|

Faltering Growth (Failure to Thrive): History Taking and Assessment

Last updated:

Overview

Also known as failure to thrive or undernutrition, faltering growth describes a lower weight, or rate of weight gain that is expected for a child’s age and sex. It suggests that the child is not receiving enough nutrition or has an underlying disease (such as malabsorption or increased caloric demand due to illness.

In the early days of life, up to 10% weight loss is normal. However, if an infant loses more than 10% of weight or does not return to birth weight after 3 weeks, this can suggest faltering growth.

Growth in children is monitored on growth charts which plot a child’s height, weight, and head circumference against what is expected for their age and sex. More detail on this can be found here.

Suspecting Faltering Growth

Overview

During the first few days of life, faltering growth is considered to occur if any of the following apply:

  • Weight loss >10% of birth weight
  • Weight does not return to birth weight by 3 weeks of age

After the first few days of life, faltering growth is considered to occur if any of the following apply:

  • Weight falls ≥1 centiles and birthweight was <9th centile
  • Weight falls ≥2 centiles and birthweight was between 9-91st centiles
  • Weight falls ≥3 centiles and birthweight was >91st centile
  • Current weight is <2nd centile, regardless of birthweight

For children >2 years old:

  • <2nd centile suggests undernutrition or a small build
  • <0.4th centile suggests likely undernutrition

All growth measurements should be recorded in the parent/carer’s Personal Child Health Record (‘red book’).

History Taking

Overview

With each symptom, always (if relevant) ask about:

  • When did it start?
  • Did it come on suddenly or gradually?
  • Is it continuous or intermittent?
  • Has this ever happened before?

Paediatric systems review

Briefly screen for the following, and adjust where appropriate:

  • Screening for general features:
    • Fever, chills, rigours, sweating
    • Crying – is it consolable or inconsolable?
    • Growth, weight loss 
    • Behaviour, appetite, alertness, activity, sleeping
  • Screening for cardiorespiratory features:
  • Screening for gastrointestinal features:
    • Vomiting, diarrhoea, constipation, stool character (e.g. mucus, blood, melaena etc.)
    • Abdominal pain, abdominal distension
  • Screening for genitourinary features:
    • Urine output and hydration – number of wet nappies, number of times using the toilet
    • Dysuria, frequency, urgency, enuresis, loin pain
    • Haematuria
    • Scrotal swelling
  • Screening for neurological features:
    • Headaches, neck stiffness, photophobia
    • Level of consciousness
    • Seizures, fits, falls, or ‘funny turns’
    • Changes in gait, abnormal movements
    • Vision changes, hearing changes
    • Hypotonia (floppiness), hypertonia (stiffness, spasticity)
  • Screening for ear, nose, and throat features:
    • Ear: pain, discharge, hearing changes
    • Nose: epistaxis, discharge, congestion
    • Throat, mouth, and neck: sore throat, neck swelling, limited neck movement, mouth ulcers
  • Screening for haematological features:
  • Screening for skin features:
    • Rash, itching, crusting, oozing, changes in skin pigmentation
  • Screening for musculoskeletal features:

Birth

  • How was the pregnancy?
    • Any abnormal scan results or extra scans? Why?
    • Any problems? – including maternal illness, diabetes, alcohol, drinking, drug use
  • What happened during birth?
    • Number of weeks gestation?
    • Weight at birth?
    • Birth location? – such as in hospital, at home?
    • Mode of delivery? – vaginal delivery, caesarean section?
    • Any complications to both the mother or child during or after birth?
    • Did they need to stay in hospital for longer/was there any admission to neonatal intensive care?

Feeding and toileting

  • Ask about diet and appetite:
    • What is their diet and appetite usually like and what is it like now?
    • Breastfed or formula milk?
    • When and how did weaning start?
  • Ask about toileting:
    • Are they toilet trained?
    • How often do they go to the toilet/how many wet nappies?
  • What are their mealtime routines like?

Growth

  • How is their weight?
    • Are they gaining weight, staying the same, or struggling to gain weight?
    • Do they have their personal child health record (PCHR, the ‘red book’)
  • Have they started puberty?
    • Usually 8-13 for girls, 9-14 for boys 

Development

  • Is the child meeting developmental milestones?
  • Are there any concerns with development?
  • How is school/nursery progress and attendance?
  • Perform a developmental assessment if necessary

Immunisations

  • Are they up to date with their immunisations?

General past medical history

  • Do they have any other medical conditions?
  • Have they ever had any previous surgery?
  • Do they take any regular medications?
  • Do they take any over-the-counter medications, herbal remedies, or supplements?

Family history

  • Is there any family history of anything similar?
  • In some autosomal recessive inherited diseases, consanguinity may be possible, ask about this sensitively if necessary

Allergy history

  • Are they allergic to anything?
    • What happens during the allergic reaction?

Social history

  • Ask about their home situation:
    • Who’s at home?
      • Ask about parents/carers, siblings, and other people at home
    • What support does the child and parent/carer have?
    • What is their housing situation? – e.g. cramped housing
    • What are the parent’s occupations?
    • How is the parents’/carers’ mental health?
  • Ask about the child’s activities including school and nursery:
    • Does the child go to school/nursery?
    • Has the child had to stay home from school/nursery?
  • Ask about smoking, drinking, and illicit drug use sensitively:
    • Does anyone smoke inside or outside of the house?
    • Does anyone drink alcohol inside the house?
      • If relevant, does the young person drink alcohol?
    • Does anyone at home use illicit drugs?
      • If relevant, does the young person use illicit drugs?
  • Ask questions regarding safeguarding:
    • Are they known to social services?
    • Are there any safeguarding concerns?
    • You may need to separately ask the child about safeguarding concerns including:
      • Are they at risk of harm?
      • Are they being made to do things they don’t want to do?
  • Ask about possible infectious contacts:
    • Is anyone else at home ill?
    • Has anyone in school/nursery been ill?
    • Has there been any recent foreign travel?

Physical Examinations

Overview

  • Plot and check growth charts
  • Check vital signs (temperature, heart rate, capillary refill time, and respiratory rate)
  • Perform a general examination looking for:
    • Features of dehydration:
      • Such as tachycardia, hypotension, reduced skin turgor, sunken eyes/fontanelles, cold peripheries
    • Dysmorphic features:
    • Features of nutritional deficiencies:
      • Such as pallor and anaemia, bone pain or lower limb abnormalities in rickets, hair changes
    • Changes in mental status:
      • Such as lethargy, fatigue, listless, difficult to rouse
    • Features of congenital heart disease:
      • Such as murmurs, cyanosis, clubbing, syncope, oedema 
    • Muscle wasting and cachexia:
      • May be due to undernutrition itself or underlying malignancy/systemic disorders
    • Jaundice:
    • Features of Child Maltreatment:
      • Such as poor hygiene, unexplained injuries, severe nappy rash due to unchanged nappies

Other examinations may need to be performed depending on the suspected underlying cause.

Investigations

Overview

investigations are guided by clinical presentation and if needed, are generally carried out in secondary care. Some non-invasive routine tests may be appropriate in primary care and can include:

Differential Diagnoses

Overview

There is a wide range of causes for faltering growth and more than one may be present. Some of the causes of faltering growth can include:

  • Inadequate nutrient intake:
    • Lack of healthy food availability
    • Child maltreatment
    • Feeding difficulties or problems with breastfeeding/bottle feeding (e.g. cleft lip and palate, poor appetite, problems with weaning)
    • Developmental delay
    • Eating disorders
    • Lack of understanding of age-appropriate food and feeding
  • Inadequate absorption of nutrients:
    • Persistent vomiting due to:
      • Gastro-oesophageal reflux
      • Gastrointestinal tract obstruction
      • Infection
      • Neuromuscular disorders
    • Malabsorption due to:
  • Excessive calorie expenditure and poor metabolism:

Small but healthy

5% of children fall below the 5th centile on growth charts. If their growth has a constant trajectory and a thorough assessment finds no concerning features, a child may be small but healthy. This may be due to the parents being small or infants with a constitutional delay in growth.

Management

In the first few days after birth (birth – 1 month)

In all cases, discuss with other healthcare professions involved in care (e.g. midwives/health visitors) and identify and discuss parent/carer concerns.

If weight loss is <10% of birth weight and assessment normal:

  • Reassure parent/carer – weight loss usually stops at 3-4 days and most infants return to birth weight by 3 weeks of age
  • Ensure parent/carer has adequate support (e.g. from midwives/healthcare visitors)
  • Arrange follow-up and monitor growth – no more than daily if the infant is <1 month old

If weight loss >10% or the infant has not returned to birth weight by 3 weeks old:

  • Discuss with/refer to paediatrics with urgency depending on the clinical situation if any of the following apply:
    • Signs/symptoms suggesting acute/chronic underlying disorder
    • Rapid weight loss/severe undernutrition
    • Safeguarding concerns and suspected child maltreatment
    • Slow linear growth/unexplained short stature
    • No response to management in primary care
    • If new signs/symptoms develop or any of the above occur after initial assessment
  • Ensure parents/carers have adequate support (e.g. from midwives/healthcare visitors)
  • Arrange follow-up and monitor growth – no more than daily if the infant is <1 month old

After the first few days of birth (1 month – 18 years)

Discuss with/refer to paediatrics if:

  • Suspected child maltreatment or safeguarding concerns
    • Signs/symptoms suggesting acute/chronic underlying disorder
    • Rapid weight loss/severe undernutrition
    • Slow linear growth/unexplained short stature
    • No response to management in primary care
    • If new signs/symptoms develop or any of the above occur after initial assessment

If referral is not needed, management in primary care may include:

  • Considering factors including mealtime arrangements, age-appropriate foods, food aversion/avoidance, parent-child interactions, appetite
  • Considering feeding support for milk-fed infants and those who are weaning
  • Managing breastfeeding problems
  • Considering referring to a dietician/psychologist/speech and language therapist/social services etc. depending on the clinical situation
  • Arranging follow-ups at regular intervals, using growth charts to monitor weight

Patient Advice

If a referral is not indicated and there are no features of a concerning underlying diagnosis, the following advice may be helpful for parents/carers:

  • Make sure mealtimes are relaxed/enjoyable and not brief or too long (20-30 minutes)
  • Encourage regular meal routine and eating together as a family or with other children
  • Encourage children to feed themselves and allow them to be ‘messy’ with food
  • Serve food that is appropriate to the child’s developmental stage (e.g. texture, type, and quantity)
  • Set appropriate boundaries for mealtime behaviour while avoiding punishing behaviours/coercive feeding
  • Avoiding too many energy-dense drinks (e.g. milk) as this can reduce a child’s appetite

Prognosis

  • In children without an underlying disorder, with interventions such as dietary advice, recovery in weight usually starts within 4-8 weeks and may take several months
  • If an underlying condition is present, the prognosis depends on the nature of the underlying condition and its treatment

Author