Failure to Thrive / Faltering Growth in Children
Faltering growth, previously known as “failure to thrive,” is a key indicator of underlying health or social issues in children. The term is preferred to “failure to thrive” as it is less pejorative and reflects that the problem is a symptom rather than a diagnosis. The UK’s National Institute for Health and Care Excellence (NICE) provides clear guidelines for its recognition, assessment, and management.
Definition and Identification
Faltering growth is defined by a slower rate of weight gain than expected for a child’s age and sex. The following are key thresholds for concern, as per UK guidance:
A fall across two or more weight centile spaces in children aged 2-24 months.
A fall across three or more weight centile spaces in children with a birth weight above the 91st centile.
A weight that falls below the 2nd centile for age, irrespective of birth weight.
The most crucial step is to plot accurate serial measurements of weight, length/height, and head circumference on the UK-WHO growth charts. This allows for a visual representation of the growth trajectory over time.
Assessment and Causes
The assessment should be holistic and comprehensive, looking for physical, social, and psychological factors.
History
A detailed history is the most valuable part of the assessment.
Feeding History: A very detailed account of what, when, and how much the child is fed. Observe the child’s feeding behaviour and interaction with the caregiver.
Social and Family History: Enquire about parental mental health, social support, and any signs of neglect.
Symptom History: Ask about symptoms that may suggest an underlying cause, such as vomiting, chronic diarrhoea, frequent infections, or developmental concerns.
Examination
General: Observe the child’s appearance, looking for signs of malnutrition like reduced subcutaneous fat and muscle mass. Note any dysmorphic features that may suggest a genetic syndrome.
Systemic: A full systemic examination is crucial to identify potential organic causes:
Respiratory: Listen for crepitations or wheezing (e.g., in cystic fibrosis).
Cardiovascular: Listen for murmurs (e.g., in congenital heart disease).
Abdomen: Palpate for organomegaly (e.g., liver or spleen enlargement).
Causes
Causes are often classified into three categories:
Inadequate Caloric Intake: This is the most common cause. Reasons include inadequate feeding, poor feeding technique, behavioural feeding difficulties, or social factors (e.g., poverty).
Increased Caloric Requirements: The child is using up more energy than they are consuming due to an underlying chronic condition such as cystic fibrosis, congenital heart disease, or a metabolic disorder.
Reduced Absorption: The child cannot absorb nutrients properly due to conditions like coeliac disease, cow’s milk protein intolerance (CMPI), or inflammatory bowel disease (IBD).
Investigations and Management
Investigations should be guided by the history and examination findings. Most children with faltering growth will not need extensive testing.
Initial Investigations
First-line tests (if an organic cause is suspected):
FBC and Ferritin: To check for anaemia, which is common.
U&E, LFT, Bone Profile: To assess kidney, liver, and bone health.
Coeliac Screen: For children who have started eating gluten.
Urinalysis: To rule out a chronic urinary tract infection.
More specialised tests: These are only done if a specific condition is suspected. Examples include a sweat test for cystic fibrosis or a thyroid function test for hypothyroidism.
Management
Management is a team effort involving healthcare professionals, parents, and caregivers.
Education and Support: Provide a significant amount of education and reassurance to parents, as they often feel blamed.
Dietary Interventions:
Increase Energy Intake: Advise on increasing the energy density of foods by adding cheese, butter, or cream.
Snacks: Recommend three meals and two high-energy snacks a day.
Behavioural Support: Advise on mealtime routines, avoiding punitive approaches, and promoting a relaxed feeding environment.
Referral to a Specialist: Refer to a paediatric dietitian for a detailed dietary assessment and a personalised plan. Referral to a paediatrician is necessary for:
Rapid weight loss.
Severe undernutrition.
Signs of an underlying medical condition.
Safeguarding concerns.
Follow-up: Regular follow-up is essential to monitor growth and the effectiveness of the management plan. The frequency of weighing should be appropriate for the child’s age to avoid adding to parental anxiety.