Faltering growth involves a slower than expected gain in weight in a child, defined in the NICE guidelines (2017) as:
- Weight <2nd centile (regardless of birthweight)
- A fall across ≥1 centile spaces if the birthweight was <9th centile
- A fall across ≥2 centile spaces if the birthweight was 9th-91st centile
- A fall across ≥3 centile spaces if the birthweight was >91st centile
Centile spaces are the distance between two centile lines on a growth chart. The distance between the 75th and 50th centile lines is a centile space. A weight that falls this distance is a drop across one centile space. For example, if the initial weight of a child is plotted halfway between the 9th and 25th centile lines and several months later is plotted halfway between the 2nd and 9th centile lines, they have dropped a full centile space.
Red flags for weight loss in the first weeks of life are:
- Losing more than 10% of their birth weight
- Not regaining their birthweight by 3 weeks
Causes of Faltering Growth
Anything that leads to inadequate energy and nutrition can lead to faltering growth. The causes can be categorised as:
- Inadequate nutritional intake
- Difficulty feeding
- Malabsorption
- Increased energy requirements
- Inability to process nutrition
Causes of inadequate nutritional intake include:
- Inadequate maternal intake during breastfeeding
- Reduced availability of food (e.g., poverty)
- Family or parental problems
- Neglect
- Pyloric stenosis (causing vomiting)
Causes of difficulty feeding include:
- Tongue tie
- Poor suck (e.g., cerebral palsy)
- Cleft lip or palate
- Genetic conditions causing an abnormal facial structure
Causes of malabsorption include:
- Cystic fibrosis
- Coeliac disease
- Cow’s milk intolerance
- Chronic diarrhoea
- Inflammatory bowel disease
Causes of increased energy requirements include:
- Hyperthyroidism
- Chronic disease (e.g., congenital heart disease or cystic fibrosis)
- Malignancy
- Chronic infections (e.g., HIV or immunodeficiency)
Inability to process nutrients may result from:
- Inborn errors of metabolism
- Type 1 diabetes
Assessment
Establishing the cause of faltering growth involves taking a detailed history, performing an examination and completing relevant investigations. Key areas need to be assessed include:
- Pregnancy, birth, developmental and social history
- Feeding or eating history
- Observing feeding
- Assessing the physical and mental health of the mother
- Observing parent-child interactions
- Plotting the height and weight on a growth chart
- Calculating the BMI centile on a growth chart (if older than 2 years)
- Calculating the mid-parental centile on a growth chart (the expected height centile for the child of these parents)
A feeding history in an infant includes asking about:
- Breast or bottle feeding
- Feeding times
- Volume and frequency
- Any difficulties with feeding
An eating history in an older child involves asking about food choices, food aversion, mealtime routines and appetite. Asking the parent to keep a food diary can be helpful.
Outcomes from the assessment that could suggest inadequate nutrition or a growth disorder are:
- More than two centile spaces below the mid-parental height centile
- BMI below the 2nd centile
Investigations
NICE guidelines from 2017 on faltering growth recommend testing for:
- Urinary tract infection (urine dipstick)
- Coeliac disease (anti-TTG antibodies)
Focused investigations should be considered where additional signs or symptoms suggest an underlying diagnosis, such as cystic fibrosis or pyloric stenosis.
Management
Management depends on the cause and may involve input from the multidisciplinary team. All children with faltering growth should have regular reviews to monitor weight gain. Frequent reviews can increase parental anxiety.
Midwives, health visitors and lactation consultants can assist with breastfeeding difficulties. Supplementing with formula milk can improve growth, but often results in breastfeeding stopping. Breastfeeding before giving top-up feeds and expressing when not breastfeeding can encourage lactation to continue.
Inadequate nutrition is managed based on individual circumstances, and may involve:
- Regular structured mealtimes and snacks
- Reduced milk consumption to improve appetite for other foods
- Dietician input
- Energy-dense foods to boost calories
- Nutritional supplement drinks
Where other measures fail and there are serious concerns, the multidisciplinary team may consider enteral tube feeding. This needs to have clear goals and a defined endpoint.
Last updated October 2025
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