🔑 Key Learning

  • Faltering growth is defined by a slower-than-expected rate of weight gain or a drop across centiles.
  • Common causes include inadequate intake, malabsorption, chronic illness, and neglect.
  • Short stature may result from constitutional delay or hormone deficiencies (GH). 

⚖️ Failure to Thrive (Faltering Growth)

🧬 Pathophysiology

  • Faltering growth is not a diagnosis but a sign of an underlying issue.
  • Defined by weight or height falling significantly below expected centiles.
  • Common in primary care (5% prevalence).

🧪 Causes

  • Inadequate intake: feeding issues, eating disorders, neglect.
  • Malabsorption: coeliac disease, IBD, recurrent vomiting.
  • Excess losses: congenital heart disease, CF, diabetes, malignancy.

👀 Clinical Identification

NICE defines faltering growth as any of:

  • Weight loss > 10% of birth weight
  • Failure to regain birth weight by 3 weeks of age.
  • Weight falling across:
    • 1 centile if BW < 9th centile
    • 2 centiles if BW between 9th–91st centile
    • 3 centiles if BW > 91st centile
  • Current weight < 2nd centile (regardless of BW)
  • BMI < 2nd centile in children > 2 years
  • Length/height > 2 centiles below mid-parental centile

💊 Management - NICE guidelines

Early infancy (first few days of life)

  • <10% weight loss with normal feeding: reassure.
    • Reassurance - weight loss usually stops after 3-4 days of life and should return to BW by 3 weeks
  • 10% weight loss or failure to regain by 3 weeks: discuss with paediatrics.

Beyond the neonatal period

  • Red flags: Refer to paediatrics
    • Safeguarding concerns
    • Rapid, unexplained loss of weight
    • Unexplained short stature or slow linear growth
    • Or symptoms of signs of underlying acute/chronic illness which may be causing FTT
  • If stable, trial the following conservative measures:
    • Encourage family mealtimes and self-feeding.
    • Diet and nutrition advice.
    • Consider paediatric dietitian, SLT, psychologist if needed.
    • Monitor growth closely.
    • If no improvement with above measures, escalate to secondary care.

📉 Short Stature

⏳ Constitutional Delay of Growth and Puberty

🧬 Pathophysiology

  • Delayed puberty onset leads to delayed growth spurt.

👀 Clinical Features

  • Short stature in adolescence
  • Normal investigations and bone age delay
  • Family history often present

💊 Management

  • Most cases managed conservatively
  • Growth and puberty eventually occur
  • If psychosocially affected: consider sex steroid therapy to induce pubertal changes
    • e.g. Boys: IM testosterone 50–100 mg every 4 weeks

⛽ Growth Hormone Deficiency

👀 Clinical Features

  • Infancy: may present with hypoglycaemia
  • Childhood:
    • Reduced growth velocity
    • Short stature
    • Truncal adiposity
    • Low muscle mass

🧪 Investigations

  • Serum IGF-1 and IGFBP-3
  • GH stimulation testing:
    • Insulin tolerance test is gold standard

💊 Management

  • Recombinant human growth hormone (GH)
    • 0.7–1.0 mg/m²/day as daily subcutaneous injection

📝 Exam Clues & Clinchers

  • Weight loss >10% in neonate or not regained BW by 3 weeks → red flag - refer
  • Failure to pass meconium, FTT, distended abdomen → think Hirschsprung’s
  • Short adolescent boy, delayed puberty, low bone age, FHx → likely constitutional delay
  • Short stature + truncal obesity + low IGF-1 → growth hormone deficiency
    • Insulin tolerance test!

🔗 Useful Links and References