Faltering growth: recognition and management of faltering growth in children

1.2.1 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):

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

1.2.3 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.

1.2.4 If there is concern about faltering growth or linear growth in a child over 2 years of age, determine the BMI centile:

1.2.5 Record all growth measurements in the parent- or carer-held Personal Child Health Record.

1.2.6 If there is concern about faltering growth:

1.2.7 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.

1.2.8 Be aware that the following factors may be associated with faltering growth:

1.2.9 Recognise that in faltering growth:

1.2.10 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:

1.2.11 Based on the feeding history and any direct observation of mealtimes, consider whether any of the following are contributing to faltering growth:

1.2.12 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.

1.2.13 Be aware that investigations (other than those recommended in recommendation 1.2.6) are unlikely to reveal an underlying disorder in a child with faltering growth who appears well with no other clinical concerns.

1.2.14 If a child with faltering growth develops new clinical symptoms or signs after the initial assessment, reconsider whether investigations are needed.

1.2.15 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:

1.2.16 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.

1.2.17 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.

1.2.18 If supplementation with an infant formula is given to a breastfed infant because of concern about faltering growth after the early days of life:

1.2.19 When there are concerns about faltering growth, discuss the following, as individually appropriate, with the infant's or child's parents or carers:

1.2.20 If necessary, based on the assessment, advise on food choices for infants and children that:

1.2.21 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:

1.2.22 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.

1.2.23 Consider a trial of an oral liquid nutritional supplement for infants or children with continuing faltering growth despite other interventions (see recommendations 1.2.16 to 1.2.22).

1.2.24 Regularly reassess infants and children receiving an oral nutritional supplement for faltering growth to decide if it should be continued. Take into account:

1.2.25 Only consider enteral tube feeding for infants and children with faltering growth when:

1.2.26 If enteral tube feeding is to be used in an infant or child with faltering growth, make a plan with appropriate multidisciplinary involvement for:

1.2.27 If there are concerns about faltering growth (see recommendation 1.2.1), measure the weight at appropriate intervals taking account of factors such as age and the level of concern, but usually no more often than:

1.2.28 Monitor weight if there are concerns about faltering growth (see recommendation 1.2.1), but be aware that weighing children more frequently than is needed (see recommendation 1.2.27) may add to parental anxiety (for example, minor short-term changes may cause unnecessary concern).

1.2.29 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 (see recommendation 1.2.27).

1.2.30 If there are concerns about faltering growth monitor length or height at intervals, but no more often than every 3 months.

1.2.31 If an infant or child with faltering growth has any of the following discuss with, or refer to, an appropriate paediatric specialist care service:

1.2.32 Do not admit infants or children with faltering growth to hospital unless they are acutely unwell or there is a specific indication requiring inpatient care, such as a plan to begin tube feeding (see recommendation 1.2.25).