Changes

September 2023 — reviewed. A literature search was conducted in June 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No changes to clinical recommendations have been made, but the topic has been restructured.

Update

Goals

To support primary healthcare professionals to:

• Assess and manage infants with significant or persisting weight loss in the early days of life.
• Assess and manage older infants and children with faltering growth after the early days of life.
• Provide information, advice, and support to parents/carers.
• Refer the infant or child to secondary care or the multidisciplinary team, where appropriate.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

NICE quality standards

• Babies and preschool children have their measurements plotted on a growth chart if there are concerns about faltering growth.
• Babies and preschool children have a detailed feeding or eating history taken if there are concerns about faltering growth.
• Babies and preschool children have a management plan with specific goals if there are concerns about faltering growth.
• Mothers are supported to continue breastfeeding if their baby is given supplementation with formula because of concerns about faltering growth.

[NICE, 2020]

What is it?

• Faltering growth (also known as failure to thrive) is a term used to describe a slower rate of weight gain in childhood than expected for age and sex. 
  
  • The term 'faltering growth' is preferred as periods of slow growth may represent temporary variation from the expected pattern, and the word 'failure' may be seen as negative and potentially critical of parents/carers.
• Diagnostic criteria for faltering growth vary between different healthcare providers. 
  • In the UK, growth in children is monitored on growth charts which combine the World Health Organization (WHO) growth standards (based on longitudinal studies of healthy breastfed infants) and UK birth and preterm growth data.
    • Lines highlighted on the growth charts are called centiles (short for percentile). These mark the weight or height below which a specific percentage of children matched by age and gender will fall. For example, 25% of children are below the 25th percentile.
    • A child's growth parameters (weight, length/height, and head circumference) can be plotted on these charts to visually represent growth over time.
    • If a child gains weight more slowly than expected for age and sex, plotted measurements will move to a lower centile on the chart.
    • Epidemiological data suggest that healthy children usually progress relatively consistently along a growth centile. 
  • Further information on UK WHO growth charts is available from the Royal College of Paediatrics and Child Health (RCPCH) website.
    • Note that there are separate centile charts for boys and girls as well as for very preterm infants, children with significant health problems, and children with Down’s syndrome. 

[NICE, 2021; BMJ, 2023]

What causes it?

In the early days of life:

• Weight loss of up to 10% of birth weight is common and is usually associated with body fluid adjustments.
• This weight loss usually stops after about 3 or 4 days of life, and birthweight is usually regained before 3 weeks of age as feeding is established.
• If weight loss is more than 10% of birth weight or weight does not return to birth weight by 3 weeks of age, this may indicate ineffective establishment of feeding.

In older infants and children:

• Faltering growth is caused by inadequate calorie intake (the most common cause), inadequate nutrient absorption, and/or increased calorie demand or expenditure.
• A range of factors may contribute to the problem, and a specific underlying cause may not be identified. 
• Risk factors for inadequate calorie intake include:
  • Feeding problems, such as:
    • Ineffective suckling.
    • Inadequate breast milk.
    • Difficulty with attachments.
    • Problems with the breasts (such as pain, mastitis, or thrush).
    • Ineffective bottle feeding.
    • Incorrect preparation of infant formula.
    • Weaning problems.
  • Medical conditions, such as:
    • Gastro-oesophageal reflux or oesophagitis.
    • Mechanical feeding difficulties (such as cleft lip/palate).
    • Poor oral neuromotor coordination.
    • Poor appetite or anorexia.
  • Social/family or environmental factors, such as:
    • Lack of knowledge of age-appropriate healthy foods.
    • Poor parent/carer–child interactions (for example, not responding to mealtime cues).
    • Poor parent/carer feeding skills.
    • Inadequate feeding patterns, routine, or environment.
    • Health or religious beliefs (may result in a restricted diet).
    • Family stress (such as divorce, housing problems, substance misuse, and financial problems).
    • Child maltreatment.
    • Emotional deprivation.
    • Poor access to healthy food.
• Risk factors for inadequate nutrient absorption include: 
  
  • Iron deficiency anaemia.
  • Chronic GI conditions, such as Coeliac disease, cystic fibrosis, chronic diarrhoea or vomiting, or inflammatory bowel disease (IBD).
  • Food allergies or sensitivities.
  • Pancreatic cholestatic conditions.
• Risk factors for increased calorie demand or expenditure include:  
  • Chronic infections, such as HIV infection and tuberculosis.
  • Metabolic and endocrine disorders, such as hyperthyroidism, diabetes mellitus, and inborn errors of metabolism.
  • Chronic lung disease of prematurity.
  • Congenital heart disease.
  • Inflammatory conditions, such as asthma and IBD.
  • Malignancy.
  • Renal failure.
  • Burns.
• Other factors that may be associated with faltering growth include: 
  • Excessive fluid intake, such as water, milk, or juice — may lead to satiety before meals.
  • Feeding aversion (behaviour at mealtime indicating a persistent unwillingness to eat, such as spitting, refusal, or distress when presented with food).
  • Preterm birth or low birth weight.
  • Congenital abnormalities.
  • Neurodevelopmental concerns. 
  • Maternal postnatal depression or anxiety.

[Homan, 2016; Larson-Nath, 2016; Rogol, 2020; NICE, 2021; BMJ, 2023]

How common is it?

• Faltering growth is a common problem that can present at any point between birth and adolescence. Children with faltering growth may be identified by routine growth monitoring or by parental/carer or health professional concerns [NICE, 2021]. 
• The prevalence of faltering growth depends on the population studied and the diagnostic criteria used [NICE, 2021]. In the US, it may occur in up to 10% of children in primary care and in about 5% of children who are hospitalized. The rate of detection depends on the vigilance of individual healthcare professionals [Homan, 2016].
• Faltering growth has been associated with lower socioeconomic status, lower parental education level and other increased psychosocial stressors in the home environment [Smith, 2022; BMJ, 2023]. 
• There is no gender or race predisposition to faltering growth [Smith, 2022].

What are the complications?

• Potential complications of faltering growth or undernutrition in childhood include:
  
  • Stunting (poor linear growth) — associated with chronic and severe faltering growth.
  • Impaired cognitive function.
  • Developmental delay.
  • Persisting problems with appetite and feeding.
  • Reduction in IQ that is maintained into adulthood [Baptista Menezes, 2020].

[Shields, 2012; NICE, 2021; Smith, 2022; BMJ, 2023]

What is the prognosis?

• Early identification and management of faltering growth may reduce the risk of complications, such as stunting.
• If faltering growth is due to an underlying condition, the prognosis will be dependent on the specific condition and its treatment.
• In children with no specific cause for faltering growth, simple interventions to increase nutritional intake may be effective in improving weight gain.

[Shields, 2012; Homan, 2016; Larson-Nath, 2016; NICE, 2021; BMJ, 2023]

When should I suspect faltering growth?

• During the first few days of life:
  • Suspect faltering growth if weight loss is more than 10% of birth weight or weight does not return to birth weight by 3 weeks of age. 
• After the first few days of life:
  • Consider using the following as thresholds for when to suspect faltering growth (a centile space being the space between adjacent centile lines on the UK World Health Organization (WHO) growth charts):
    • 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.
    • When current weight is below the 2nd centile for age, regardless of the birth weight. 
  • If faltering growth is suspected (for example, based on the criteria above):
    • Weigh the infant or child.
    • Measure their length (from birth to 2 years old) or height (if aged over 2 years).
    • Plot the above measurements and available previous measurements on the UK WHO growth charts to assess weight change and linear growth over time. 
  • If there are concerns about an infant's length or a child's length or height:
    • If possible, obtain the biological parents' heights and work out the mid-parental height centile. Instructions for calculation of the mid-parental height and use of the mid-parental centile comparator are printed on the UK WHO growth charts.
    • If the child's length or height centile is below the range predicted from parental heights (more than 2 centile spaces below the mid-parental centile), this could suggest undernutrition or a primary growth disorder. 
  • If there is concern about faltering growth or linear growth in a child over 2 years of age:
    • Determine the body mass index (BMI) centile using the UK WHO centiles and the accompanying BMI centile 'look-up chart' or by calculating the BMI (weight in kg/height in metres squared) and plotting this on the BMI centile chart.
    • If the BMI is below the 2nd centile, this may reflect either undernutrition or a small build.
    • If the BMI is below the 0.4th centile, this suggests probable undernutrition. 
• Record all growth measurements in the parent or carer-held Personal Child Health Record.

How should I assess an infant with weight loss in the early days of life?

• Take a history. 
  • Ask about any specific concerns of the parents/carers or other healthcare professionals.
  • Take a detailed feeding history to identify any feeding problems.
    
    • Ask about what is eaten, how much, and how often. A diary recording food intake (types and amounts) and mealtime issues (for example, settings and behaviour) may help inform management strategies and assess progress. 
    • Review fluid intake. Excessive fluid intake (such as water, milk, or juice) may lead to satiety before meals.
    • Consider direct observation of feeding by a healthcare professional with appropriate training and expertise (usually a health visitor or midwife).
  • Ask about associated symptoms that may indicate acute or chronic illness, such as fever, pain, coughing, shortness of breath, dysphagia, vomiting, or diarrhoea.
• Examine the infant.
  • Assess vital signs, including temperature, heart rate, capillary refill, and respiratory rate.
  • Carry out a general examination, looking for signs of dehydration or of a medical condition that might account for weight loss.
  • Look for signs of maltreatment, such as poor hygiene or unexplained injuries. For more information, see the CKS topic on Child maltreatment - recognition and management.
  • Exclude differential diagnoses (such as prematurity).
• Arrange investigations only if they are indicated based on the clinical assessment.

How should I assess an infant or child with faltering growth after the early days of life?

• Take a detailed history.  
  • Ask about any specific concerns of the parents/carers or other healthcare professionals.
  • Take a detailed feeding or eating history to identify any feeding or eating problems.
    • Ask about what is eaten, how much, and how often. A diary recording food intake (types and amounts) and mealtime issues (for example, settings and behaviour) may help inform management strategies and assess progress. 
    • Review fluid intake. Excessive fluid intake (such as water, milk, or juice) may lead to satiety before meals.
    • Consider direct observation of feeding or mealtimes by a healthcare professional with appropriate training and expertise (usually a health visitor or midwife).
  • Ask about other risk factors for faltering growth, including: 
    • Personal or family history of medical conditions such as constipation, gastro-oesophageal reflux, Coeliac disease, or diabetes.
    • Social and environmental factors, such as health or religious beliefs (may result in a restricted diet), mental health problems (such as anxiety and depression), and poor access to healthy food.
  • Ask about the mother's pregnancy and birth history, including alcohol, tobacco, and illicit drug use during pregnancy; use of medications; and any illness during pregnancy. Be aware that preterm birth, neurodevelopmental concerns, and maternal postnatal depression or anxiety may be associated with faltering growth.
  • Ask about associated symptoms that may indicate acute or chronic illness, such as fever, pain, coughing, shortness of breath, dysphagia, vomiting, or diarrhoea.
• Examine the child.  
  
  • Assess vital signs, including temperature, heart rate, capillary refill, and respiratory rate.
  • Carry out a general examination, looking for signs of dehydration or of a medical condition that might account for weight loss.
  • Look for signs of maltreatment, such as poor hygiene or unexplained injuries. For more information, see the CKS topic on Child maltreatment - recognition and management.
  • Exclude differential diagnoses (such as prematurity).
• Investigations should be guided by the clinical assessment.
  • Consider investigating for:
    • Urinary tract infection. For more information, see the CKS topics on Urinary tract infection - children, Urinary tract infection (lower) - women, and Urinary tract infection (lower) - men.
    • Coeliac disease, if the child's diet has included gluten-containing foods. For more information, see the CKS topic on Coeliac disease.
  • Arrange further investigations only if they are indicated based on the history and examination.

What else might it be?

• Prematurity — infants born prematurely may grow below their age-matched peers. The correct growth chart must be used for accurate interpretation.
• Compromised in-utero growth (small for gestational age) — infants with compromised in-utero growth often have poor postnatal growth, particularly if growth parameters are similarly affected.
• Small but healthy children — by definition, 5% of children will track below the 5th percentile on growth charts. If growth has a consistent trajectory and a thorough assessment reveals no concerning features, a child may be small but healthy. For example, infants who have small parents and are growing to their genetic potential or those with constitutional delay in growth.
  • Indicators of whether the child is small but healthy or experiencing faltering growth include past medical history, feeding behaviour, development, physical examination, and response to feeding recommendations.

Scenario: Weight loss in the first few days after birth

From birth to 1 months.

Scenario: Weight loss after the early days of life

From age 1 month to 18 years.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of faltering growth.

Search dates

Unrestricted - June 2023.

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for EBSCO Medline.

• (MH "Failure to Thrive") 
• AB (fail* N3 thriv*) OR TI (fail* N3 thriv*) 
• AB FTT OR TI FTT 
• AB (falter* N3 (grow* or weight*)) OR TI ( falter* N3 (grow* or weight*)) 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.