24
Lisa Cooke and Julie Lanigan
Faltering Weight
Introduction
Growth monitoring is the cornerstone of paediatric care.
Faltering weight may be a marker of undernutrition or
­disease, and early recognition allows prompt intervention
to  protect short‐ and long‐term health. Therefore, regular
monitoring is advised throughout infancy and early
­childhood [1].
Definitions
Failure to thrive (FTT) is an outdated term previously used
to describe infants and young children who failed to reach
their expected growth [2]. This definition is still used by
some clinicians and researchers. However, ‘faltering growth’
or ‘faltering weight’ is now the most widely accepted defini-
tion for infants and children with inadequate weight gain.
Growth assessment
Growth charts are used to compare measurements in chil-
dren of the same age and sex. It is recommended that inter-
national growth standards are used, which are based on
infants and children growing under optimal conditions in a
range of settings, i.e. the WHO Child Growth Standards [3].
The UK‐WHO 0–4 years growth charts combine data from
the WHO standards with UK term and preterm data. The
UK 2–18 years growth charts combine data from the UK 1990
growth reference for 4–18 years with the WHO standards for
2–4 years [4]. Growth is monitored according to progression
along centiles [1, 3]. The growth of healthy infants and chil-
dren will normally follow an established centile from about
2 weeks of age. However, small deviations are common and
not always a cause for concern [5].
Clinical Paediatric Dietetics, Fifth Edition. Edited by Vanessa Shaw.
© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/shaw/paediatricdietetics-5e
Defining faltering weight
In infancy and early childhood, faltering weight is identi-
fied by downward centile crossing. The degree of centile
crossing that would lead to concern depends on birthweight
(Table 24.1).
Weight below the 2nd centile on the UK‐WHO 0–4 years
and UK 2–18 years growth charts indicates faltering regard-
less of birthweight. Infants and children exhibiting the growth
patterning described in Table 24.1 are at risk of growth falter-
ing, and regular monitoring is recommended [6].
Further measurements
Where there is concern about growth faltering, weight
should be measured and plotted on the relevant growth
chart. Previous measurements should also be plotted to
allow a longitudinal assessment of growth. In addition,
length (in infants and children under 2 years of age) and
height (in older children) should be measured. Where there
are concerns regarding a child’s length or height, parents’
height should be measured, and the mid‐parental height
centile (MPC) calculated. If the child’s length or height is
more than two centile spaces below the MPC, this could
suggest undernutrition or a growth disorder [7]. Head cir-
cumference is also a useful indicator of growth in the first
2 years of life.
Mid‐upper arm circumference (MUAC) is a useful anthro-
pometric measure of nutritional status that can be done sim-
ply with minimal equipment. Data show that in a
well‐nourished population, there are very few children aged
6–60 months with a MUAC less than 115 mm. Those with a
MUAC less than 115 mm have a highly elevated risk of death
compared with those who are above this cut‐off [3].

Table 24.1  Centile crossing relative to birthweight.
Birthweight centile Fall across weight centiles causing concern
<9th centile One or more centile spaces*
9th–91st centile Two or more centile spaces
>91st centile Three or more centile spaces
*A centile space is the distance between two adjacent centile lines.
Growth charts are the most reliable tools for identifying
faltering weight. However, the following features are com-
monly reported in association with weight faltering:
• muscle wasting, poor skinfold thickness
• thin, wispy hair
• visible or prominent bones (e.g. pointed chin in a baby)
• pale complexion (could suggest iron deficiency)
• poor sleep pattern
• developmental delay (particularly in communication skills)
• emotional and behavioural issues (ranging from with-
drawn/passive to active/chaotic with poor concentration)
Research has shown that health professionals do not
always recognise faltering weight. Batchelor and Kerslake
found that one in three children whose weight had fallen
substantially were not identified [8]. There were various rea-
sons for non‐recognition: lack of awareness of the problem,
well‐cared‐for children with no signs of physical neglect, no
reported feeding difficulties, acceptance of children as small
and underuse of growth charts.
The prevalence of faltering weight varies between and
within populations and is influenced by socio‐economic fac-
tors. For example, 5% of infants living in deprived inner city
areas are affected, but it occurs across a wide social range [9].
Causes
Historically, the focus has been on differentiating faltering
in weight as ‘organic’ (resulting from an underlying medi-
cal condition) or ‘non‐organic’ (related to unknown psycho-
social factors). It is now clear that only 5% of cases of
faltering weight have an underlying medical problem. The
two categories are not mutually exclusive, and undernutri-
tion is recognised as the primary cause of poor weight gain
in infancy [10].
During infancy and early childhood, relative energy and
nutrient requirements are high to support rapid growth.
Infants and young children are at risk of nutritional deficien-
cies due to feeding difficulties and, in a minority of cases,
food insecurity. For some children, medical conditions may
be the underlying cause of growth faltering (Table 24.2) [11].
Despite an apparently adequate intake, gastrointestinal
disorders may lead to faltering weight because of malabsorp-
tion, e.g. coeliac disease. Children with congenital cardiac or
respiratory defects may show poor growth due to breathing
problems, anorexia or increased energy requirements caused
by their disease.
Causes 465
Table 24.2  Factors contributing to faltering weight.
• Inability to digest or absorb nutrients
⚬⚬ Coeliac disease
⚬⚬ Cystic fibrosis
• Excessive loss of nutrients
⚬⚬ Vomiting
⚬⚬ Chronic diarrhoea
⚬⚬ Protein‐losing enteropathy
• Increased nutrient requirements due to underlying disease
⚬⚬ Chronic cardiac or respiratory failure
⚬⚬ Chronic infection
• Inability to fully utilise nutrients
⚬⚬ Metabolic disease
• Reduced intake of nutrients
⚬⚬ Functional problems
⚬⚬ Suck–swallow incoordination
⚬⚬ Oral hypersensitivity
Table 24.3  Factors contributing to inadequate intake.
• Delayed/problematic progression of solids
• Early feeding difficulties, e.g. tube feeding, gastro‐oesophageal reflux
• Poor appetite following illness or dental problems
• Parental attitudes to food and feeding, including cultural practices
• Behavioural difficulties, e.g. coercive feeding
• Limited or rigid parenting skills
• Parental ill health, e.g. maternal depression
• Family characteristics, e.g. chaotic household and lack of routine,
poor facilities, neglect
Children with neurological dysfunction may have prob-
lems with oromotor development, which can affect the abil-
ity to suck and swallow. They may also suffer from oral
hypersensitivity and therefore refuse to feed. Children with
metabolic disorders can present with faltering weight as a
result of poor feeding or inability to utilise energy correctly.
Faltering weight is common in infants born prematurely;
their special nutritional needs and oromotor problems are
reviewed separately (p. 96).
For children with poor weight gain and no apparent medi-
cal problem, inadequate energy intake is the underlying
cause. Many factors contribute to inadequate intake as dis-
cussed below (Table 24.3).
Early feeding problems
For many infants, growth begins to falter around the time of
complementary feeding. During complementary feeding the
diet is expanded to include a wider range of foods aiming to
establish a diet that meets nutritional requirements. As the
infant’s oromotor skills develop, this allows the introduction
of new foods with a wider range of tastes and textures.
Complementary feeding is a time when infants become
accustomed to new foods. If this period of acceptance of new
foods, in particular those with more ‘lumpy’ textures and
bitter tastes, is interrupted, progression through the intro-
duction of solid foods can be difficult and may compromise
the nutritional adequacy of the diet. Overdependence on
466 Faltering Weight

cow’s milk and fruit juice is common in infants and toddlers.
This may restrict intake of solid foods, leading to insufficient
energy intake to support normal growth [12, 13].
As complementary feeding progresses, infants show
increasing independence and a desire to self‐feed. It is
important that infants are given opportunities to develop
self‐feeding skills.
Infants and young children with faltering weight are
reported to experience more feeding problems compared
with those growing normally [14]. In a case–control study,
infants with faltering growth were introduced to solids and
finger foods later than a control group and were described as
variable eaters with low appetite and poor feeding skills.
While causality could not be defined from this observational
study, findings suggest that feeding difficulties may increase
the likelihood of faltering weight [15].
Faltering growth is often accompanied by chronic feeding
difficulties [14]. For example, one study found that children
with faltering weight also had severe feeding difficulties,
according to parental reports. Parents described stressful
mealtimes, children crying, clamping their lips, turning away,
pushing food away, spitting out food and being sick [16].
Behavioural feeding problems, including food refusal,
can present at an early age, and there are many contributing
factors [17]. One of the earliest forms of infant communica-
tion occurs during feeding, with the caregiver and infant
responding and reacting to each other. When interactions
are appropriate, feeding is termed responsive. However,
parental feeding interactions may be affected by worry, anx-
iety or concern about a child’s intake and will influence how
a child reacts to food. Feeding cues relayed by the child, e.g.
signalling discomfort, might not be appropriately inter-
preted by the caregiver. For young infants with gastro‐
oesophageal reflux, food might well be associated with
vomiting and pain. Feeding can then be an unpleasant expe-
rience, leading to food refusal. There are many reasons for
food refusal including extreme temperatures of food, inap-
propriately sized pieces, insensitive feeding or reluctance of
parents to allow the child to feed themselves fearing an
inevitable ‘mess’. If the child has dental caries, then pain
may be a factor. Feeding problems can cause severe distress
and disruption to family life and if unchecked can lead to
persistent weight faltering.
Family and maternal influences
Some studies have focused on psychosocial characteristics of
the family and the environment of the child with faltering
weight. Parents’ inability to provide emotional nurturing
may well contribute to the problem. Family conflict before
the age of 7 years has been shown to have a strong and sig-
nificant association with slow growth [18].
Maternal attitudes towards food and feeding have been
shown to have an influence on the eating habits of children.
McCann et  al. reported that mothers of children whose
weight faltered showed greater dietary restraint, both con-
cerning what they ate themselves and what they were
prepared to offer their children [19]. In another study, infants
of mothers who were both depressed and deprived showed
poorer weight gain [20].
Poverty
Poverty is not a factor in isolation, and there is little evi-
dence to suggest an increased risk of faltering weight in the
poorest families [20]. However, it has been suggested that
children from larger families are at increased risk of weight
faltering [7].
Neglect and abuse
Two population studies found that between 5% and 10% of
children who had faltering weight were registered with
social services as having suffered abuse or neglect [15, 21]. It
is suggested that children in abusive or neglecting families
are at an increased risk of faltering weight, but these families
only represent a small proportion of all cases.
Outcomes for children with poor weight gain
Nutrition in the early years of life is a major determinant of
growth and development and influences future adult health
[22]. Evidence suggests that poor weight gain from birth to
6–8 weeks of life is a stronger predictor of developmental
delay than poor weight gain over the remainder of the first
year [23]. A meta‐analysis found that infants with early onset
faltering weight were likely to be shorter and thinner than
age‐matched peers. Evidence supporting adverse effects of
early faltering on later growth and intellectual development
was not strong. However, it was acknowledged that poor
growth could be an important marker and indicate the need
for intervention in children where there is neglect, a medical
condition, developmental problems or feeding issues [24].
Early home intervention has been reported as mitigating the
effects of faltering weight [25].
Assessment of faltering weight
Health visitors, with appropriate training, are ideally
placed to identify children with faltering weight when they
undertake routine child health checks. In the UK, babies are
weighed at birth, 8, 12 and 16 weeks, 1 year and at school
entry. If there is concern, they should be weighed more
often (p. 2).
A holistic assessment, preferably undertaken at home,
should evaluate a child’s intake, feeding behaviour and fam-
ily circumstances. The health visitor can provide a detailed
picture of family life, where it is not possible for this to be
completed by a dietitian. The paediatric dietitian can help to
clarify any dietary concerns and assess nutritional adequacy.
Should the child appear to have affected oromotor skills,
assessment by a speech and language therapist (SLT) may be
beneficial. If available, joint consultations with the SLT and

dietitian can not only save time but can also offer reassur-
ance and reduce anxiety for the family.
A multidisciplinary team approach has been advocated
where the medical and psychosocial aspects are combined
into a clear focus on food and feeding [26, 27]. A full paediat-
ric assessment can be undertaken including medical and
feeding history, dietary intake and psychosocial and devel-
opmental aspects. Potential members of a multidisciplinary
feeding team include:
• paediatrician
• paediatric dietitian
• specialist health visitor
• clinical psychologist
• nurse/nursery nurse
• SLT
Joint working enables discussion of individual cases and
close cooperation between families and professionals.
Clinical investigations only need to be undertaken if there are
any suggestions of symptoms in order to exclude organic dis-
ease and to reassure anxious parents. The feeding clinic‐style
approach is resource costly, although offers a really good
approach to managing ongoing difficulties. There are very
few of these services available, but when in place they offer a
‘one‐stop shop’ with opportunities for positive outcomes.
Dietary assessment
It is important to construct a complete picture of all aspects
of and influences on the child’s feeding. Early feeding his-
tory, together with the start and progression of solids, will
help to identify if there were problems in the first year of life.
Dietary recall with further information on the variety, tex-
tures and frequency of foods offered and eaten, mealtime
routines and drinks taken through the day will all help in the
assessment of the child’s current intake. It is important to
understand the family practices and dynamics around food
as these are important factors that may influence poor intake
in the child. Information on where food is purchased and its
preparation within the home will also help in understanding
which strategies will best fit the family and their lifestyle.
Discussion with the parent/caregiver will identify how long
mealtimes last and whether they are stressful. Gathering
background information will help to identify any difficulties
experienced by the family.
There is little research on the dietary intake of children
with faltering weight. One study raised the difficulties in
collecting dietary information and suggested that only a
minority of children with faltering weight will have dietary
histories that are obviously inadequate, but that wider rang-
ing nutritional assessment will be more revealing [28].
A food diary is a useful tool in supporting nutritional
assessments and can provide information on the quality of
diet and help identify dietary inadequacies [29]. Food dia-
ries that have been validated for use in children are availa-
ble from Nutritools and can be downloaded from their
website [30].
Assessment of Faltering Weight 467
Table 24.4  Poor feeding techniques.
• Infant fed with a bottle in a semi‐lying position
• Infant fed with a bottle while asleep (‘dream’ feeding)
• Anxious parent following the child around with food or forcefully
feeding a child
• Excessive cleaning of the child with every mouthful of solids
• Dummy (pacifier) or infant bottle available at any time
• Child discouraged from participating in feeding itself
• Child chastised with threats or punishment for not eating
Observing a child eating is useful to obtain more informa-
tion about:
• seating of the child and parent positioning
• child’s interest in its own food or food of other family
members
• quantity, texture and type of food offered and what is
eaten
• child’s desire or ability to feed or drink by themselves
• child’s oromotor function and self‐feeding skills
• interaction between the child and parent, including
parental response to child’s cues
• communication between the child and parent, e.g. verbal
encouragement
• atmosphere and emotions at mealtime
If there is a specialist team available, it is possible, with
parental agreement, to video mealtimes. This is difficult to
do unless home visits for appointments are possible.
However, most parents have smart phones and may be able
to bring short videos of their child feeding into clinic.
Observations of mealtimes can allow parents to see feeding
from a different perspective. For example, a parent who
viewed a feeding session made the following comment:
‘Well I’m not surprised she’s not eating. I didn’t realise I was
so forceful. If someone tried to feed me like that, I wouldn’t
eat either’. When parents are able to suggest changes and
contribute to the management plan, there is a greater chance
of success. A mealtime video helps the dietitian to support
the parents with positive adjustments to feeding. Feeding
observations can also highlight ineffective feeding of an
infant or young child (Table 24.4), allowing issues to be sen-
sitively raised with parents.
It is important to listen to parental concerns and their view
should be taken into account. It is also useful to know who
else is involved in the care and feeding of the child. For some
children, with parental agreement, it is useful to observe the
child’s behaviour around food in a setting other than the
home, e.g. nursery, children’s centre or school. This can help
identify differences in eating and feeding, adding further
valuable information to a supportive action plan for the
family.
Assessment of oromotor function
For a small number of children who may have neurodevel-
opmental problems or continue to exhibit food refusal and
faltering weight, it is important for a SLT to assess oromotor
468 Faltering Weight
function. Such assessments, often in conjunction with video-
fluoroscopy, will identify those who are unable to coordi-
nate their suck–swallow reflex. These children are likely to
aspirate feeds and may require nasogastric or gastrostomy
feeding. The SLT will also detect oral hypersensitivity and be
able to help with desensitisation programmes. In certain
areas, occupational therapists (OT) lead on oral desensitisa-
tion programmes. Joint appointments with the dietitian, SLT
and OT can help with children who have physical issues
with feeding, leading to faltering growth.
Nutritional management
Nutritional requirements
A dietary intake that provides energy and protein require-
ments for age [31, 32] will usually allow for maintenance of
growth along an established centile. Additional protein and
energy will be required to allow for rate of weight gain to
improve (catch‐up growth). Guidelines suggest that the per-
centage of energy supplied from protein should be between
8.9% and 11.5% to provide optimal improvement of lean and
fat mass [33].
A formula for predicting energy requirements to improve
weight gain in infants and young children has been sug-
gested [34]:
120 ideal weight for height kg
kcal kJ /kg
actual weight kg
This may mean an intake of 1.5–2.0 times, the normal rec-
ommended energy requirements for age. Experience and
judgement should be used when advising additional energy
density, making sure that fortification of the diet does not
displace other foods or is provided at the expense of essen-
tial nutrients. Therefore, close monitoring with regular
review is essential.
Anaemia is common in children with faltering weight,
and in one study one‐third of a sample had iron deficiency
anaemia [35]. Often young children who falter in growth are
high consumers of cow’s milk, which is low in dietary iron
and may inhibit iron absorption. Excessive intake is also
associated with gastrointestinal bleeding and iron depletion
in infants and young children. There is also evidence that
zinc deficiency affects growth [36]. Requirements for vita-
mins, minerals and trace elements are increased during peri-
ods of rapid growth, and a suitable supplement should be
included if the child’s intake is thought to be inadequate. No
guidelines exist, but intakes should be at least appropriate
for the proposed energy intake.
Achieving nutritional requirements
Following a detailed feeding assessment, a strategy for
catch‐up growth needs to be planned. The main nutritional
objectives are:
• to improve protein and energy intake
• to promote weight gain enabling catch‐up and allowing
optimum growth
• to correct nutritional deficiencies and achieve an ade-
quate nutritional intake
If a child is underweight for height and failing to gain
weight at the expected rate, whatever they are consuming is
not enough for their needs. Working in partnership with par-
ents and engaging them in any decisions on nutritional
intervention is crucial.
In a young breastfed infant where weight is faltering, the
maternal diet needs to be assessed, and its quantity and
quality improved. It is essential that observation of the
mother breastfeeding is carried out to make sure the infant is
latched on correctly. Additionally, an understanding of the
mother’s mental and general health and well‐being is needed
to identify factors that may affect faltering growth [37].
Supplementation of breastfeeds may be necessary, but this
should be done under dietetic supervision and with caution
as it may suppress production of breastmilk. The breastfeed-
ing mother will need lots of support around her. A study in
formula‐fed infants found greater benefits from using a
ready‐to‐feed nutrient‐dense formula (Table 1.18) compared
with adding energy supplements to standard infant formula
[38]. Full‐strength high energy formula has been shown to be
tolerated well by infants under the age of 12 months with
faltering weight, but some may benefit from a gradual intro-
duction to avoid increased bowel frequency [39].
In general, young children have high energy requirements
relative to their size. In cases of poor weight gain, when
catch‐up growth is the aim, requirements are even higher.
This is difficult to achieve as many children have small appe-
tites and consume small food portions at any one time. There
are various ways of increasing energy intake:
• regular meals
• snacks in between meals
• use of energy‐dense foods
• fortification of foods
• supplements
• enteral feeding
Emerging evidence supports that rapid growth in the first
year of life can lead to metabolic concerns later in life [40].
Therefore, growth faltering should be managed with energy
requirements adjusted on an individual basis to allow for
healthy catch‐up growth and avoidance of continued rapid
growth once the child’s previously established centile is reached.
Provision of regular feeding
Children need a routine with regular meals, which include
energy‐ and nutrient‐dense foods. It is advisable to start with
small quantities and offer realistic portions of everyday fam-
ily foods, with the opportunity for the child to be given more
if they can manage. Emphasis may need to be removed from
mealtimes, and the importance of a balanced intake over the
day emphasised.

Frequent snacks
Meals alone will usually not enable the child to catch up.
One study found that when children with faltering weight
were offered a high energy snack, they took more at the next
meal compared with a control group where there were no
concerns about growth [41]. In clinical practice, small regu-
lar snacks as well as meals are advised to encourage interest
in food and improve appetite, so increasing overall energy
intake. Excess juice and milk consumption encountered in
many young children should be discouraged, and solid food
should be offered before fluids.
Energy‐dense foods
Children need to consume as wide a variety of foods as pos-
sible from the four main food groups: bread, other cereals
and potatoes; meat, fish and alternatives; full‐fat milk and
dairy foods; and fruit and vegetables (Table  2.11) with a
greater emphasis on energy‐dense foods. Foods with a very
high fibre content are bulky and may have high phytate lev-
els, compromising both energy intake and the bioavailability
of micronutrients, and so should be limited.
Fortification of foods
Energy‐dense products, such as butter, margarine and
cheese, can be added to popular foods. Dried full‐fat milk
powder can be used to fortify puddings, soups and milk. If
necessary, the iron status of young children can be improved
initially by giving iron supplements and, in the longer term,
encouraging children to consume iron‐containing foods.
Supplements
The use of dietary supplements is not recommended for chil-
dren with no medical reason for poor weight gain. The use of
these products can medicalise the problem and give the
impression to parents or caregivers that they do not have a
role in helping their child to improve nutritional intake.
However, for children who are unable to take an adequate
intake from food alone, dietary supplements may be neces-
sary and can be prescribed. Carbohydrate, fat or protein sup-
plements can be used to enrich foods, or ready‐to‐feed
nutrient‐ and energy‐dense drinks (oral nutritional supple-
ments) may be more suitable (Tables  1.19, 1.21, and 12.5).
The principle of frequent feeding, regular meals and snacks,
use of energy‐dense foods and fortification of solids with
extra energy still applies.
A case study of a child with faltering growth is given in
Table 24.5.
Enteral feeding
If the child has severe faltering weight and it is not possible
to achieve a reasonable intake orally, enteral feeding
Summary 469
(nasogastric or gastrostomy) may be required initially. Full
follow‐up support should be offered to allow for the child
and family to continue to move forward with oral feeding
where appropriate.
Behavioural management
For the child where there are negative associations with
food, parents should be helped in a sensitive way, offering
support and constructive advice, with no blame attached
and no criticism of their parenting. Behavioural manage-
ment includes:
• avoidance of force feeding
• positive reinforcement of good feeding behaviour; aber-
rant behaviour should be ignored, e.g. by turning the
face away from the child
• a time limit of 20–30 minutes for mealtimes
• small, frequent meals are a possibility to maximise the
opportunity for feeding practice and to reduce the pres-
sure to eat at any one meal
Young children with feeding difficulties often benefit from
messy play. In a relaxed and fun way, a child is encouraged
to touch, feel, smell and possibly attempt different food
tastes and textures. The case study in Table  24.5 illustrates
the benefit from play experience, which tackles fears around
food, mess and delayed self‐feeding skills.
The Paediatric Specialist Group of the British Dietetic
Association offers supportive resources that provide advice
to families on the management of children who are refusing
to eat.
Social care
In some families where there has been no improvement or
poor weight gain continues, with evidence of parental ina-
bility to address the child’s physical, nutritional and emo-
tional needs, a common assessment framework (CAF) may
be initiated by a concerned professional. In many cases this
is the health visitor, but it can be initiated by any healthcare
professional who feels this is necessary. A CAF is a shared
assessment and planning framework to identify a child’s
additional needs and coordinates the services to meet them.
If the family still struggles to engage and no progress is
made, a referral to social care services, requesting input from
a social worker under the category of a ‘child in need’, is
necessary. This will enable a better assessment of the family
dynamics and allows support from a wider range of services.
Referral to social services is very important whenever there
are concerns about a child’s care, safety or well‐being [42].
Summary
To thrive, children need adequate nutrition, appropriate
nurturing and supportive parenting. The routine use and
correct interpretation of growth charts help the prompt
470 Faltering Weight

Table 24.5  Case study: Dietetic management of a child with faltering growth.

Summary

Anthropometry: Baby boy Arlo born at term weighing 3.62 kg. Breastfed for 6 weeks and then started on a standard infant formula. Lives with
mum and has an older sibling aged 5 years. Referred from GP at 2 years of age with faltering growth. Weight = 10.2 kg (9th centile).
Height = 85.5 cm (25th centile).
Clinical: Faltering growth and becoming ill with lots of coughs and colds. Mum reports child is grumpy and not sleeping well, listless and
lethargic, crying a lot. Mum is a single parent, exhausted with older child and struggling with Arlo’s lack of sleep and behaviour.
Dietary: Intake inadequate, drinking lots of milk and very little solid food. Diet very low in fruit and vegetables and iron‐rich foods.
Environment: Mum has few cooking skills and relies on processed food. Family lives in a small flat with only a hob, fridge with freezer box and
microwave oven. Mum receiving benefits and has very little money. Has a small table in the lounge.

Chronology Medical history/assessment Dietetic intervention

1–6 months old Thriving well. No problems when checked

by health visitor
6 months old Started solid foods
Wt = 8 kg (50th centile)
Length = 68 cm (50th centile)
2 years old Frequent coughs and colds and regular visits
to GP
Wt = 10.2 kg (9th centile)
Ht = 85.5 cm (25th centile)
Two centile drop in weight from 6 months of
age so GP referred to dietitian
2 years and 2 months old Wt = 10.3 kg (2nd centile)
Ht = 86 cm (9th–25th centile)
Appointment with dietitian
Diet history:
8 a.m.: 200 mL cow’s milk
Mid‐morning: banana
Lunch: 2–3 tsp. scrambled egg/2–3 tsp.
beans on ½ slice toast
250 mL cow’s milk
Mid‐afternoon: 200 mL cow’s milk
Tea: 2 tsp. cottage pie/fish pie
1 pot fromage frais
Bedtime: 200 mL cow’s milk
Dietary assessment:
Total energy = 760 kcal (3175 kJ) of which
555 kcal (2320 kJ) from 850 mL cow’s milk
Total protein = 34 g of which 30 g from
850 ml cow’s milk
EAR for energy = 1000 kcal (4180 kJ/day,
82 kcal (345 kJ/kg/day)
RNI for protein = 14.5 g/day, 1.2 g/kg/day
Advised:
• Eat around the table as a family at set mealtimes
• Keep mealtimes to no longer than 20 minutes
• Do not offer alternative food, use finger foods, try and all eat
the same as a family
• Reduce milk feeds to mid‐afternoon and bedtime only
• Add extra, butter/margarine to foods like mashed potato,
vegetables, pasta, rice
• Add grated cheese to pasta and potato
• Offer 3 meals and snacks at the table
• Give a multivitamin
• Given written information to back up advice: ‘Help my child
won’t eat’ diet sheet*
• Written letter to GP for prescription for multivitamin
preparation
• Review in 4 weeks with a plan to suggest oral nutritional
supplements instead of cow’s milk if weight not increasing due
to inadequate intake of food
• Discussed with mum whether she can access a local nursery
for Arlo to give her support and some free time

EAR, estimated average requirement; RNI, reference nutrient intake; GP, general practitioner.
*Available from the British Dietetic Association Paediatric Specialist Group. https://www.bda.uk.com/specialist-groups-and-branches/paediatric-
specialist-group.html

identification of suboptimal weight gain. Regular surveil-
lance, e.g. by the primary care team, and early intervention
are important to help ensure adequate nutritional intake and
correct growth faltering.
Many factors contribute to poor weight gain, and interven-
tions will require a multidisciplinary team approach to
­enable investigation into possible underlying organic causes
­including medical diagnoses and social factors; assessment of
dietary intake, oromotor function and feeding; and identifica-
tion of behavioural difficulties. It is important that parental
concerns are acknowledged and there is avoidance of blame.
Parenting strengths and difficulties should be acknowledged,
and support offered to encourage responsive feeding prac-
tices. A strong working partnership between the care team
and the family is essential for the successful management of
growth faltering and should be upheld at all times.

Learning points: faltering weight
• Faltering weight may be a marker of undernutrition or disease
• Regular monitoring is advised throughout infancy and early
childhood
• Prompt referral is recommended to investigate possible
underlying medical causes
• Timely dietetic intervention is recommended to support
catch‐up growth and prevent further weight faltering
• UK‐WHO Growth Charts 0–4 years should be used to assess
weight faltering in term infants and young children
References, further reading, guidelines, support groups
and other useful links are on the companion website:
www.wiley.com/go/shaw/paediatricdietetics-5e
Summary 471
• UK‐WHO Neonatal and Infant Close Monitoring Growth
Charts should be used to assess weight faltering in preterm
infants
• Feeding difficulties are common in infants and young
­children and increase risk of nutritional deficiencies
• There are many other signs of malnutrition, e.g. wasting, dry
skin, thin hair and fatigue, that should also be considered
(Table 1.5)