned, and which children
need further investigation.
If a child is not growing as we would expect, this is called failure to thrive or faltering growth. Plotting measurements over
time is the most useful way to assess a child’s growth, which is important as it is re
nutritional status.
1
There are multiple phases of normal growth, with the most rapid rate of growth occurring in the
then grow along a more steady trajectory until the pubertal growth spurt, which is another period of rapid growth that ends
when adolescents reach their
The exception to this progressive growth throughout childhood is the
acceptable to lose up to 10% of birth weight whilst feeding is established. 1
80% of babies will have regained birth weight by
two weeks of life, but if the weight loss is greater than 10% on day
assessment and evaluation of feeding.
1
After the newborn period, children should grow predictably, and NICE guidelines give thresholds for concern based on
measurements plotted on growth charts\:
2
A fall across one or more weight centile spaces, if birth weight was below the ninth centile
A fall across two or more weight centile spaces, if birth weight was between the 9th and 91st centiles
A fall across three or more weight centile spaces, if birthweight was above the 91st centile
When current weight is below the second centile for age, whatever the birth weightAetiology
There are multiple reasons a child might have faltering growth; this is a clinical sign and not a diagnosis and should
prompt careful examination and consideration of further investigations.
However, the most common cause of faltering growth is inadequate dietary intake.
3

Di

In establishing likely causes for faltering growth, it is important to consider the nutrients which are needed for growth and
whether the child has decreased intake, poor absorption, increased losses or a higher-than-normal metabolic demand.
1
It is worth remembering that children with certain genetic syndromes (for example Down's Syndrome, Achondroplasia,
DiGeorge Syndrome, Turner's Syndrome and many others) are not expected to follow the usual patterns of growth as short
stature is a part of their condition. For this reason some of these conditions (but not all) have their own growth charts, for
example Down's Syndrome.
Table 1. Causes for faltering growth.
Category Causes
Inadequate food provided - social circumstances (e.g. poverty
Inadequate
nutrient intake
or neglect)
Problems with eating - fussiness/food aversions, mechanical
problems (e.g. muscle weakness or problems with teeth),
swallowing issues (e.g. CNS pathology), feeling of fullness (e.g.
constipation
Inadequate
nutrient
absorption or
increased
losses
,
iron de
)
Lifestyle - inappropriate nutrient intake (e.g. unbalanced diet,
poor parental understanding of requirements)
Malabsorption (e.g.
cystic
,
coeliac disease
,
Crohn’s disease
, short gut syndrome)
Vomiting (e.g. gastroesophageal re
pyloric stenosis
)
Diarrhoea (e.g. chronic infections,
ulcerative colitis
)Increased
nutrient
requirements
or ine
utilisation
Congenital heart disease (e.g.
VSD
)
Malignancy
Metabolic diseases (e.g. type one diabetes, hyperthyroidism)
Chronic in
cystic
)
Chronic systemic diseases (e.g.
renal failure
)

Assessment

It is important to take a thorough paediatric history, including birth and early neonatal period, history of illnesses, family
history of growth concerns and a careful dietary history (a food diary can be useful here).
Asking the straightforward question,
“ I n t h e p a s t m o n t h , w a s t h e r e a n y d a y w h e n y o u o r a n y o n e i n y o u r f a m i l y w e n t h u n gr y
b e c a u s e y o u d i d n o t h a v e e n o u g h m o n e y f o r f o o d ?” has been shown to be an e
4
A full systemic examination is needed to look for evidence of chronic diseases, genetic syndromes or neglect.
Plotting growth
When plotting on centile charts, it is important to ensure the correct chart is used. There are a variety of growth charts
appropriate to the child’s gender, age, prematurity (\<32 weeks), and some speci
Syndrome. Always remember to correct for preterm birth until at least one year of age by plotting the measurement at their
current age, then drawing a dotted line and an arrow back the number of weeks they were preterm.
Figure 1. The growth chart for a male infant who was born at 28 weeks gestation. If you look at his weights without correcting for his
gestation there would be a concern, however with the correction being made for him being born 12 weeks early, you can see that he
is growing nicely along the 25th centile.Figure 2. An example of a male toddler who has faltering growth- a year ago at the start of the measurements he is between the 25th
and the 50th centiles, but now is just under the 2nd centile- this child would need to be assessed to establish the cause of his failure
to thrive.
Mid-parental height can be calculated, which gives an estimate of the child’s predicted
potential”)\:
1
Males\: (mum’s height + dad’s height)/2 + 7cm
Females\: (mum’s height + dad’s height)/2 - 7cm
If the child’s current height centile is more than two centiles below the mid-parental height centile, this could indicate a
problem with growth.
1
Investigations
Once faltering growth has been established, investigations are guided by history and examination
may require no investigations if the history points to inadequate nutrient intake which can be remedied, although
consequences of poor intake such as vitamin D and iron levels might be considered.
1
First line tests looking for medical causes would include FBC, blood
in

Management

Dietary advice and advice about mealtimes with children should be given, and the child should be seen again after an
appropriate interval (shorter in younger children) to reassess and plot further measurements.
1
Some children require a dietician referral, especially if they are particularly fussy eaters or have food aversions. If these
strategies are unsuccessful, the child should be referred to secondary care for further assessment.
Advice around mealtimes for children1
Mealtimes should be relaxed and enjoyable
Balanced, nutritional meals should be o
Ideally children should eat with the family- parents and/or other children
Young children should be encouraged to feed themselves, even if this is messy
Mealtimes should not be too brief or too long
Reasonable boundaries should be set for mealtime behaviour (while avoiding punitive approaches)
Coercive feeding should be avoided
There should be regular eating schedules (for example three meals and two snacks in a day)Complications
Globally, up to one-third of children are not thriving due to malnutrition. 5
This can lead to permanent short stature, as well
as systemic complications such as immunode
di
6,7

References

Harris DB. Faltering growth. InnovAiT. 2024;0(0). doi\:10.1177/17557380241246244
NICE (2017) Overview. Faltering growth\: Recognition and management of faltering growth. Available from\: [LINK]
Homan GJ (2016) Failure to thrive\: A practical guide. American Family Physician 94(4)\: 295–299.
Kleinman RE, Murphy JM, Wieneke KM, et al. (2007) Use of a single-question screening tool to detect hunger in families
attending a neighborhood health center. Ambulatory Pediatrics\: The O
7(4)\: 278–284.
UNICEF (2019) The state of the world’s children 2019. Children, food and nutrition\: Growing well in a changing world.
Available from\: [LINK]
Perrin EC, Cole CH, Frank DA, et al. (2003) Criteria for determining disability in infants and children\: Failure to thrive\:
Summary. In\: AHRQ Evidence Report Summaries. Rockville, MD\: Agency for Healthcare Research and Quality (US); 1998–
2005, p. 72.
Corbett SS and Drewett RF (2004) To what extent is failure to thrive in infancy associated with poorer cognitive
development? A review and meta-analysis. Journal of Child Psychology and Psychiatry 45(3)\: 641–654.

Related notes

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