Faltering growth (also known as failure to thrive) describes when a child is not growing as expected. This may reflect underlying poor health or nutrition. By routinely assessing a child’s height and weight throughout childhood, growth measurements can be plotted over time on centile charts and faltering growth can be identified. As causes and management of faltering growth differ by age, this article will address faltering growth in children >1 year old.
Figure 1. Growth charts for girls and boys aged 2-9 years [1]
Contents
Patterns of Childhood Growth
In the first few days of life, babies typically lose weight whilst they establish feeding. Then, rapid growth occurs in the first year of life. Children then grow at a steady rate until puberty, where another period of rapid growth occurs until final height is reached.
NICE guidelines define faltering growth as a fall in weight across:
- 1 weight centile spaces, if birthweight is below the 9th centile
- 2 weight centile spaces, if birthweight is between the 9th and 91st centile
- 3 weight centile spaces, if birthweight is above the 91st centile
Causes of Faltering Growth
The causes for faltering growth differ by age.
Causes can be categorised broadly into inadequate nutritional intake, inadequate nutrient absorption, excessive nutrient loss and increased metabolic demand. It is important to consider a wide differential, including medical, social and psychological factors.
| Inadequate Nutritional Intake | Inadequate food availability Poverty Neglect Unbalanced diet Difficulty eating Food aversion e.g. avoidant/restrictive food intake disorder (ARFID) Environmental factors disrupting focus on eating Feeling of fullness e.g. due to constipation Difficulty swallowing e.g. eosinophilic oesophagitis or vascular ring |
| Inadequate Nutrient Absorption | Pancreatic exocrine insufficiency, e.g. Cystic fibrosis, Schwachman-Diamond syndrome GI disorders Coeliac disease Inflammatory bowel disease |
| Excessive Nutrient Loss | Persistent vomiting Diarrhoea – may be due to coeliac disease, inflammatory bowel disease or immunodeficiency Infection Inflammatory bowel disease |
| Increased Metabolic Demand | Chronic cardiorespiratory disease e.g. severe asthma, congenital heart disease Chronic systemic disease e.g. cystic fibrosis, lupus erythematosus Endocrine disease e.g. hyperthyroidism, type 1 diabetes mellitus Chronic infection e.g. HIV, immunodeficiency Malignancy |
| Syndromic Causes | Trisomy 21 Turner syndrome Russel-Silver syndrome Diencephalic syndrome |
Assessment
- Take a detailed pregnancy, birth, developmental and social history, including asking about food security
- ‘In the last month, have you or anyone in your family eaten less than you felt you should because there wasn’t enough money for food?’
- Take a detailed eating history
- Eating history should include behaviours surrounding food (e.g. problems chewing/swallowing, food aversion), food choices, appetite and meal-time routines. Food diaries can be helpful here
- Plot child height, weight and BMI (if older than 2 years) on growth chart. In children <2 years old, head circumference should also be plotted
- Review if height, weight or both are faltering, as the necessary investigations will alter depending on this
- Faltering growth describes height AND weight deviating from the expected pattern, and is more likely to be caused by a factor listed in the table above.
- Review if height, weight or both are faltering, as the necessary investigations will alter depending on this
- Short stature describes height < 2 standard deviations below the mean for age and sex within a population, and an underlying endocrine cause is more likely to cause this (e.g. growth hormone deficiency, hypothyroidism, Cushing syndrome)
- BMI = weight / height2
**BMI below the 2nd centile suggests faltering growth
- Ensure the correct growth chart is used. Separate growth charts exist for:
- Gender
- Age
- Prematurity (<32 weeks)
- Specific conditions e.g. Down’s syndrome, Turner syndrome
- Calculate mid-parental height (an estimate of the child’s predicted final height)
- Males = (mum’s height + dad’s height)/2 + 7cm
- Females = (mum’s height + dad’s height)/2 – 7cm
**Height ³ 2 centile spaces below mid-parental height suggests faltering growth
Examination
- Inspect for signs of neglect e.g. poorly kempt child, dirty, etc
- Look for dysmorphic features that may suggest syndromic cause
- Examine for signs of chronic disease
| Sign | Condition |
| Clubbing | Congenital heart disease Cystic fibrosis Bronchiectasis Inflammatory bowel disease Malabsorption |
| Gluteal muscle wasting | Malabsorption e.g. Coeliac disease |
| Conjunctival pallor | Anaemia |
| Leukonychia | Anaemia |
| Harrison’s sulcus | Chronic respiratory illness Malnutrition, Rickets |
| Organomegaly | Inflammatory bowel disease Cystic fibrosis Malignancy Rheumatological problem such a juvenile idiopathic arthirits or lupus |
| Scars | Previous abdominal surgery in e.g. cystic fibrosis (for meconium ileus) or for necrotising enterocolitis. Previous surgery may have resulted in short gut syndrome depending on how much bowel has been removed. |
- Examine for signs of hyperthyroidism
- Goitre
- Tachycardia
- Fine tremor
- Muscle wasting
- Proximal myopathy
- Hyperreflexia
- Hair loss
- Signs of thyroid eye disease – lid retraction, lid lag, exophthalmos
- Examine for signs of precocious puberty, which can reduce final height
- Look for signs of bulimia e.g. poor dentition, bite marks on knuckles from purging
Investigations
- NICE recommends investigating for urinary tract infection and coeliac disease (anti-tTG and IgA) if concerned about faltering growth
- Consider further investigations as guided by assessment
- Bloods: FBC, Blood film, Iron studies, B12, Folate, Vitamin D, U+Es, LFTs, TFTs, Inflammatory markers, HIV testing
- Specific investigations
- Sweat test and genetic testing for cystic fibrosis
- Faecal calprotectin +/- endoscopy for IBD
- Immunoglobulins and vaccine responses if concerned about immunodeficiency
- Markers of chronic rheumatological conditions e.g. anti dsDNA
- Karyotype in girls with reduced height +/- delayed puberty for Turner syndrome
Management
Management of faltering growth is dependent on cause. A holistic approach is required, and input from the multidisciplinary team is necessary.
Regular reviews are required to monitor height and weight.
Underlying causes should be sought and managed
To optimize feeding, dietician input may be very valuable. Regular eating schedules with focus on eating together as a family in a relaxed environment should be encouraged. Children may require short-term dietary fortification with energy-dense foods supplement drinks, given after meals (i.e. not as meal replacements). Families should be counselled to provide a healthy, balanced diet.
In severe cases, enteral tube feeding may be considered. However, it is essential to establish clear goals (e.g. goal weight) and a defined end-point before commencing enteral feeding. This decision should only be made after specialist multidisciplinary assessment.
Complications
Immediate complications of malnutrition include electrolyte abnormalities, micronutrient and specific vitamin deficiency, impaired immune function and resultant recurrent infections. Long-term, malnutrition can result in short stature, impair academic performance and neurodevelopmental complications including behavioural difficulties and developmental delay.
References
- https://www.rcpch.ac.uk/resources/uk-who-growth-charts-2-18-years
- https://bestpractice.bmj.com/topics/en-us/747/pdf/747/Faltering%20growth.pdf
- https://www.ncbi.nlm.nih.gov/books/NBK459287/
- https://www.nice.org.uk/guidance/ng75
- https://pmc.ncbi.nlm.nih.gov/articles/PMC9247442/
- https://www.nice.org.uk/guidance/ng78/chapter/recommendations#diagnosis-of-cystic-fibrosis
- https://cks.nice.org.uk/topics/hyperthyroidism/
- https://bestpractice.bmj.com/topics/en-gb/749
Written by Lizzie Hatton, Junior Clinical Fellow at Great Western Hospitals
Edited by Dr Bex Evans Paediatric Registrar
