Faltering Growth in Children Care Pathway Overview

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The growth of an infant falls below the 0.4th centile or crosses 2 centiles downwards on a growth chart or weight is 2 centiles below length centile. 

Red Flags
Possible child protection issue (see Safeguarding Children Section for further information and contact details)
Differential Diagnosis

Look for features of any medical disorder that might explain poor growth. Usually faltering growth is due to undernutrition without an underlying medical disorder. If signs or symptoms suggest an underlying problem (e.g. congenital heart disease or respiratory illness), refer to paediatrics. Consider a dipstick test for urinary tract infection and blood tests for coeliac disease if the diet includes gluten.

Offer reassurance and advise parents and carers that in well infants, effortless regurgitation of feeds:

  • Is very common (it affects at least 40% of infants).
  • Usually begins before the infant is 8 weeks old.
  • May be frequent (5% of those affected have 6 or more episodes each day).
  • Usually becomes less frequent with time (it resolves in 90% of affected infants before they are 1 year of age).
  • Treatment or further investigation is not normally required.

Review infant or child if:

  • Regurgitation becomes persistently projectile — admission is required.
  • There is bile-stained vomiting or haematemesis — admission is required.
  • There are new concerns, such as signs of marked distress, feeding difficulties, or faltering growth — suggests a diagnosis of gastro-oesophageal reflux
  • There is persistent, frequent regurgitation beyond the first year of life

See Cow’s Milk Protein Allergy pathway

See GORD pathway

See Lactose Intolerance pathway
Initial Assessment
  • The height/length of an infant are measured to properly interpret changes in weight using appropriate growth charts to be able to diagnose. 
  • Diagnosis is made when the growth of an infant falls below the 0.4th centile or crosses 2 centiles downwards on a growth chart or weight is 2 centiles below length centile.

Please see the Early Years – UK - WHO growth charts and resources.

Start by looking at the history of the pregnancy with regard to:

  • Smoking
  • Alcohol consumption
  • Use of medications
  • Any illness during the pregnancy

As a general rule, placental insufficiency will lead to a small-for-dates baby who emerges hungry and eager to feed.Catch up growth will usually be seen after birth.

  • Examine infant feeding:
    • With bottle-fed babies it is easy to see exactly how much is taken at each feed.
    • With breastfeeding this is obviously more challenging, however monitoring urine and stool output gives a good indication of how much milk has been ingested.
    • Breastfeeding should be assessed by a trained individual (e.g. health visitor with expertise or infant feeding specialist)
    • Note whether the child seems content with the feed, dissatisfied and craving more or uninterested.
  • Ask about the frequency of wet nappies and dirty nappies. At least 6 heavy wet nappies after 5-6 days of age indicates a sufficient milk intake.
  • Ask about the nature of the stool:
    • At least 2 soft yellow stools (£2 coin size minimal) in a baby over 4-5 days old indicates a sufficient intake of breastmilk. Stools may become less frequent after 4-6 weeks, a baby will develop their own pattern and providing the stool is soft and yellow the baby is not constipated
    • Chronic diarrhoea will result in failure to gain weight.
  • Ask about illness in the child.
  • Observe how the mother interacts with the child - note whether she is caring and concerned or cold and distant.
  • Note whether there is any indication of developmental delay (such as delay in walking or delay in talking).

Look at the baby in respect of the following questions:

  • Does this look a healthy, lively and active child?
  • Are there any features suggestive of a syndrome such as Down's syndrome or Turner syndrome?
  • Does the child look well-nourished or starved?
  • Are there any other obvious features such as:
    • Cyanosis?
    • Tachypnoea?
    • Jaundice?
  •  When picked up, does muscular tone feel normal and does the baby respond as if used to affection?
  • Is the child alert and responsive?

Plot height, weight and head circumference on a chart. If possible, plot earlier readings too, as trends or falling through the centiles are much more important than isolated readings.

Note pulse rate and respiratory rate.

Other physical signs may include:

  • Oedema
  • Hepatomegaly
  • Rash or skin changes
  • Hair colour and texture abnormalities
  • Signs of vitamin deficiency
Initial Primary Care Management

Breast fed baby:

Breastfeeding is recognised as best for baby, and the benefits of breastfeeding extend well beyond basic nutrition. Health professionals should encourage breastfeeding and ensure that support is given if needed.

If any difficulties with breastfeeding, refer to the midwife or health visitor for expert advice and support.

If baby is less than 28 days old with exceptional or ongoing feeding problems contact the Specialist Infant Feeding Midwife on 07799341200 (please do not give this number to the patient).

Unresolved feeding concerns for babies more than 28 days old can be discussed with the Health Visiting Infant Feeding Lead on 07798534298 (please do not give this number to the patient).

Please also see Countywide Infant Feeding Pathway.

When to Refer

Well infants with faltering growth should be referred for support and advice from their health visitor initially.If advice and support in the community does not lead to improved growth, consider referral to secondary care (paediatric services).

Unwell children should be referred to paediatric services.

If concerns are urgent contact Paediatric Consultant Advice Line on 0300 4225800.

Alternatively refer to Paediatrics or contact the Paediatricians via Advice and Guidance.

Ongoing Care

The team to whom the infant is referred should indicate who is responsible for review and discontinuation. If the team hand responsibility back to the GP this should be with an indication of what the goal is at which point discontinuation can occur.

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