1.1.3 Faltering Growth Policy

1. Definition

According to NICE: "The term 'faltering growth' (previously called 'failure to thrive') is widely used to refer to a slower rate of weight gain in childhood than expected for age and sex. The term faltering growth is preferred as periods of slow growth may represent temporary variation from the expected pattern and the word 'failure' may be seen as pejorative. Various definitions of faltering growth have been used in the past, meaning estimates of prevalence in the UK vary widely."

Although there may be a medical cause, the majority of children with faltering growth are children who have no organic disorders. The cause of faltering growth in the absence of a specific underlying health condition is likely to be complex and multifactorial. This often occurs in the overall context of emotional deprivation and neglect; therefore, the child not only fails to grow but fails to develop intellectually and emotionally.

(Children with medical disorders which affect their growth may also be neglected).

2. Recognition

Recognition and professional curiosity that a child's growth is faltering, depends upon regular monitoring of the child's growth and the alertness of professionals and carers to the realisation that growth is not progressing normally.

In a proportion of cases, this may be associated with other features such as developmental delay.

It is important to remember that older children's growth can also falter. Health assessments of children of school age, for example by school nurses, may reveal impairment of a child's growth, but medical checks are less frequent for older children and, therefore, professionals need to be very alert to the problem in this age group.

Stated in NICE Faltering Growth guidance, professionals should '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 birth weight was below the 9th centile;
• A fall across 2 or more weight centile spaces, if birth weight was between the 9th and 91st centiles;
• A fall across 3 or more weight centile spaces, if birth weight was above the 91st centile;
• When current weight is below the 2nd centile for age, whatever the birth weight.

If there is concern about faltering growth (for example, based on the criteria in recommendation 1.2.1):

• 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.'

3. Referral for Medical Assessment

When potential faltering growth of preschool children may initially come to the attention of a health visitor. The health visitor should consider, after discussion with the parents, referring the child to the GP for a medical assessment. The GP will arrange to see the child and assess from a medical point of view, whether there is any obvious cause for the child's faltering growth. This will include an assessment of the child's growth and development, and may involve a referral for a specialist paediatric assessment.

If a child is referred to, or presents to a Paediatrician with faltering growth, they should undertake an assessment of the child, including assessment of the child's growth and development, to determine whether there is any obvious cause for the child's faltering growth.

When faltering growth comes to the attention of staff working with children, for example, in a Children's Centre, nursery or school, after discussion with the parents, the child should be referred to the GP for a medical assessment. The health visitor/school nurse should also be informed of the referral.

If at any stage there is significant concern on the part of any staff working with children about a particular child growth or development, then a referral for a medical assessment should take place.

4. Management of Risk

When continued monitoring of a child's growth and development takes place because of concerns about faltering growth, there must be effective sharing of information and it must be clear to all professionals concerned and parents/carers what action they are required to take and when, with a clear recorded plan in the child’s health record.

This monitoring will usually take place as part of an Early Help / Early Support assessment. For example, a Paediatrician may wish to review the child in 6 weeks time, the Health Visitor may check the weight at intervals in between and the Dietician will advise the family so that they can implement the advice at home.

Close monitoring and regular review should take place and specific timescales should be set. The younger the child, the more critical the timescales - as brain growth is occurring at a significant rate, and therefore, longer timescales may not be adequate to safeguard and promote the child's welfare.

5. Communication and Liaison

It is essential that when children are seen outside the primary care setting and this includes where children are seen by Community Paediatricians, that a letter recording the assessment and discussion with parents and plans for future management is sent to the GP, health visitor or school nurse if involved and copied to the Dietician, other involved professionals and if relevant, Children's Social Care Services and  parents

Effective management of children with faltering growth requires timely and effective communication between professionals and family.

6. Child Protection Referral

If at any time there is concern that faltering growth is, or may become, a child safeguarding issue and that the child is suffering or likely to suffer Significant Harm, then the situation should be discussed with Children's Social Care Services and if appropriate a referral to Children's Social Care Services must be made under the e Referrals Procedure.

7. Further Information

See NICE Faltering Growth guidance for further information about Faltering Growth.