Faltering growth in children

This is a recent guideline from NICE, which gives advice on managing faltering growth in children. A lot of this is common sense, but as it is a new guideline, I will summarise the bits relevant to us. I will not deal with weight loss in the first few days, as this is generally managed by the midwives, but there is advice there if needed.

When should you worry about an infant's growth?

If they have faltering growth:

  • >1 centile fall if birth weight was < 9th centile
  • >2 centile falls if birth weight was 9th to 91st centile
  • >3 centile falls if birth weight was > 91st centile
  • If weight is < 2nd centile, whatever the birth weight.
  • If height is > 2 centiles below mid-parental height (ie take both parents heights and plot the mid point on a chart).

NB - if weight is < 2nd centile, this can be undernutrition or small stature, but < 0.4th centile is likely to be undernutrition.

What should you be measuring?

Weight and height (or length if they are under 2 yrs). Plot on WHO chart.

If > 2 yrs, work out BMI and plot BMI on WHO chart, or BMI centile chart.

How to assess a child with faltering growth.

  • Do a clinical, social and developmental assessment.
  • Feeding and eating history (consider asking parents to do a diary of food intake with amounts and types and any mealtime issues).
  • Consider associated features, e.g. preterm birth, neurodevelopmental disorder, maternal anxiety or depression. Also consider a multifactorial cause (e.g. an underlying issue and difficult carer/child interactions).
  • Investigations. Consider checking for UTI, coeliac disease and any other investigations suggested by the assessment.
  • Observation of mealtimes. This should be considered and should be done by a trained person (I'm not sure who is trained, but I guess the health visitors are a good starting point).

Causes to consider in milk-fed infants

  • Ineffective bottle or breast feeding.
  • Feeding patterns used.
  • Feeding environment.
  • Feeding aversion (eg signs of distress with feeding, spitting out, avoidance behaviour etc).
  • Parent / carer interactions with infant and how they respond to feeding cues.
  • Physical disorders.

Causes to consider in children eating food

  • Mealtime practices
  • Foods offered
  • Food avoidance or aversion.
  • Carer interactions with infant and response to child's cues.
  • Little appetite.
  • Physical disorders.


Offer a management plan.

Offer feeding support (whether breast fed or bottle).

Give advice. A useful leaflet can be found on patient.co.uk.

  • Relaxed and enjoyable mealtimes.
  • Eat together.
  • Encourage child to feed themselves.
  • Let them be messy with food.
  • Mealtimes not too long and not too short.
  • Reasonable boundaries, but not punitive.
  • Avoid coercive feeding.
  • Regular routines (eg 3 meals / 2 snacks).
  • Avoid too much milk or energy rich drinks (as they decrease the appetite for food).

Ensure that foods offered are appropriate for the age of the child and that they optimise nutritional and energy density.Insidious onset

If they need more nutrients than can be achieved through food, consider supplements, or referral and monitor regularly.

How often to review children

  • Daily if < 1m
  • Weekly if 1 - 6m
  • 2 weekly if 6 - 12m
  • Monthly if > 1 yr.
  • Height / length - every 3 m

NB - doing it more frequently may lead to parental concern increasing.

When to refer children.

  • Suspicion of underlying disorder.
  • Not responding to above interventions.
  • Slow / linear growth or unexplained short stature.
  • Rapid loss of weight or malnutrition.
  • Safeguarding concerns.

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