by Dr Samantha Ross, General Practitioner and GPwSI in Preschool Growth and Nutrition
Weight Faltering describes a pattern of growth and can be defined as a sustained drop in 2 centile spaces over 2 weighing intervals on the WHO growth chart. Other definitions of failure to thrive exist and encompass the concept of suboptimal growth.
Weight faltering is multifactorial and aspects such as maternal depression, feeding difficulties, behavioural issues and the complex interplay of factors affecting input and output (which include illness, economic factors and other issues) should be considered when evaluating cases.
Previous evidence suggested the vast majority of cases are due to undernutrition, with a minority due to organic causes. Weight faltering is more prevalent in the safeguarding population as a whole1. Interestingly, weight faltering is seen in all socio-economic groups.
Accurate measurements of weight, length and occipitofrontal circumference (OFC- ‘head circumference’) measurements should be plotted on the correct growth chart. A detailed feeding, medical and social history are helpful in determining causes. It is common for infants to track a growth centile, but GPs should also be aware that moderate movement up and down a growth chart are common. However, recent data has shown that after the first four months as few as 0.5% children will cross two centile spaces2. Additionally, only 0.5% UK children will be below the 2nd centile at 12 months3.
The WHO growth charts were compiled from data on breast fed infants in 5 countries and reflect growth patterns in this population. Based on these charts, only 0.5% of infants weight falter, so this should help to demonstrate normality in breastfed infants and avoid unnecessary supplementation in these infants in particular. In those cases where weight faltering is apparent, assessment should ensure the exclusion of underlying contributory factors.
All those under the 0.4th centile should be assessed by an appropriate person (usually a paediatrician).
Weight faltering due to undernutrition and feeding issues responds well to timely management. In many cases, this can be managed in the community rather than in secondary care. It is important for GPs (in conjunction with colleagues) to be able to establish and distinguish normal feeding behaviour and differentiate cases needing further review early. In a small number of cases long term growth and cognition can be affected. For further information, please refer to NICE Guideline NG75:
For breastfed infants with weight faltering, referral for a breastfeeding assessment to a speciality service to assist with techniques to optimise feeding is vital. Supplementary feeds may be necessary alongside techniques to improve feeding and milk supply (see our pages on ‘Expressed Breastmilk Feeding‘ and ‘Infant Milks and Bottle Feeding‘ for more information on supplementation).
It is important to assess every baby and child holistically within the context of their family and environment and be aware of safeguarding (child protection) and vulnerability concerns. Sharing information with child protection teams and social services where you have concerns in a timely manner is important. All GPs have a responsibility to ensure they remain up to date and maintain competencies in safeguarding and child protection. Local training should be available, and GPs should refer to local guidance when considering any child where there may be concerns.
RCPCH: UK-WHO Growth Charts – Guidance for Health Professionals Information to support measuring and plotting growth, including videos. Also includes links to downloads for plotting newborns and preterm infants.
RCPCH: Information on the Personal Child Health Record The ‘Red Book’
Unicef Baby Friendly Initiative: Breastfeeding Assessment Tool for Health Visitors Useful tool for assessing breastfeeding efficacy in the early weeks.
- Wright C, Birks E. Risk factors for failure to thrive: a population-based survey. Child: Care, Health and Development, 2000;26:5–16.
- Wright C, Lakshman R, Emmett P, Ong K. Implications of adopting the WHO 2006 Child Growth Standard in the UK: two prospective cohort studies. Archives of Disease in Childhood. 2008;93:566-569
- Wright C, Garcia A. Child under-nutrition in affluent societies: what are we talking about? Proceedings of the Nutrition Society. 2012;71(4):545-555
See also the Clinical Review:
Shields B, Wacogne I, Wright C. Weight faltering and failure to thrive in infancy and early childhood. BMJ. 2012;345(25)e5931-e593931
Published April 2017, Updated October 16th 2019