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Faltering growth: recognition and management of faltering growth in children

Terms used in this guideline

  • Child

    Pre-school children from 1 year of age

  • Food or feeding aversion

    Behaviours sometimes observed in infants or children indicating a persistent unwillingness to eat. Such behaviours, depending upon age, might include signs of distress when presented with food, spitting of food or avoidance behaviour

  • Infant

    A baby up to 1 year of age

  • Linear growth

    This is the increase in length (under 2 years of age) or height (2 years or older) over time in infants and children

  • Oral liquid nutritional supplement

    A high-energy liquid feed designed for enteral use, usually selected and prescribed after specialist advice from a paediatric dietitian

  • Undernutrition

    This is what happens when nutrition is not sufficient. An infant or child with undernutrition may be abnormally thin, may weigh less than expected for their length or height, and if prolonged, undernutrition can lead to stunting (length or height less than expected for age)

Weight loss in the early days of life

  • Be aware that:
    • it is common for infants to lose some weight during the early days of life
    • this weight loss usually stops after about 3 or 4 days of life
    • most infants have returned to their birth weight by 3 weeks of age
  • If infants in the early days of life lose more than 10% of their birth weight:
    • perform a clinical assessment, looking for evidence of dehydration, or of an illness or disorder that might account for the weight loss
    • take a detailed history to assess feeding (see NICE’s guideline on postnatal care up to 8 weeks after birth)
    • consider direct observation of feeding
    • ensure observation of feeding is done by a person with appropriate training and expertise (for example, in relation to breastfeeding and bottle feeding)
    • perform further investigations only if they are indicated based on the clinical assessment
  • Provide feeding support (see recommendations in NICE’s guideline on postnatal care up to 8 weeks after birth) if there is concern about weight loss in infants in the early days of life, for example if they have lost more than 10% of their birth weight
  • If infants lose more than 10% of their birth weight in the early days of life, or they have not returned to their birth weight by 3 weeks of age, consider:
    • referral to paediatric services if there is evidence of illness, marked weight loss, or failure to respond to feeding support (see recommendations in NICE’s guideline on postnatal care up to 8 weeks after birth)
    • when to reassess if not referred to paediatric services
  • If an infant loses more than 10% of their birth weight in the early days of life, measure their weight again at appropriate intervals depending on the level of concern, but no more frequently than daily
  • Be aware that supplementary feeding with infant formula in a breastfed infant may help with weight gain, but often results in cessation of breastfeeding
  • If supplementation with an infant formula is given to a breastfed infant:
    • support the mother to continue breastfeeding
    • advise expressing breast milk to promote milk supply and
    • feed the infant with any available breast milk before giving any infant formula

Faltering growth after the early days of life

Thresholds

  • Consider using the following as thresholds for concern about faltering growth in infants and children (a centile space being the space between adjacent centile lines on the UK WHO growth charts):
    • a fall across 1 or more weight centile spaces, if birthweight was below the 9th centile
    • a fall across 2 or more weight centile spaces, if birthweight was between the 9th and 91st centiles
    • a fall across 3 or more weight centile spaces, if birthweight was above the 91st centile
    • when current weight is below the 2nd centile for age, whatever the birthweight

Measurement of weight and height or length

  • If there is concern about faltering growth:
    • weigh the infant or child
    • measure their length (from birth to 2 years old) or height (if aged over 2 years)
    • plot the above measurements and available previous measurements on the UK WHO growth charts to assess weight change and linear growth over time
  • If there are concerns about an infant’s length or a child’s length or height, if possible obtain the biological parents’ heights and work out the mid-parental height centile. If the child’s length or height centile is below the range predicted from parental heights (more than 2 centile spaces below the mid-parental centile) be aware this could suggest undernutrition or a primary growth disorder
  • If there is concern about faltering growth or linear growth in a child over 2 years of age, determine the BMI centile:
    • using the UK WHO centiles and the accompanying BMI centile ‘look-up chart’ or
    • by calculating the BMI (weight in kg/height in metres squared) and plotting this on the BMI centile chart
  • Then:
    • if the BMI is below the 2nd centile, be aware this may reflect either undernutrition or a small build
    • if the BMI is below the 0.4th centile, this suggests probable undernutrition that needs assessment and intervention
  • Record all growth measurements in the parent- or carer-held Personal Child Health Record

Assessment

  • If there is concern about faltering growth:
    • perform a clinical, developmental and social assessment
    • take a detailed feeding or eating history
    • consider direct observation of feeding or meal times
    • consider investigating for:
      • urinary tract infection (follow the principles of assessment in NICE’s guideline on urinary tract infection in under 16s)
      • coeliac disease, if the diet has included gluten-containing foods (follow the principles of assessment in NICE’s guideline on coeliac disease)
    • perform further investigations only if they are indicated based on the clinical assessment
  • If observation of eating or feeding is needed because of concern about faltering growth, ensure this is done by a person with appropriate training and expertise
  • Be aware that the following factors may be associated with faltering growth:
    • preterm birth
    • neurodevelopmental concerns
    • maternal postnatal depression or anxiety
  • Recognise that in faltering growth:
    • a range of factors may contribute to the problem, and it may not be possible to identify a clear cause
    • there may be difficulties in the interaction between an infant or child and the parents or carers that may contribute to the problem, but this may not be the primary cause
  • Based on the feeding history and any direct observation of feeding, consider whether any of the following are contributing to faltering growth in milk-fed infants:
    • ineffective suckling in breastfed infants ineffective bottle feeding
    • feeding patterns or routines being used
    • the feeding environment
    • feeding aversion
    • parent/carer–infant interactions
    • how parents or carers respond to the infant’s feeding cues
    • physical disorders that affect feeding
  • Based on the feeding history and any direct observation of mealtimes, consider whether any of the following are contributing to faltering growth:
    • mealtime arrangements and practices
    • types of foods offered
    • food aversion and avoidance
    • parent/carer–child interactions, for example responding to the child’s mealtime cues
    • appetite, for example a lack of interest in eating
    • physical disorders that affect feeding
  • Consider asking the parents or carers of infants and children with faltering growth to keep a diary recording food intake (types and amounts) and mealtime issues (for example, settings, behaviour) to help inform management strategies and assess progress
  • Be aware that investigations (other than those recommended in the Assessment section) are unlikely to reveal an underlying disorder in a child with faltering growth who appears well with no other clinical concerns
  • If a child with faltering growth develops new clinical symptoms or signs after the initial assessment, reconsider whether investigations are needed

Interventions for faltering growth

  • Together with parents and carers, establish a management plan with specific goals for every infant or child where there are concerns about faltering growth. This plan could include:
    • assessments or investigations
    • interventions
    • clinical and growth monitoring
    • when reassessment to review progress and achievement of growth goals should happen
  • Provide feeding support (see recommendations in NICE’s guideline on postnatal care up to 8 weeks after birth) if there is concern about faltering growth in the first weeks of life. Consider whether such feeding support might be helpful in older milk-fed infants, including those having complementary solid foods
  • Be aware that while supplementary feeding with infant formula may increase weight gain in a breastfed infant if there is concern about faltering growth, it often results in cessation of breastfeeding
  • If supplementation with an infant formula is given to a breastfed infant because of concern about faltering growth after the early days of life:
    • support the mother to continue breastfeeding
    • advise expressing breast milk to promote milk supply and
    • feed the infant with any available breast milk before giving any infant formula
  • When there are concerns about faltering growth, discuss the following, as individually appropriate, with the infant’s or child’s parents or carers:
    • encouraging relaxed and enjoyable feeding and mealtimes
    • eating together as a family or with other children
    • encouraging young children to feed themselves
    • allowing young children to be ‘messy’ with their food
    • making sure feeds and mealtimes are not too brief or too long
    • setting reasonable boundaries for mealtime behaviour while avoiding punitive approaches
    • avoiding coercive feeding
    • establishing regular eating schedules (for example 3 meals and 2 snacks in a day)
  • If necessary, based on the assessment, advise on food choices for infants and children that:
    • are appropriate to the child’s developmental stage in terms of quantity, type and food texture
    • optimise energy and nutrient density
  • In infants or children who need a further increase in the nutrient density of their diet beyond that achieved through advice on food choices, consider:
    • short-term dietary fortification using energy-dense foods
    • referral to a paediatric dietitian
  • Advise the parents or carers of infants or children with faltering growth that drinking too many energy-dense drinks, including milk, can reduce a child’s appetite for other foods
  • Consider a trial of an oral liquid nutritional supplement for infants or children with continuing faltering growth despite other interventions
  • Regularly reassess infants and children receiving an oral nutritional supplement for faltering growth to decide if it should be continued. Take into account:
    • weight change
    • linear growth
    • intake of other foods
    • tolerance
    • adherence
    • the views of parents or carers

Monitoring

  • If there are concerns about faltering growth (see Thresholds), measure the weight at appropriate intervals taking account of factors such as age and the level of concern, but usually no more often than:
    • daily if less than 1 month old
    • weekly between 1–6 months old
    • fortnightly between 6–12 months
    • monthly from 1 year of age
  • Monitor weight if there are concerns about faltering growth (see Thresholds), but be aware that weighing children more frequently than is needed may add to parental anxiety (for example, minor short-term changes may cause unnecessary concern)
  • Be aware that weight loss is unusual except in the early days of life, and may be a reason for increased concern and more frequent weighing than is recommended
  • If there are concerns about faltering growth monitor length or height at intervals, but no more often than every 3 months

Referral

  • If an infant or child with faltering growth has any of the following discuss with, or refer to, an appropriate paediatric specialist care service:
    • symptoms or signs that may indicate an underlying disorder
    • a failure to respond to interventions delivered in a primary care setting
    • slow linear growth or unexplained short stature (see Monitoring)
    • rapid weight loss or severe undernutrition
    • features that cause safeguarding concerns (see the NICE guideline on child maltreatment)

Organisation of care

  • Ensure there is a pathway of care for infants and children where there are concerns about faltering growth or weight loss in the early days of life that:
    • clearly sets out the roles of healthcare professionals in primary and secondary care settings
    • establishes and makes clear the process for referral to and coordination of specialist care in the pathway
  • Provide community-based care for infants and children where there are faltering growth concerns or weight loss in the early days of life with a team (the ‘primary care team’) that includes, for example:
    • a midwife
    • a health visitor
    • a GP
  • Ensure that the primary care team has access to the following healthcare professionals with expertise relevant to faltering growth:
    • infant feeding specialist
    • consultant paediatrician
    • paediatric dietitian
    • speech and language therapist with expertise in feeding and eating difficulties
    • clinical psychologist occupational therapist
  • Consider identifying a lead healthcare professional to coordinate care and to act as the first point of contact for parents of children with faltering growth, for example if several professionals are involved

Information and support

  • Recognise the emotional impact that concerns about faltering growth or weight loss in the early days can have on parents and carers and offer them information about available:
    • professional support
    • peer support
  • Follow the principles in the NICE guideline on patient experience in NHS services in relation to communication (including different formats and languages), information and shared decision-making
  • Provide information on faltering growth or weight loss in the early days of life, to parents or carers that is:
    • specific to them and their child
    • clearly explained and understandable to them
    • spoken and in writing
  • If there is concern about faltering growth in an infant or child or weight loss in the early days of life, discuss with the parents or carers:
    • the reasons for the concern, and how the growth measurements are interpreted
    • any worries or issues they may have
    • any possible or likely causes or factors that may be contributing to the problem the management plan (see Interventions for faltering growth)

full document available from…

National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT

https://www.nice.org.uk/guidance/ng75

National Institute for Health and Care Excellence.

Faltering growth: recognition and management of faltering growth in children. September 2017.

First included: December 2017.