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 infants (children <1 year old).
Figure 1. Growth charts for girls and boys aged 0-2 years [1]
Contents
Patterns of Childhood Growth
In the first few days of life, it is considered acceptable for babies to lose up to 10% of their birth weight whilst they establish feeding. This weight loss normally stops after day 4 of life and is normally regained after 3 weeks. If a baby loses >10% of its birth weight by day 5 of life, further assessment is required.
In the first year of life, rapid growth occurs. 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
Figure 2.
In black, growth points plotted show steady weight gain for an infant male between the 85th-97th centile.
In red, growth points plotted show weight gain for an infant male, but the centile has dropped from between the 50th-85th to between the 3rd-15th centile. This growth chart suggests faltering growth and the infant would need to be assessed to identify a cause.
Causes of Faltering Growth
Causes can be categorised broadly into inadequate nutritional intake, inadequate nutrient absorption, excessive nutrient loss and increased metabolic demand. Certain syndromes can also cause failure to thrive.
| Inadequate Nutritional Intake | Difficulty supplying breast milk Poor milk production due to breast surgery, anaemia, endocrine issues or can be idiopathic Poor milk let-down due to smoking, psychological factors Difficulty feeding Genetic conditions associated with abnormal facial structure e.g. Pierre Robin syndrome Tongue tie (assess using TABBY tool) Cleft lip/palate Poor suck e.g. cerebral palsy Swallowing issues – this can be due to prematurity, or neurological problems such as congenital myopathy or spinal muscular atrophy (SMA) |
| Inadequate Nutrient Absorption | Pancreatic exocrine insufficiency, e.g. Cystic fibrosis, Schwachman-Diamond syndrome Cow’s milk protein allergy (must be severe to cause faltering growth) |
| Excessive Nutrient Loss | Vomiting Gastro-oesophageal reflux disease (must be severe to cause faltering growth) Pyloric stenosis – typically presents at 5-6 weeks of age with projectile vomiting and metabolic alkalosis + hypochloraemia Diarrhoea Infection |
| Increased Metabolic Demand | Small for gestational age Congenital heart disease (Most commonly undiagnosed VSD) Metabolic disease Hyperthyroidism / Hypothyroidism Type 1 diabetes mellitus Chronic systemic disease e.g. cystic fibrosis Chronic infection e.g. HIV, immunodeficiency Malignancy, e.g. Neuroblastoma, Wilms’s tumour, Hepatoblastoma |
| Syndromic Causes | Prader-Willi syndrome Russel Silver syndrome Down syndrome Turner syndrome Diencephalic Syndrome |
Assessment
- Take a detailed pregnancy and birth history
Risk Factors for Sepsis
| Early Onset Neonatal Sepsis | Maternal sepsis treated with IV antibiotics Invasive group B streptococcal infection in previous baby or maternal group B streptococcal colonisation Intrapartum fever Prematurity (<37 weeks) Prolonged rupture of membranes (>24h if term or >18h if preterm) Chorioamnionitis [11] Â |
| Late Onset Neonatal Sepsis | Prematurity (<37 weeks) History of invasive procedures e.g. urinary catheter, central catheter, mechanical ventilation , surgery [12] |
- Complications during birth
- Anomalies on antenatal scans
- Take a feeding history, including feed type (i.e. breast vs bottle), feeding times, duration, frequency and volume
- New-borns should feed minimum 8 times 24 hoursFeeds should last 5-30 minutes and occur every 2-4 hours
- It’s important to ask about how often the baby is waking for feeds or if they are needing to be woken up to feed and if the baby is falling asleep whilst feeding as this indicates they probably aren’t getting much milk
Daily feed volume increases with day of life if feeding with formula
| Day 0 | 60ml/kg/day |
| Day 1 | 90ml/kg/day |
| Day 2 | 120ml/kg/day |
| Day 3 onwards | 150ml/kg/day |
- Ask about stool and urine output
- Low urine and/or stool output indicates inadequate feedingBabies should have 2 wet nappies on day 2 of life, 3 wet nappies on day 3, and so on until 6 wet nappies from day 7 onwardsFrom day 5 onwards, babies should have 3 yellow stools a day. However, stool frequency is very variable in babies, and formula-fed babies may only open their bowels once or twice a week
Urates (orange/brown pigment) in urine after 3 days of life indicate inadequate intake
- Observe feeding
- If breastfeeding, examine mum’s nipples for bleeding, evidence of thrush or other factors that may limit feeds
- Observe if the baby is calm whilst feeding, and settled after feeding
- Observe for suck-swallow pattern: rapid sucking at the beginning of feed, followed by slower and deeper sucking with visible swallowing indicates effective feeding
- Signs of ineffective feeding include
- Rapid sucking throughout the feed
- Noisy feeding
- Baby feeding for a prolonged time and then crying after feed, as if they are still hungry
- Waking often for feeds
- Observe parent-child interactions, including how parents respond to infant’s feeding cues
- Early cues: stirring in their sleep, mouth opening, licking lips, rooting
- Mid cues: stretching, head bobbing, increasing physical movement
- Late cues: crying, agitation
- Assess mum’s physical and mental health – consider if maternal support (e.g. from health visitor, community midwife or GP) is required
- Examine the infant
- Look for dysmorphic features that suggest a syndromic cause
- Colour: jaundice, pale
- Tone and reflexes
- Behaviour: alert vs lethargic, waking to feed
- Examine the palate to the back to exclude a cleft soft palate – you will need a tongue depressor for this, you have not excluded a cleft palate unless you have visualised the uvula
- Assess for signs of cardiovascular and respiratory disease e.g. palpate pulses, auscultate the chest, listen for a murmur
- Evidence of dehydration
- Assess for sepsis, jaundice and hypoglycaemia
- If a baby’s weight loss is significant, serum sodium should be checked and consideration of fluid replacement and feeding plan is required
- If shocked, give 10ml/kg 0.9% NaCl IV bolus
- Plot child length, weight and head circumference on the growth chart
- Ensure the correct growth cart is used. Separate growth charts exist for:
- Gender
- Age
- Prematurity (<32 weeks) – plot for corrected gestational age until children are 2 years old
- For example, if a baby is born at 24 weeks gestation and you are plotting their weight when they are 16 weeks old, you would plot them as a new-born term (40 weeks_ baby
- There are specific growth charts for certain syndromes e.g., Trisomy 21, Turner syndrome
- Ensure the correct growth cart is used. Separate growth charts exist for:
Investigations
- Consider investigations such as serum bilirubin, sodium and glucose in the first instance
- Consider a partial or full septic screen, depending on assessment and risk factors for sepsis
- Consider specialist investigations e.g. genetic testing for cystic fibrosis, or abdominal ultrasound for pyloric stenosis
Management
Management of faltering growth is dependent on cause, and multidisciplinary team input is often required.
If breastfeeding, support from midwives and/or health visitors may help. Feeding should be responsive to baby’s feeding cues.
Supplementing feeds with expressed breast milk or formula milk may be indicated, although this may result in cessation of breastfeeding.
If the mother wishes to continue breastfeeding, they should be advised to breastfeed before top-up feeds, and express breast milk when not feeding. Having a mum express breast milk is very useful in determining how much milk baby is getting. If the mother’s milk supply is good and she expresses a lot of milk, but baby is not gaining weight, the issue is more likely to be related to difficulty feeding, such as poor suck/latch. However, if little milk is expressed, poor weight gain is more likely related to low milk supply.
Domperidone (a dopamine receptor antagonist) is occasionally used in breastfeeding mums to increase their milk supply.
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.
References
- https://www.rcpch.ac.uk/resources/uk-who-growth-charts-0-4-years
- https://www.nice.org.uk/guidance/ng75
- https://www.aap.org/en/patient-care/newborn-and-infant-nutrition/growth-faltering-in-newborns-and-infants/?srsltid=AfmBOooWYgXzPK0NlEt2wGARAvoTT87xeQIAI3Ybo_sW_aKU0jLF91Vx
- https://www.nice.org.uk/guidance/ng194/chapter/Recommendations#planning-and-supporting-babies-feeding
- https://www.cambspborochildrenshealth.nhs.uk/feeding-and-eating/feeding-cues-and-signs-of-getting-enough-milk/#feeding-cues
- https://pmc.ncbi.nlm.nih.gov/articles/PMC9247442/
- https://www.nice.org.uk/guidance/ng78/chapter/recommendations#diagnosis-of-cystic-fibrosis
- https://bestpractice.bmj.com/topics/en-us/680
- https://litfl.com/paediatric-dehydration-assessment/
- https://www.ncbi.nlm.nih.gov/books/NBK436022/
- https://www.nice.org.uk/guidance/ng195/resources/visual-summary-on-neonatal-infection-determining-the-need-for-antibiotic-treatment-of-babies-within-72-hours-of-birth-pdf-9078464413
- https://www.nice.org.uk/guidance/ng195
Written by Lizzie Hatton, Junior Clinical Fellow at Great Western Hospitals,
Edited by Dr Bex Evans, Paediatric Registrar
