Growth monitoring in babies and children is an important part of paediatric care. Faltering growth previously termed failure to thrive (FTT) is widely used to describe a significant interruption in the expected rate of growth compared with other children of similar age and sex. It usually applies to young children, especially babies rather than older children or teenagers. (1, 2) and is used as marker for undernutrition or disease. Early recognition protects health therefore regular monitoring is advised through infancy and early childhood (2).

Weight loss of up to 10% of birthweight is common in the first days of life and usually relates to body fluid adjustments but birth weight is usually regained before 3 weeks of age when feeding is established (4). A slower rate of weight gain than expected after the early days of life is characterized as Faltering growth.

Growth Assessment

Growth assessment charts (6) are a tool used to monitor growth in children. They are designed to help parents and healthcare professionals assess the health and development of children in terms of height, weight, and head circumference.  Growth is measured using international standards which are based on infants and children growing under optimal conditions in a range of situations and geographical areas (3).  The World Health Organization (WHO) has produced growth standards, based on longitudinal studies of healthy breastfed infants. These standards, along with UK term and preterm infant growth data, have been incorporated into UK WHO growth charts for monitoring growth in UK (5).

Growth assessment charts provide a percentile ranking and are tailored to account for the differences in growth of boys and girls, as well as differences between different ethnic groups and genetic conditions. The plotting of a child's weight, length or height and head circumference on percentile lines provide a visual representation of growth over time. Epidemiological data suggest that healthy infants and children will usually progress along a specific centile line from early infancy (4)

Definitions and diagnosing faltering growth

There are 2 definitions of faltering growth (2):

• Weight faltering is defined as downward crossing of weight through centile spaces , low weight for height or no catch-up from a low birth weight.
• Growth faltering is defined as height falling down through length/height centile(s) as well as weight. A low height centile or height less than expected from parental heights.

Weight below the 2^nd centile on the UK-WHO 0-4 years and UK 2-18 years growth charts (6) indicates faltering regardless of birthweight (6). A cause for concern is highlighted when a child’s weight drops one or more centile lines, and their birth weight is less than 9^th percentile or two or more centile spaces when their birth weight is 9^th-91^st percentile and if their weight is above the 91^st percentile cause for concern is indicated at drop of three or more centile spaces (4, 5)

Length in children under 2 years should be measured and height in children over 2 years. If there are concerns regarding a child’s length or height the parent should be measured and the mid-parental height centile (MPC) be plotted. If the child’s length or height is more than 2 centile spaces below the MPC this may indicate undernutrition or a growth disorder (7)

Causes of Faltering Growth

It is important to identify the causes of faltering growth to address the issues and prevent further decline.

There are many potential causes of faltering growth, including both medical accounting for approximately 5% of cases and undernutrition is recognised as the primary cause of poor weight gain in infancy. A medical condition such as a chronic illness, genetic disorder, or hormonal imbalance can cause some children to experience faltering growth. Environmental factors, such as inadequate nutrition, poor hygiene, or lack of physical activity can also contribute to the problem.

Medical Causes of Faltering Growth

The most common medical causes of faltering growth are chronic illnesses, genetic disorders, and hormonal imbalances. Common chronic illnesses that can cause faltering growth are cystic fibrosis, asthma, allergies, diabetes, congenital abnormalities, and gastrointestinal disorders such as coeliac disease. These cause an inability to absorb nutrients as is the cause with gastrointestinal disorders and cystic fibrosis or slow growth due to increased breathing and energy expenditure in children with congenital cardiac disorders.

Genetic disorders are caused by a change or mutation in a person’s DNA. These mutations can interfere with the normal growth and development of a child. Common genetic disorders that can cause faltering growth include Down Syndrome, Turner Syndrome, and muscular dystrophy.

Children with Neurological disorders may have problems with ormotor development affective suck and swallow which can cause oral hypersensitivity sometimes referred to feeding or bottle aversion causing the infant to refuse to feed. (4)

Undernutrition

Faltering growth in most cases has no apparent medical problem so inadequate nutritional intake appears to be the underlying cause.

In children where no medical cause has been identified early feeding problems can be caused for several reasons including a poor suck and latch in breast fed babies or a tongue tie that prevents inadequate transfer of milk. In breast fed baby's faltering growth is caused by reduced milk intake by the baby, either because of difficulties with positioning and attachment or lack of access to the breast/chest (15)

Starting solids at or around 6 months is a time when infants are introduced to a wide range of tastes, and textures to promote oromotor skills. If this important developmental stage is interrupted particularly those of lumpier textures then onward progression can be difficult and may compromise nutritional adequacy of the diet. Northstone 2001 and Coulthard 2009 found that children introduced to lumpy solids after the age of 9 months were significantly less likely to be having family foods at 15 months and seven years, when compared to those introduced between 6 and 9 months. At each age, those introduced late (10 months or older) to lumps were more difficult to feed and had more definite likes and dislikes. In addition, they were reported as having significantly more feeding problems at seven years (8, 9)

Once weight starts to falter the affects seem to perpetuate. Blisset 2002 found that infants and young children with faltering weight are reported to experience more feeding difficulties compared with those growing normally (10). These feeding problems can present in stressful meal times, food refusal, spitting out food or gagging and being sick (9).

Children can refuse food for a number of reasons from family and maternal influences, poverty, neglect or abuse. Behavioural feeding problems including food refusal can present at any age (4). One of the first forms of communication between a parent and child is during feeding. When feeding is responsive it is associated with more desirable eating behaviours (12), however parental personality leading to worry anxiety or concern about a child’s food intake or fear of choking can influence how a child reacts to foods (14)

Another reason for food refusal is a baby’s association of food causing them to be pain or any other unpleasant experience. This is often seen in infants with reflux or with allergies who vomit or a child who cut through a few teeth at the same time resulting in painful gums or a stressful mealtime environment where the parent dislikes mess therefore inhibiting self-feeding.

Whatever the reasons for faltering growth it is important to identify the cause so that support can be implemented quickly to avoid persistent weight faltering (13)

Assessment

Health care professionals with appropriate training such as health visitors are best to identify faltering growth in infants and children in the first instance when they undertake routine health checks in which the infant or child is weighed and measured (4). When concerns of faltering growth are identified the health visitor will make a referral to the paediatric dietitian who will address nutritional adequacy. Support from other health care professionals may be needed such as speech and language therapists in the case of any affected oromotor. When other medical aspects are involved with faltering growth or when social aspects are thought to be involved the child may benefit from attending a multi-disciplinary feeding team involving the paediatrician, paediatric dietitian, specialist health visitor, clinical psychologist, nurse and speech and language therapist.

Faltering grow in the first year of life 

It is important to construct a complete picture of all aspects of influences on a child's feeding by evaluating the feeding history and progression of solids to identify concerns in the first year of life. If the baby is breastfed and the infant has not returned to their birth weight or growth and dropped off the centiles from birth then observation of breast feeding by a person with appropriate training and expertise in this area such as health visitor or lactation consultant (5) is important to ensure a baby is breastfeeding efficiently and that the baby is getting the full proportion of fore and hind milks. It is also important to assess the maternal diet for nutritional inadequacies and adequate protein, calories, iron, calcium and fluid is met to meet the requirements of a breastfeeding women. The mothers mental and general health should be assessed, since stress, anxiety and worry can affect breast milk production. 

See table below for a list of contributions to faltering growth in an infant. 

Dietary Assessment

Diet recall or 3 days food diary to get a picture of nutritional intake:

Pattern of food, bottles and breastfeeds.

texture,

variety and frequency of foods offered

mealtime routines and length of mealtimes and snacks

Family practices and dynamics around food.

Mealtime environment eg are they stressful?

information on where food is purchased and preparation within the home.

Observation of the child eating with in person or a parent taking a video.

Seating position of the child and parent position

child's interest in their own food and that of other family members

quantity, type and texture of the food offered and eaten

child ability to eat and drink themselves

interaction and communication between the child and the parent observing parents response to child's cues and verbal encouragement.

Atmosphere and emotions at mealtimes.

Encouraging the parent to take a video can help the to observe their own body language and they way they speak to the infant. Parents often allow their own emotions and worry to cause them unintentionally to be forceful or coercive in their manor which can put pressure on the infant cause a negative experience. It is important to listen to parents concerns and their view should always been taken into account. It is also important to know who else is involved in providing food and meals to the child and any differences in their habits in different feeding environments and with different people. 

Nutritional Management  for Faltering Growth

After initial assessment of dietary intake the dietitian will assess nutritional intake and compare it to nutritional requirements for their age and size. A dietary intake that meets their requirements of energy and protein will usually allow for maintenance of growth along their current centile line. In the case of a child that has fallen off their centile lines and is diagnosed with faltering growth then they will need additional energy and protein above their requirements to encourage catch up growth. A child may need as much as 50-100% more calories to encourage catch-up, however an adequately experienced paediatric dietitian will make a judgement based on the child and to make sure that additional supplementation of calories does not displace normal meals and snacks or at the expense of essential nutrients. Close monitoring is therefore essential.

It is common for children with faltering growth to become anaemic due to their reliance on milk products which contains little iron. In a study 1/3 children with faltering growth presented with anaemia. Requirements for vitamins, minerals and trace elements is increased during periods of growth, it is therefore recommended that vitamin and mineral be given to the infant during periods of catch up growth. 

The main nutritional objectives are:

• To improve protein and energy intake
• To promote weight gain to catch-up to their birth centile
• to correct any nutritional inadequacies of the diet and achieve an adequate nutritional intake. 

Dietetic Interventions for faltering growth

1. https://www.ncbi.nlm.nih.gov/books/NBK458459/

2.https://patient.info/doctor/faltering-growth-in-children

3. 3 World Health Organization and the United Nations Children’s Fund https://www.who.int/nutrition/publications/severema lnutrition/9789241598163_eng.pdf. Accessed 4 November 2019
4. Clinical Paediatric Dietetics 5th edition  (p 465) 
5. https://www.nice.org.uk/guidance/ng75/resources/faltering-growth-recognition-and-management-of-faltering-growth-in-children-pdf-1837635907525 

6 https://www.rcpch.ac.uk/resources/growth-charts

7 Blair PS, Drewett RF, Emmett PM et al. Family, socioeconomic and prenatal factors associated with failure to thrive in the Avon Longitudinal Study of Parents and Children (ALSPAC). Int J Epidemiol, 2004, 33 839–847.

7 7. Shrimpton R, Victora CG, de Onis M, Lima RC, Blössner M, Clugston G. Worldwide timing of growth faltering: implications for nutritional interventions. Pediatrics. 2001; 107:E75. PMID: 11331725.

8 Coulthard H, Harris G and Emmett P: Delayed introduction of lumpy foods to children during the complementary feeding period affects child’s food acceptance and feeding at 7 years of age 
Maternal and Child Nutrition 2009; 5:75–85 https://pubmed.ncbi.nlm.nih.gov/19161546/

9 Northstone K, Emmett P, Nethersole F and the ALSPAC study team: The effect of age of introduction to lumpy solids on foods eaten and reported feeding difficulties at 6 and 15 months.
J Hum Nutr Diet 2001;14:43-54 https://pubmed.ncbi.nlm.nih.gov/11301932/

10 Blissett J, Harris J, Cunningham J et al. Faltering growth: a case study and recommendations for practice. Community Pract, 2002, 11 424–427.

11 Underdown A. When Feeding Fails: Parents’ Experiences of Faltering Growth. London: Children’s Society, 2000.

12  Julia M. Finnane BHlthSc ¹, Elena Jansen PhD ¹, Kimberley M. Mallan PhD ^1 2, Lynne A. Daniels PhD ^1 3 Mealtime Structure and Responsive Feeding Practices Are Associated With Less Food Fussiness and More Food Enjoyment in Children Accepted 11 August 2016, Available online 1 October 2016, Version of Record 6 January 2017 https://www.sciencedirect.com/science/article/abs/pii/S1499404616307217

13  Scaglioni S, De Cosmi V, Ciappolino V et al. Factors influencing children’s eating behaviours. Nutrients, 2018, 10(6) 706

14  Leuba, A.L., Meyer, A.H., Kakebeeke, T.H. et al. The relationship of parenting style and eating behavior in preschool children. BMC Psychol 10, 275 (2022). https://doi.org/10.1186/s40359-022-00981-8

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