Understanding Faltering Growth in Infants

What is Faltering Growth?

Faltering growth (FG), previously known as failure to thrive, refers to a slower rate of weight gain in infants and young children compared to recognized growth standards. It is characterized by a downward deviation from the growth patterns expected for a child's age and gender1.

According to the international expert opinion published in 2023, time frame was included into the definition: Growth Faltering is a fall in WFA z-score of >= 1.0 that occurs over a period of 1 month or more and does not include the first 2 weeks after birth. 2

Commonly, FG can also signal an underlying health condition. Left untreated, it can impact a child's long term physical and cognitive development. 2

Causes of Faltering Growth

Infants are vulnerable to malnutrition because of their limited body reserves alongside with higher nutrient requirements for growth and development. 2 Pediatric malnutrition (undernutrition) is defined as an imbalance between nutrient requirements and intake that results in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other relevant outcomes 3 Based on its etiology, Faltering Growth can be classified in two:

  • Illness related, with or without infection/inflammation
  • Non-illness related, caused by environmental/behavioral factors associated with decreased nutrient intake/delivery (or both); this might be compounded by infection 2.

Prevalence of Illness-Related faltering Growth2

  • Malnutrition is not uncommon in children admitted to hospital, regardless of their underlying illness, and is often neglected in their specialist management.

  • The prevalence of infants with FG admitted to hospital with illness-related and non-illness related etiology is not well known because of a lack of dynamic anthropometric measurements.

  • Current studies report very different rates of disease-related malnutrition according to hospital type and size, methodology, and the population selected, with disease-related malnutrition prevalence ranging from 6% to 51% in hospitalized children.

The mechanisms of nutrient imbalance in disease-related Faltering Growth2

REDUCED OR RESTRICTED INTAKE 

Sucking and swallowing disorders

Secondary anorexia

Eating disorders

Cancer, cardiac and/or lung diseases, neurological disease (CP), injury, GORD, swallowing dysfunction, ADHD

INCREASED NUTRIENT REQUIREMENTS

Inflammation (altered utilization of nutrients), hypermetabolism, infection

CF, CHD, liver and renal disease, trauma, cancer, burns, infection, neurologic, endocrine diseases

EXCESSIVE LOSSES

Malabsorption, vomiting, protein-losing enteropathy

Untreated celiac disease, CF, cholestasis, intestinal failure including SBS, intractable diarrhea, IBD, severe dermatologic disease.

Consequences of Faltering Growth

The impact of FG extends far beyond mere physical size and also impacts cognitive function. If not addressed promptly, it can have significant and varying consequences.

  • Short-term: Increased susceptibility to infection, delays in reaching developmental milestones, diminished muscle tone
  • Long-term: Potential challenges include compromised intellectual development, persistent growth deficits, and an elevated risk of chronic health issues.
Download Infographic

Nutritional management of Faltering Growth should consider the cause of the growth faltering and interventions should be tailored towards the underlying problem. 2

Well-nourished children tend to have better clinical outcomes

Cystic fibrosis

  • Lung Function 11
  • Health-Related QOL12

Surgery

  • Complications 13,14
  • LOS 13,14

Oncology

  • Infections 15
  • Mortality 17

Intensive Care

  • Morbidity 16-17
  • Mortality 16-17

Current Practices: Methods of Increasing the Nutritional Density of a Feed

Energy and Nutrient Dense Formulas (ENDF)

ENDFs are scientifically formulated to meet the comprehensive nutritional requirements of vulnerable infants experiencing FG. ENDFs have a balanced nutrient profile that supports optimal growth and development as well as lower osmolality for safe digestion.

RTF ENDF are superior in efficacy and safety versus current practices

What are the latest international recommendations? 2

The latest Expert Opinion Guide General Clinicians on Catch-up Growth in Infants and Young Children with Faltering Growth, confirmed the recommendation that: 

  • In formula-fed infants ready to use energy dense therapeutic feeds with proven efficacy should be used, where available, 
  • Modular additions of only fat and carbohydrates to feed and food should be avoided, as this reduces the protein energy ratio
Download Expert Opinion

At Nutricia, we understand the delicate needs of infants at risk of faltering growth. Through proper recognition, and nutritional management, we can help ensure that all children have the opportunity for healthy growth and development. Nutricia is committed to leading the way in providing advanced nutritional solutions for those in need. 

Discover our meticulously designed ready to use ENDFs for catch up growth.

Discover Infatrini

  1. McDougall P et al. The detection of early weight faltering at the 6-8 week check and its association with      
  2. family factors, feeding and behavioural development. Arch Dis Child 2009;94:549-52.
  3. Cooke R et al. Catch-Up Growth in Infants and Young Children With Faltering Growth: Expert Opinion to 
  4. Guide General Clinicians. JPGN 2023;77: 7–15
  5. Mehta NM et al. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. J Parenter Enteral Nutr 2013;37:460–81.
  6. Schaible UE et al. Malnutrition and infection: Complex mechanisms and global impacts. PLoS Medicine. 2007;4(e115):0806-12.
  7. Stechmiller JK. Understanding the role of nutrition and wound healing. Nutr Clin Pract. 2010;25:61-8.
  8. Baker et al., Journal of Nutrition, 2007
  9. Ross F, et al. Preoperative malnutrition is associated with increased mortality and adverse outcomes after paediatric cardiac surgery. Cardiol Young. 2017;27:1716-25.
  10. Pollitt E et al. Effects of an energy and micronutrient supplement on mental development and behavior under natural conditions in undernourished children in Indonesia. Eur J Clin Nutr 2000;54:S80-90.nder natural conditions in undernourished children in Indonesia. Eur J Clin Nutr 2000;54:S80-90.
  11. Berkman DS et al. Effects of stunting, diarrhoeal disease, and parasitic infection during infancy on cognition 
  12. in late childhood: a follow-up study. Lancet 2002;359:564-71.
  13. Pozo J, Argente J. Delayed puberty in chronic illness. Best Pract Res Clin Endocrinol Metab. 2002;16(1):73-90.
  14. Galler JR, et al. Socioeconomic outcomes in adults malnourished in the first year of life: a 40-year study. Pediatrics. 2012;130(1):e1-7.
  15. Lai H J et al. Recovery of birth weight z-score within 2 years of diagnosis is positively associated with pulmonary status at 6 years of age in children with cystic fibrosis. Pediatrics. 2009 feb; 123(2);714-22.
  16. Shoff S M et al. J. of Cystic Fibrosis. 2013:746-753.
  17. Secker DJ, Jeejeebhoy KN. Subjective Global Nutritional Assessment for children. Am J Clin Nutr 2007;85:1083–9.
  18. Ladd MR et al. Malnutrition increases the risk of 30-day complications after surgery in pediatric patients with Crohn disease. J Pediatr Surg. 2018 Nov;53(11):2336-2345.
  19. Gürlek Gökçebay D, Emir S, Bayhan T et al. Assessment of Nutritional Status in Children With Cancer and Effectiveness of Oral Nutritional Supplements. Pediatr Hematol Oncol. 2015;32(6):423-32.
  20. Amirjani S et al. Undernutrition and 60-day mortality in critically ill children with respiratory failure: a prospective cohort study. BMC Pediatrics. 2023, 23:271.
  21. Bechard LJ et al. Nutritional Status Based on Body Mass Index Is Associated With Morbidity and Mortality in Mechanically Ventilated Critically Ill Children in the PICU* Critical Care Medicine 2016; 44(8):530-1537.
  22. ASPEN Fact Sheet Nutrition Management of Term Infants with Growth Failure, 2024 Available at: https://www.nutritioncare.org/uploadedFiles/Documents/Guidelines_and_Clinical_Resources/EN_Resources/Infant-Growth-Failure-Factsheet.pdf
  23. Marino LV, Meyer R, Cooke ML. Cost comparison between powdered versus energy dense infant formula for undernourished children in a hospital setting. e-SPEN Journal 8; 2013; 145-149.

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