Paediatrics

Faltering Growth

Faltering growth is a concerning change in a child's growth trajectory, usually weight first; the commonest mechanism is inadequate intake, so accurate serial measurements, feeding observation and whole-child assessment come before indiscriminate investigations.

In a nutshell

Faltering growth is a concerning change in growth trajectory, not simply a low weight. NICE thresholds include a fall across 1, 2 or 3 weight-centile spaces depending on birthweight, or weight below the 2nd centile. Most cases reflect inadequate intake. Take a detailed feeding history, observe a feed or meal, assess development and social context, and investigate only specific clinical clues. Provide feeding support, monitor appropriately and refer rapid/severe, persistent, linear-growth, organic or safeguarding concerns.

Classic presentation

An otherwise well infant has crossed two weight-centile spaces downward; observing a bottle feed reveals poor technique and low intake, with no indication for routine blood screening.

Key points

The trajectory matters more than a single low measurement.
NICE concern thresholds depend on birthweight centile: 1 space below the 9th, 2 spaces from the 9th to below the 91st, 3 spaces at or above the 91st, or weight below the 2nd centile.
Feeding assessment, observation and the whole-child/social assessment are first line.
Routine blood tests are unlikely to help a well child without other clinical concerns.
Rapid weight loss, severe undernutrition, slow linear growth, organic symptoms or safeguarding concerns need specialist referral.
Avoid coercive feeding and unnecessarily frequent weighing; agree measurable goals and review them.

First-line investigation

Accurate serial growth plotting plus detailed feeding history and observation, with developmental, clinical and social assessment.

Management

Confirm the trajectory and cause

Plot accurate serial weight, length/height and head circumference on the appropriate UK-WHO chart and interpret centile crossing using birthweight.^1,2
Take a detailed feeding/eating history, observe a feed or meal where useful, and assess development, examination, social context and safeguarding.^1,3

Support intake

Give practical feeding support, use relaxed responsive mealtimes and avoid coercion; protect breastfeeding if supplementation is needed.^1,4
Use dietetic support and short-term fortification when food-choice advice is insufficient; consider oral supplements only after other interventions and reassess their effect.^1,7

Refer and investigate selectively

Target tests to symptoms and signs such as urinary infection, coeliac disease, malabsorption or chronic organ disease; do not perform indiscriminate screening in a well child.^1,5,6
Refer rapid/severe weight loss, severe undernutrition, slow linear growth, failure of primary-care intervention, suspected organic disease or safeguarding concerns.^1,3

Monitor without over-measuring

Weigh at age- and concern-appropriate intervals, measure length/height no more often than every 3 months when monitoring, and reassess the agreed goals and need for specialist support.¹

Exam traps

A small child tracking a stable centile is not automatically faltering.
Do not order routine blood screening before history, examination and feeding observation.
Faltering length or head circumference suggests more prolonged/severe disease or another cause.
Do not equate faltering growth with neglect, but never omit safeguarding assessment.
Tube feeding is a specialist decision after multidisciplinary assessment and failure of other interventions.

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.