Faltering Growth (Failure to Thrive)

NICE guideline [NG75] NICE guideline Faltering growth: recognition and management of faltering growth in children. Published: Sep 2017.

Article Last Updated:20/09/2026

Faltering Growth (Failure to Thrive)

Definition and Thresholds

Faltering growth, traditionally referred to as failure to thrive, describes a slower rate of weight gain than expected for a child’s age and sex. ^{[NICE NG75]}

Features suggesting faltering growth:

Poor weight gain (often indicated by dropping centiles)
+/- Actual weight loss

Expected weight changes depend on the neonatal period: ^{[NICE NG75]}

Period	What is expected?	Threshold for concern
Early days after birth	Some weight loss (<10%) is normal but usually stops by day 3-4 See rationale here	>10% loss of birth weight, OR Birth weight not regained by 3 weeks
After early days of life	Healthy neonates, infants, and children should track along a relatively consistent growth centile	Current weight <2nd centile Threshold by centile drops (based on birth weight centile): 2 centile drop (if birth 9th-91st centile) 1 centile drop (if birth <9th centile) 3 centile drop (if birth >91st centile)

Period

What is expected?

Threshold for concern

Early days after birth

Some weight loss (<10%) is normal but usually stops by day 3-4

See rationale here

>10% loss of birth weight, OR
Birth weight not regained by 3 weeks

After early days of life

Healthy neonates, infants, and children should track along a relatively consistent growth centile

Current weight <2nd centile

Threshold by centile drops (based on birth weight centile):

2 centile drop (if birth 9th-91st centile)
1 centile drop (if birth <9th centile)
3 centile drop (if birth >91st centile)

Causes

^{[NICE NG75]}

Category	Examples / causes
Inadequate intake	Ineffective breast or bottle feeding Feeding aversion Inappropriate feeding routines Inappropriate food choices
Physical disorders affecting feeding	Swallowing difficulties Cleft palate Significant reflux Neurological disorders causing oromotor dysfunction
Systemic medical conditions	Cystic fibrosis Coeliac disease

Associated factors include: ^{[NICE NG75]}

Preterm birth
Neurodevelopmental concerns
Maternal postnatal depression or anxiety

Growth Monitoring

^[DHSC]

Parameter	Measurement standards	Routine timing
Weight	From birth to 2 y/o → weigh naked (with no nappy) >2 y/o → weigh in a vest + underwear	Birth First week 8, 12 and 16 weeks in line with immunisation schedules 12-month and 2-to-2-and-a-half-year health and development reviews
Length or height	From birth to 2 y/o → measure length From 2 y/o onwards → measure height	Birth Clinically indicated or whenever there are concerns about growth, weight gain or general health
Head circumference		Birth 6-8 week health and development review Any point where concern arises

Plot the growth parameters on a UK-WHO growth chart

Growth monitoring in infants born prematurely (<37 weeks of gestation)

Growth parameters must be plotted using corrected age (rather than chronological age) ^[RCPCH]

Corrected age: 40 weeks minus gestational age at birth
Corrected age should be used until:
- 1 year, if born 32-36 weeks of gestation (moderate to late preterm)
- 2 years, if born <32 weeks of gestation (very preterm)

Assessment and Investigation

Clinical Assessments

Perform the following: ^{[NICE NG75]}

Clinical, developmental and social assessment
Feeding and eating history
Assess growth monitoring (see section above)

Consider the following: ^{[NICE NG75]}

Direct observation of breastfeeding, bottle feeding or mealtimes (ideally by someone with appropriate feeding expertise)
Food diary (asking parents / carers to record types and amounts of food consumed + mealtime issues / behaviour)

Investigations

Consider investigating for: ^{[NICE NG75]}

Urinary tract infection
Coeliac disease – if the child has consumed gluten-containing foods

Only perform further investigations if there are clinical indications

If a child with faltering growth is otherwise well, do NOT routinely perform extensive investigations. ^{[NICE NG75]}

Investigations beyond those clinically indicated are unlikely to identify an underlying disorder if there are no other clinical concerns. ^{[NICE NG75]}

Management

Referral Criteria

Refer to (or discuss with) paediatric specialist, if an infant or child with faltering growth has ANY of the following: ^{[NICE NG75]}

Signs or symptoms that may indicate an underlying disorder
Failure to respond to primary care interventions (step 1 and 2 interventions below)
Slow linear growth or unexplained short stature
Rapid weight loss or severe undernutrition
Features that cause safeguarding concerns

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 (e.g. plan to begin enteral feeding) ^{[NICE NG75]}

Interventions for Faltering Growth

^{[NICE NG75]}

Step	Management
Step 1 = optimise feeding and dietary intake	Address feeding difficulties and provide feeding support where needed (e.g. breastfeeding/suckling technique, bottle-feeding technique, feeding routines) Encourage relaxed, non-coercive mealtimes and regular eating routines (e.g. 3 meals + 2 snacks/day in young children) Advise on developmentally appropriate foods and optimise energy and nutrient density If further enrichment is needed, consider short-term food fortification +/- paediatric dietitian referral For breastfed infants requiring formula supplementation, support continued breastfeeding, encourage expressing, and give available breast milk before formula Avoid excessive energy-dense drinks, including milk, because they may reduce appetite for food
Step 2 = oral nutritional supplementation	Consider a trial of an oral liquid nutritional supplement (if faltering growth despite step 1) Regularly reassess whether it is still required
Step 3 = enteral feeding	Only consider if there are serious concerns about weight gain + other interventions have failed to improve growth, after specialist MDT assessment

Step

Management

Step 1 = optimise feeding and dietary intake

Address feeding difficulties and provide feeding support where needed (e.g. breastfeeding/suckling technique, bottle-feeding technique, feeding routines)
Encourage relaxed, non-coercive mealtimes and regular eating routines (e.g. 3 meals + 2 snacks/day in young children)
Advise on developmentally appropriate foods and optimise energy and nutrient density

If further enrichment is needed, consider short-term food fortification +/- paediatric dietitian referral

For breastfed infants requiring formula supplementation, support continued breastfeeding, encourage expressing, and give available breast milk before formula

Avoid excessive energy-dense drinks, including milk, because they may reduce appetite for food

Step 2 = oral nutritional supplementation

Consider a trial of an oral liquid nutritional supplement (if faltering growth despite step 1)

Regularly reassess whether it is still required

Step 3 = enteral feeding

Only consider if there are serious concerns about weight gain + other interventions have failed to improve growth, after specialist MDT assessment

References

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Faltering Growth (Failure to Thrive)

Faltering Growth (Failure to Thrive)

Definition and Thresholds

Causes

Growth Monitoring

Assessment and Investigation

Clinical Assessments

Investigations

Management

Referral Criteria

Interventions for Faltering Growth

References

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