InnovAiT, 10(12), 734–739 DOI: 10.

1177/1755738017733502

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Faltering growth

F
altering growth is a common paediatric presentation in primary care; it
often presents following routine health visitor surveillance or is highlighted
by parental concern. It is important to recognise, as it may be the presen-
tation of an underlying medical or social problem, and because there may be
long-term consequences for growth and development. Reassuringly, however,
most children with faltering growth do not fall into these groups and will improve
with community-based interventions including dietary advice and health visitor
input. This article describes the recognition, causes, assessment and management
of faltering growth in infants and children.

The GP curriculum and faltering growth

Clinical module 3.01: Healthy people: Promoting health and preventing disease requires GPs to:
. Promote self-care and empower patients and their families whenever appropriate
. Work with other members of the primary healthcare team to promote health and well-being through appropriate
health promotion and disease prevention strategies

Clinical module 3.04: Care of children and young people requires GPs to:
. Recognise normal growth, and deal with faltering growth and failure to thrive
. Have an awareness of disease prevention, well-being and safety in children and adolescents, including in the
following areas:
. Breastfeeding
. Healthy diet and exercise for children and young people
. Social and emotional well-being
. Keeping children and young people safe, safeguarding
. Demonstrate an understanding of the importance of multiagency working (working across professional and
agency boundaries) and the principles of information sharing
. Coordinate care with other primary care professionals, paediatricians and other appropriate specialists, leading to
effective and appropriate care provision, taking an advocacy position for the patient or family when needed

Defining the problem are detailed in Box 1. The definitions are used accord-
.....................................................................

........................................................... ing to initial centile, this is for practical purposes to

‘Faltering growth’ (FG) describes a pattern of growth that stabilise the phenomenon of ‘regression to the mean’;
may highlight an underlying condition and require clinical i.e. that children on higher centiles in their early months
assessment and monitoring. Despite this trigger, less and years will incline towards the 50th centile over
than 5% have major organic disease (Wright, 2000), time. They also allow for children previously on
and a wide interplay of other factors have an effect on higher centiles who then falter, to be recognised
children’s growth. sooner than may previously have been the case. Over
the first year, 1.9% of infants in the 9th to 91st centile
FG is defined using parameters of falling serial growth range will cross two centiles, and 0.2% will cross three
measurements through centiles, or at a specific centile centiles using the UK–World Health Organisation
cutoff on growth charts. Weight is the parameter most (WHO) growth standard chart (Wright & Garcia,
frequently measured, but height is also important. The 2012). It is also important to recognise that babies in
term ‘failure to thrive’ was previously used, but can their first week can lose up to 10% of their birth weight.
hold negative connotations. The current National This is physiological, and concern is raised where the
Institute for Health and Care Excellence (NICE) draft loss is more than 10% or the birth weight is not
guidelines on thresholds for FG concerns (NICE, 2017) regained by 14 days.

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Box 1. Thresholds for concern on faltering
growth.

. A fall across one or more weight centile spaces, if

birthweight was below the ninth centile
. A fall across two or more weight centile spaces, if
birthweight 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 birthweight
Source: NICE (2017). Figure 1. Example growth chart.
Reproduced with permission of the Royal College of Paediatrics
and Child Health.

Growth charts
...........................................................
Growth charts identify differences in an individual’s others have not demonstrated any long-term effects
growth pattern as compared with a population norm, (Wright, 2000).
depicting projections of children’s weight and height by
sex. They are marked with nine different centile lines Finally, it is important to appreciate that FG can have a
from the 0.4th to 99.6th centiles. The current growth significant impact on families, causing family stress and
charts used in the UK for 0–4 years are adopted from parental anxiety. This is particularly heightened at meal-
those published by the WHO in 2006 and based on times, but can spread across all domains of family life.
healthy, initially breastfed children from six countries
around the world. Growth charts for school-age children
are plotted on the 2–18 years charts (see Fig. 1) that
combine WHO data to 4 years and UK 1990 growth
reference data compiled by Royal College of Paediatrics Aetiology
...........................................................
and Child Health (2012).
Children have a high metabolic demand, particularly
All growth measurements should be recorded in the during growth spurts. Mostly, FG falls within the realms
Personal Child Health Record to aid multi-disciplinary of normal childhood development and cases are due to
communication. To assess the full picture, it is important inadequate calorie intake without medical disease or
to assess the velocity of growth parameters over time, social complications (Homan, 2016).
including historical measurements from the neonatal and
infancy periods. Major organic disease is found in 5% or less of ‘failure to
thrive’ cases, and only a small proportion of cases are
related to abuse or neglect (Wright, 2000). Therefore,
Why recognise FG?
...........................................................
careful history and examination are important to elicit
these factors. Table 1 details the medical causes for
The consequences of FG have been studied, including FG, and these should be considered in relation to the
long-term growth outcomes and affects on brain devel- child’s age and method of feeding.
opment. Faltering weight can reflect undernutrition, and
there is evidence that children with faltering weight in There are also causes and contributing factors that are
addition to body mass index (BMI) changes will later be intrinsic to the child including:
shorter on average. However, children with faltering . Intrauterine growth restriction
weight and other normal parameters are only short in . Low birth weight
line with their parental heights (Wright & Garcia, 2012). . Constitutional growth
In addition, children with ‘failure to thrive’ do show . Genetic potential
improvements in their weight parameters, but have
been shown to remain somewhat smaller than controls A variety of psycho-social risk factors may also contribute
(Wright, 2000). There is some evidence for an increased to FG. Parental mental health, including post-natal
risk of metabolic syndrome for children with faltering depression and anxiety, substance misuse and isolation
weight (Salonen et al., 2009). are important factors, as well as poverty and parental
isolation. These factors may be found separately, but
As for brain development and effects on cognition, the often overlap. Abuse and neglect are contributing fac-
evidence is mixed. Some studies have shown adverse tors, but this is a small proportion and current evidence
intellectual development on a population scale in a does not show a definite link with deprivation (Wright,
meta-analysis study (Corbet & Drewett, 2004), whereas 2000).

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Table 1. Aetiology of faltering growth.

Inadequate calorie intake Inadequate calorie Increased metabolic Chromosomal and
absorption demands and congenital
altered metabolism

. Inadequate supply of calories . Cow’s milk protein and . Chronic infection (human . Turner’s syndrome
(breast milk, dairy intolerance immunodeficiency virus, . Skeletal dysplasias
formula, solids) (enteropathy) tuberculosis, toxoplasmosis/ . Down’s syndrome
. Gastroesophageal reflux . Gastrointestinal disease other/rubella/cytomegalovirus . Fetal alcohol syndrome
disease and oesophagitis (inflammatory bowel /herpes (TORCH), urinary tract . 22q11 deletion
. Oro-motor feeding disease, infection, infection) . Prader–Willi
difficulties (e.g. cleft lip coeliac disease) . Immunodeficiencies Syndrome(early)
and palate, ineffective latch, . Cystic fibrosis . Respiratory causes:
inco-ordination, developmental (pancreatic Bronchiectasis, cystic fibrosis,
delay, behavioural) insufficiency) chronic lung disease of pre-
. Constipation . Glucosuria maturity
. Neglect/abuse . Pancreatic conditions . Congenital heart disease
. Feeding habits (child or parent . Endocrine: Thyroid disease,
driven) diabetes
. Reduced appetite . Inflammatory conditions (e.g.
secondary to disease childhood arthritis)
. Anorexia nervosa . Medications
. Anaemia and iron-deficiency . Malignancy
. Chronic kidney disease
. Chronic liver disease
. Growth hormone deficiency
...................................................................................................................................... . Inborn errors of metabolism

Bonding between the child and parent has an influence A concern regarding faltering growth is highlighted
upon the child’s physical and mental health, which can
affect growth. There can also be a lack of knowledge Accurate plong of current parameters and review of
from the parent on diet, or unusual parental dietary historical serial growth in PCHR

habits and restrictions. The child’s behaviour, especially

Full clinical assessment including Social care referral
food refusal, which may be related to family stress, can dietary assessment, history and where concerns are
impact and cause a self-perpetuating cycle. examinaon idenfied

Consider baseline invesgaons

where indicated

Altering growth in
primary care
........................................................... Community mul-disciplinary management
- dietary advice in general pracce
Consider
referral to
- health visitor referral with assessment, Paediatric
Recognition family support and growth monitoring
- consider diecian referral
specialist

FG usually presents due to family concern about a child

being smaller or shorter than peers, or following routine Figure 2. Management pathway for faltering growth.
health visitor surveillance and subsequent referral. FG is
also picked up opportunistically in general practice when
a child is found to be small for their age when presenting account of the type of feed or diet should also consider
with a different problem. the causes listed.

Following a concern being raised, it is important to Along with a systems history, a feeding history should be
ensure that weight and height have been measured taken (see Box 2) and a food diary kept for three typ-
then plotted correctly, and that previous measurements ical days. The diary should include food offered as well
have been reviewed wherever available. The care path- as food taken and should record behaviour. Questions
way and process of management is described in Fig. 2. should be adapted for age and type of feeding, e.g.
breast-feeding, formula feeding or weaned. For infants
Clinical assessment not yet weaned, the history will focus on frequency of
A good history and examination should identify most feeds through the day and night, as well as time spent at
cases where pathology exists (Khan & Rudolf, 2007). the breast or volume of formula taken. A careful history
Careful and accurate diagnosis will then determine man- for gastrointestinal symptoms, reflux and discomfort
agement options. An age-appropriate history taking should also be taken for children of this age.

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Box 2. Feeding history (adapt for age and Box 3. Dietary advice.
feeding type).
Managing dietary intake
. Infant milk history . Three meals per day with snacks between each
. Weaning age and any difficulties meal
. Current intake (amounts, type, age-appropriate) . Increase the energy density of food offered, e.g.
. Mealtimes, routines, behaviour around food and full-fat dairy products such as cheese, butter and
environment cream alternatives
. Parental response to challenges at mealtimes and . Limit excess milk intake in children following the
to feeding cues age of weaning
. Chewing or swallowing difficulties . Limit excess fruit and squash
. Snacking . Food offered should be appropriate to the child’s
. Fluids developmental stage regarding volume and texture
. Appetite
Managing behaviour
. Caregiver interest with food
Mealtimes should aim to be relaxed and fun, shared
with the family.
 Embrace playing with food and allow children to
Part of the assessment should include calculating the be messy
mid-parental height centile for the child’s genetic poten-  Regular, structured mealtimes
tial. A simple way to evaluate this is using the ‘parent  Routinely sitting at the kitchen or dining table for
height comparator’ found under the flap on the right of meals
the 2–18 years growth charts. Parent heights should be  Family mealtimes eating together
accurately measured, rather than reported, and then  Positive praise and ignoring undesired behaviour
plotted together on the scale. According to the NICE  Allow enough time to eat, but keep a limit of 30
guidelines (NICE, 2017), if the child is more than two minutes at mealtimes
centile spaces below the predicted mid-parental centile,  Avoid conflict
this suggests undernutrition or a primary growth dis-  Never force feed
order. BMI can also be calculated – if it is below the  Reduce dummy use
second centile, this may represent a small build or under-
nutrition, and if it is below the 0.4th centile, there is likely
to be undernutrition that requires intervention. The child should also be referred to a health visitor for an
assessment of feeding and mealtimes, and ideally a home
A thorough general examination should be undertaken visit. The health visitor team can offer continuing advice
looking for nutritional status, signs of anaemia and the and support for the child and their family, as well as
child’s general behaviour. This is followed by a detailed liaising back to general practice and monitoring the
systems examination looking for gastrointestinal, respira- growth parameters over time.
tory, cardiovascular and endocrine signs. A develop-
mental assessment should be incorporated with the It may also be appropriate for a dietician to review cases
history and examination, and any dysmorphic features and offer advice on dietary structure and macronutrient
identified. calorific intake. This may include the recommendation for
high-calorie specialist supplements.

In FG without other concern, serial growth can be moni-

Managing FG without tored in primary care and the community. Where the
child is gaining sufficient weight through the centiles,
other clinical concerns
...........................................................
improvement is confirmed. The NICE guidelines (NICE,
2017) recommend monitoring as follows:
Managing children with FG, without medical or social . Less than 1 month: Daily
concerns, is most often a community- and primary-care- . 1–6 months: Weekly
based multi-disciplinary intervention. It should be high- . 6–12 months: Fortnightly
lighted to the family that the cause is usually nutritional, . From 1 year: Monthly
with inadequate calorie intake. Home-based support with
dietary advice and health visitor interventions have been If, despite these interventions, the child’s growth is not
shown to be effective (Wright, 2000). satisfactory, a review of history, examination and pro-
gress with interventions is conducted. Serious consider-
In general practice, parents can be reassured that this is a ation needs to be given to specialist paediatric referral
common presentation, with energy requirements and further investigation. For infants and younger chil-
explained and advice given to increase calorie intake. dren, monitoring is more frequent and there should be
Specific suggestions for advice are detailed in Box 3. more prompt intervention and specialist referral.

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Investigations for FG

...................................................................................................................................................................................................................................................
In children with faltering weight and existing social con-
cerns, or when new suspicions around safeguarding or
........................................................... abuse arise, social care referrals will be necessary. Finally,
Investigations for FG should be undertaken ‘if signs or speech and language therapists may be involved if the
symptoms of disease are present, or where weight fal- child has difficulty with chewing or swallowing.
tering is persistent or severe’ (Shields, Wacogne, &
Wright, 2012). The NICE guidelines (NICE, 2017)
advise to consider investigating urinary tract infection
and coeliac disease, with further investigations only indi-
cated based on clinical assessment. Other investigations Key points
in a well child with no other clinical concern are ‘unlikely
to reveal an underlying disorder’. . FG is a common paediatric presentation
. Identifying and measuring growth is performed
Other investigations may be considered in primary or using structured growth charts
secondary care depending on the level of concern . Effective and thorough history and examination
raised and the child’s age, including: are important in identifying those children with
. Blood profile: Full blood count and haematinics. underlying conditions
Particularly in infants and toddlers, anaemia and . Most cases are due to inadequate calorie intake,
iron-deficiency can cause enteropathy and negatively which needs to be optimised to promote healthy
affect appetite growth and development
. Renal function tests . Effective community-based approaches include
. Liver function tests dietary advice and health visitor input
. Thyroid function tests . Specialist referral to paediatric services may be
. Vitamin D levels required for some cases
. Coeliac screen
. Urine dipstick þ/- microscopy, culture and sensitivity References and further information
. Chromosome analysis . Corbett, S. S., & Drewett, R. F. (2004). To what
. Chest X-ray extent is failure to thrive in infancy associated with
. Sweat test poorer cognitive development? A review and
meta-analysis. Journal of Child Psychology and
Psychiatry, 45(3), 641–654. doi: 10.1111/j.1469-
7610.2004.00253.x
Referrals to paediatric . Homan, G. J. (2016). Failure to thrive: A practical
guide. American Family Physician, 94(4), 295–299
care and other . Khan, F. (2016). Faltering growth. Retrieved from
professional www.minded.org.uk/Component/Details/447538
. Khan, F., & Rudolf, M. (2007). Practical paediatric
involvement
...........................................................
problems in primary care, failure to thrive:
Recognition and management in primary care.
There are some children who require referral for specialist Oxford, UK: Oxford University Press
paediatric opinion, either at the point of presentation or . NICE. (2017). Faltering growth: recognition and
following their non-response to intervention. The indica- management of faltering growth in children.
tions are listed in Box 4. Although rare, some children do Retrieved from www.nice.org.uk/guidance/ng75/
require hospital admission for FG, either in the acute set- resources/faltering-growth-recognition-and-man-
ting, or electively for dietary monitoring. In extreme situ- agement-of-faltering-growth-in-children-pdf-
ations naso-gastric feeding may be required. 1837635907525
. Olsen, E. M., Petersen, J., Skovgaard, A. M.,
Weile, B., Jorgensen, T., & Wright, C. M. (2007).
Failure to thrive: The prevalence and concurrence
Box 4. Indications for referral to paediatric of anthopometric criteria in a general infant popu-
specialist services. lation. Archives of Disease in Childhood, 92,
. Where there are any clinical concerns that faltering 109–114. doi: 10.1136/adc.2005.08033
growth is secondary to an underlying pathology . RCGP. Clinical module 3.01: Healthy people:
. Growth faltering is severe, there is evidence of Promoting health and preventing disease.
undernutrition or other growth parameters cause Retrieved from www.rcgp.org.uk/training-exams/
concern gp-curriculum-overview/online-curriculum/work-
. Growth faltering persists despite primary care inter- ing-in-systems-of-care/3-01-healthy-people.aspx
vention with community and dietary intervention . RCGP. Clinical module 3.04: Care of children and
. Infants and younger children young people. Retrieved from www.rcgp.org.uk/
training-exams/gp-curriculum-overview/online-

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curriculum/caring-for-the-whole-person/3-04-chil- . Shields, B., Wacogne, I., & Wright, C. (2012).
dren-and-young-people.aspx Weight faltering and failure to thrive in infancy
. Royal College of Paediatrics and Child Health. and early childhood. British Medical Journal, 345,
(2017). UK-WHO growth charts, 0-18 years. e5931. doi: 10.1136/bmj.e5931
Retrieved from www.rcpch.ac.uk/improving-child- . Wright, C. M. (2000). Identification and manage-
health/public-health/uk-who-growth-charts/uk- ment of failure to thrive: A community perspective.
who-growth-charts-0-18-years Archives of Disease in Childhood, 82, 5–9. doi:
. Rudolf, M. C. J., & Logan, S. (2005). What is the 10.1136/adc.82.1.5
long term outcome for children who fail to thrive? . Wright, C. M., & Garcia, A. L. (2012). Child under-
A systematic review. Archives of Disease in nutrition in affluent societies: What are we talking
Childhood, 90(9), 925–931. doi: 10.1136/ about? Proceedings of the Nutrition Society, 71,
adc.2004.050179 545–555. doi: 10.1017/S0029665112000687
. Salonen, M. K., Kajantie, E., Osmond, C., Forsen,
T., Yliharsila, H., Paile-Hyvarinen, M., . . . Eriksson,
J. G. (2009). Childhood growth and future risk of Acknowledgement
the metabolic syndrome in normal-weight men and We would like to thank Dr Rabia Aftab for her help with
women. Diabetes & Metabolism, 35(2), 143–150. the writing of this article under the InnovAiT ‘buddy’
doi: 0.1016/j.diabet.2008.10.004 scheme.

Dr Emma Roche
Paediatric Registrar, Oxford Deanery
Email: emmaLR@doctors.org.uk

Dr Baneera Shrestha
General Paediatric Consultant, Stoke Mandeville Hospital

DOI: 10.1177/1755738017733608
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AKT question relating to contraception for

teenagers
.........................................

Single Best Answer A. Copper coil

B. Depot medroxyprogesterone acetate
A 19-year-old lady comes to see you asking for contra-
C. Etonogestrel implant
ception because she has just entered a new relationship.
D. Levonorgestrel ethinylestradiol pill
She has no medical problems. She is a non-smoker. She
E. Norethisterone pill
has a body mass index of 31 kg/m2.
Answer DOI: 10.1177/1755738017733609
Which SINGLE method of contraception is MOST
likely to cause weight gain? Select ONE option
only.

Dr Anish Kotecha
GP Partner, Cwmbran Village Surgery, Wales

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