View Working Together View Working Together
 
  View Hertfordshire Safeguarding Children Board website

6.10 The Identification and Management of Failure to Thrive in Infants and Young Children

Contents

1. Introduction
2. Primary Assessment and Management by Health Professionals
  2.1 Equipment and Training on Growth Measurement
  2.2 The Role of Health Visitors
  2.3 Concerns by General Practitioner
  2.4 Concerns by Investigating Paediatrician
  2.5 Admission to the Acute Hospital Health Setting
3. Management Of Failure To Thrive Where There Are Concerns
  3.1 Common Assessment Framework
  3.2 If Parents Fail to Engage with the CAF Process
  3.3 Professionals Meeting, TAC and Strategy Meetings
  3.4 The Discharge Planning Meeting
4. When is Failure to Thrive a Safeguarding Issue?
5. Children's Services Response to Referrals
  5.1 Assessment
  5.2 Child Protection Enquiries (S47)
  5.3 Further Assessment
  5.4 References
  Appendix 1: Faltering Growth/ Failure to Thrive (FTT) Guidelines for Health Visiting Teams
  Appendix 2: Suggested Agenda for FTT Professionals Meeting
  Appendix 3: Children's Failure to Thrive Integrated Care Pathway


1. Introduction

The reason for having practice guidance on this subject is that failure to thrive is a cardinal feature of neglect, and the neglect is sometimes deliberate. Nevertheless, failure to thrive (as defined by new longitudinal weight charts) is more common than previously thought, has many causes and is often not sinister or related to neglect, as we explain below.

Failure to gain weight is essential to the concept. This failure manifests as "falling through the centiles" of the growth chart. It is often difficult to make a spot diagnosis based on a single weight, or the child's appearance, without recourse to previous measurements.

Under-nutrition accounts for 95% of cases and major organic disease <5% (although another 5% have minor medical problems). About 5% require registration under child protection protocols and another 20% have recognisable social problems. The term "Growth Faltering" may be considered less judgmental as it does not imply that there has necessarily been a failure of love or attention on the part of the parents; 1in other words most cases of failure to thrive are not due to neglect or abuse.

The incidence of organic disease is higher in younger children especially babies. For example, congenital heart disease undiagnosed by routine screening is suggested by a history of breathlessness and cyanosis. Vomiting and diarrhoea suggest a gastroenterological cause. An onset after weaning in association with irritability suggests coeliac disease. Very offensive stool, often in association with respiratory symptoms suggests cystic fibrosis.

All children with severe failure to thrive should [1] have an initial careful clinical assessment, most appropriately by the GP, and [2] be referred to the paediatrician if the FTT is severe, is associated with symptoms or there is no progress. Although we have already stated neglect is not the most frequent cause, it is important to be aware of the classic signs including persistently red hands and feet, protuberant abdomen and sparse hair.

We have utilised the term failure to thrive throughout this document because [1] it is understood by several agencies, [2] it embraces more than just growth which is relevant to safeguarding and [3] it is more than short stature.


2. Primary Assessment and Management by Health Professionals

At present we screen for failure to thrive routinely by measuring weight in all young children at specified ages. In general babies will regain their birth weight within 10 days and preterm infants within 3 weeks.

2.1 Equipment and Training on Growth Measurement

(See Appendix 1: Faltering Growth/ Failure to Thrive (FTT) Guidelines for Health Visiting Teams).

2.2 The Role of Health Visitors

The role of the heath visitor (Appendix 1: Faltering Growth/ Failure to Thrive (FTT) Guidelines for Health Visiting Teams) is to monitor and record the growth of children under 5 years in line with national and local parameters, using equipment and techniques specified by the Child Growth Foundation. Where appropriate use the Growth Faltering Protocols and in breast-fed babies the Best Practice Guidelines.

The GP/ Paediatrician should be asked to see the child to liaise on case management and if there is a rapid or persistent falling below the centiles.

2.3 Concerns by General Practitioner

  1. A thorough medical history and examination including for any dysmorphic syndrome or cardiovascular abnormality;
  2. Unless the history suggests any specific disorder, investigation should be limited and could include a full blood count and ferritin, serology for coeliac disease, urine culture, renal and thyroid function tests and possibly karyotype to exclude Turners syndrome;

    In a very young infant with FTT think about an organic cause (e.g. Congenital Heart disease, milk allergy etc);

    Management should focus on promoting a higher calorie intake. The service of a paediatric dietician is essential. Ideally a professional, usually the Health Visitor, should provide advice and support within the home. The Health Visitor is also the best person to obtain information about the child's intake, i.e. by direct observation. Sometimes the help of Children's Services may be valuable and invoke child protection protocols when the parents are resistant to help and especially when there is other collateral adverse information (e.g. parental mental health issues such as substance abuse).

2.4 Concerns by Investigating Paediatrician

The paediatrician's role is to diagnose and treat any organic disorder and to report coherently suspected neglect. Paediatricians need to work with paediatric dieticians, health visitors and possibly speech therapists to achieve a thorough evaluation of the child, family and problem. Consider the need to observe feeding at home, admit for assessment or radiological and laboratory tests. There are some general principles worth remembering.

(See also admission to hospital - below):

  • The younger the child the more likely is an organic basis to the problem;
  • The presence of symptoms (see above) usually indicates organic disease;
  • The diagnosis of "non-organic" failure to thrive which usually implies neglect requires to be clearly communicated by more than one means to the other agencies (see Section 4, When is Failure to Thrive a Safeguarding Issue?).

2.5 Admission to the Acute Hospital Health Setting

The purpose of admission to hospital is to:

  1. Exclude organic disease by history taking, examination and investigations as appropriate;
  2. Observe parental behaviour and compliance with treatment (this is not a parenting assessment);
  3. Record if the infant or child is hungry and gains weight in hospital which the child has not gained at home;
  4. Discuss any suspected chronic illness with the relevant experts;
  5. In older children with psychosocial short stature, practitioners must recognise clinical and diagnostic features of the hyperphagia syndrome described by Skuse et al. (See also the Neglect Protocol);
  6. When there are welfare concerns, a discharge planning or strategy meeting must be held with the child still on the ward. Attendees will be health visitor, ward medical and nursing staff, child protection leads, dietician and social worker and (if a strategy) police. The consultant paediatrician must follow-up this meeting with a full written medical report with a clear conclusion in a language non-medical professionals can understand;

    If the child is referred to a tertiary centre it is better that the child is discharged home via the local hospital than discharged direct from that centre, especially and particularly when there are welfare concerns.


3. Management Of Failure To Thrive Where There Are Concerns

Child Protection Concerns: Flowcharts (see Appendix 1: Faltering Growth/ Failure to Thrive (FTT) Guidelines for Health Visiting Teams, Flowcharts and Appendix 3: Children's Failure to Thrive Integrated Care Pathway).

3.1 Common Assessment Framework

If the parent/carer is willing to engage a CAF and Team Around the Child (TAC) should be generated to enable effective coordination of the care and management of the FTT.

Suggested strategies could include referral to Children's Centres, parenting groups, community nursery nurse support etc.

3.2 If Parents Fail to Engage with the CAF Process

If parents fail to engage with the CAF process, and/or the child's welfare continues to cause concern despite support and intervention at CAF level, then a referral to Children’s Services is appropriate.

Make referrals in accordance with the procedures laid out in HSCB Child Protection Procedures (see Referrals Procedure) and inform parents of the intention to refer to Children’s Services unless you consider that to do so might place the child at increased risk of harm (e.g. in cases where FII is suspected).

Attach any CAF record to the referral in order to inform decision making about how to proceed, and to provide the basis for any further assessment.

In children with disorders associated with difficulty in swallowing, such as cerebral palsy, the professional has to strike a balance between the parent's common reluctance to consent to gastrostomy and concern about the child's nutrition. Parental reluctance without other welfare concerns would not usually be a safeguarding issue. The more widespread use of gastrostomy allows parents to meet, compare notes and understand the treatment in more depth before taking the decision.

3.3 Professionals Meeting, TAC and Strategy Meetings

If the child is in the community or in hospital, a meeting of professionals will ensure, via a multidisciplinary /multiagency approach, effective collation of all information related to the history, identification and management to date of the failure to thrive.

We recommend hold the meeting in the GP practice, or hospital if the child is an in-patient, to allow effective access of information from the GP/paediatrician which will be a valuable resource in assessing historical information and parental compliance to date.

  • The meeting can explore the history, timescales, action plans to date and parental compliance with both treatment and management;
  • Conclusions can be reached as to level of risk of significant harm to the child and whether there is need for a referral to Children's Services as S17 or S47 Children Act 1989;
  • The Professional meetings should maintain effective notes of the action plans with clear timescales and review dates.

If the decision is made that the baby/child is likely to or is suffering significant harm then a referral must be made to Children's Services, see Referrals Procedure.

3.4 The Discharge Planning Meeting

May be part of the professional's or TAC meeting and would consider:

  • A clear feeding plan;
  • When the child is to be weighed, by whom and frequency;
  • Out patients follow up. To be clear as to when and to whom;
  • Other agencies involvement, outline clearly;
  • A clear statement of actions with time limits and a named person responsible for actions;
  • What will happen if the plan is not adhered to?
  • A date for a follow up meeting to ensure monitor progress.


4. When is Failure to Thrive a Safeguarding Issue?

  1. The infant or child fails to gain weight and the parent is:
    • Hostile to professional concerns;
    • Exhibits risky behaviour (exposure to violence, substance misuse, alcoholism, chaotic lifestyle);
    • Inappropriately apathetic or in denial;
    • Possibly learning disabled or suffering an active mental health problem (e.g. chronic self harm, poorly treated depression or psychosis);
    • Claims to follow professional advice but may be giving diluted feeds etc (Factitious and Induced Illness).
  2. The infant has a chronic illness or disability and the parent is uncooperative with medical treatment, exhibits some of the above problems or may not be feeding the child.


5. Children's Service Response to Referrals

5.1 Assessment

On receipt of the referral, the Team Manager will decide what response is necessary; minimum response to a referral would be to carry out an Assessment. All assessments regarding Failure To Thrive children should be dealt with on a multi-disciplinary basis. Good communication and exchange of information is essential throughout between social workers, GP, hospital dietician and paediatrician, health visitors, community paediatricians and other relevant professionals.

This assessment will explore the parents' history and any social, emotional, economic or other difficulties that may be impacting on their ability to meet the needs of the child. Use the Neglect Protocol, Children and Families Living with Substance Misuse Protocol HSCB and Children of Parents with Learning Disabilities Procedure where relevant.

5.2 Child Protection Enquiries (S47)

If the Assessment justifies a Section 47 Enquiry then a Strategy Meeting should be convened and be dealt with on a multi-disciplinary basis to include Paediatricians and Community Paediatricians, Health Visitors and other relevant professionals e.g. dietician and police. Investigation will include ascertainment of any risky parental behaviour.

Where agencies judge that the child may continue to be suffering or likely to suffer significant harm, then Children’s Services will convene an Initial Child Protection Conference within 15 days of the strategy meeting at which S47 enquiries were initiated. At the Initial Child Protection Conference, there should be sufficient information and expertise available to include Designated Doctors for Safeguarding Children to enable informed decision about what action is necessary to safeguard and promote the welfare of the child.

5.3 Further Assessment

Proceed on a multi agency basis, ensuring that chronologies are requested from health, previous input and strategies must be included and the information provided is given due consideration in the analysis and recommendations Designated Doctors and specialist child protection staff should contribute to this analysis. Other agencies in close contact with the child, such as school or nursery, should also be asked to contribute information, as should any services that are engaged in working with the parents.

It is important to pay attention to the parent's background, the obstetric history, the fate of any previous children, parental mental health, educational history (see Children of Parents with Learning Disabilities Procedure, Impact of Parental Learning Disability) adult males including a full ascertainment of the forensic record, the level of support for the parent and the level of parental competence and compliance with professional concerns. Parental hostility is a serious warning sign. The hospital ward and community surveillance can only screen for parental competence, the parent and child may need admission to a special unit for assessment. The HSCB Neglect Protocol describes this process in more detail.

Convene a legal planning meeting where there is continued concern re failure to thrive with significant child protection concerns which require hospital admission and/or foster care. Good weight gain in foster care is usually the ultimate proof of parental neglect and is ultimately diagnostic. In infants, hospital admission for investigations is the preliminary manoeuvre.

5.4 References

  1. Batchelor, J. (1 999) Failure to Thrive in Young Children. Research and Practice Evaluated. The Children's Society London;
  2. Batchelor, J. and Kerslake, A. (1990) Failure to Find Failure to Thrive: The Case for Improved Screening, Prevention and Treatment in Primary Care. London: Whiting and Birch;
  3. Boddy, J. and Skuse, 0. (1 994) Annotation: the process of parenting in failure to thrive. Journal of Child Psychology and Psychiatry, 35 131, p401 - 24;
  4. Department of Health (2009) Using the new UK-World Health Organisation 0-4 years growth charts;
  5. UK-WHO Growth Charts, Royal College of Paediatrics and Children Health (RCPCH);
  6. Wright CM, Avery A, Epstein M, Birks E, Croft D. A new chart to evaluate weight faltering. Arch Dis Child. 1998; 78: 40-43;
  7. Skuse D et al. A new stress related syndrome of growth failure and hyperphagia in children, associated with reversibility of growth hormone insufficiency. Lancet 1996; 348: 353-58.

    NB: Failure to thrive vignettes which relate to anonymised specific cases can be obtained by application to Dr J Heckmatt Email: John.Heckmatt@hchs.nhs.uk.


Appendix 1: Faltering Growth/ Failure to Thrive (FTT) Guidelines for Health Visiting Teams

Defining Failure to Thrive

Babies do not all grow at exactly the same rate and there is a wide variation in what is considered to be 'normal growth. In general a baby will usually lose up to 10 per cent of their body weight in the first few days of life (see Commissioning Local Breastfeeding Support Services, DOH 2009). This is rapidly regained, usually at a slower rate for breast fed babies (see additional guidance for faltering growth in breast fed babies). A baby will usually then settle into a pattern of growth, following a centile that predicts expected weight gain in the child held record book.

FTT may be diagnosed if a child's weight slips down through two or three standard centiles. Staff should use guidance from the new (2009) UK World Health Organisation 0-4 years growth charts for guidance on when to weigh and measure babies and children.

For greater definition of failure to thrive staff may also use the Weight Monitoring Charts or the Thrive Lines published by Harlow Printing (http://www.healthforallchildren.co.uk/). The use of these is fully described in the second edition of the Child Surveillance Manual.

Key Principles

  • FTT is the failure to gain weight and/or height at a satisfactory rate;
  • The health visitor or school health nurse provides an Assessment and intervention and is responsible for continued monitoring;
  • Faltering growth is due to insufficient calorie intake in approximately ninety per cent of cases with no serious underlying medical or social cause and is likely to respond to dietary and feeding management alone;
  • In the minority of cases where the reasons for faltering growth are more complex a referral to the GP or paediatrician should follow;
  • If at any time there is concern about possible child abuse or neglect a referral should be sent Children's Services;
  • Hospital admission is seldom required but is indicated should the child be suffering severe malnutrition or for management of serious organic disease.

Rationale

FTT occurs in about five per cent of children. Simple interventions within the community are usually effective. In only approximately five per cent of these children is there a primary organic cause for faltering growth and in a further five per cent there is a need to invoke child protection procedures (Boddy and Skuse, 1994).

FTT occurs in children from all socio-economic groups and cultures. Children with disabilities are a high risk group. Health visiting teams need to be mindful of pre- conceptions that faltering growth only happens in poorer families. (Batchelor and Kerslake, 1990).

Early identification of FTT is required and responded to appropriately. If FTT is not addressed the child's development may be delayed and there may be increasing family stress and poor parent/child interaction. Dysfunctional eating behaviour may develop or become more severe.

Abnormal Growth Patterns in Infants and Young Children

20% of infants and children's weight will fall through 1-2 centiles at some time.

  1. Children whose weight has been between 9th and 90th centile
    (UK cross sectional reference data 1996)
    • These individuals may well improve spontaneously but will require ongoing monitoring;
    • 10% of this group will fall through more than 2 centiles, (one weight only);
    • This may be related to short term illness or family upset and will require further observation and monitoring;
    • 5% of this group will fall through more than 2 centiles, (more than one weight);
    • This is likely to indicate a problem therefore further investigation is needed.

      Example
    1. Abdul's weight crossed completely through two interceptive spaces from a baseline position taken at eight weeks i.e. from the 75th centile two months to the 25th centile at five months. This would be described as a moderate growth faltering with approximately 5% of children's weight falling this far;
    2. Naomi's weight fell rather more and crossed four centile spaces between two and six months and this weight loss would be considered severe;

      Catch up within 2 centile bands constitutes partial recovery and monitoring should continue, with prompt action if there is further decline;

      Catch up through one centile constitutes recovery.
  2. Children: weight >90%

    A fall through 3 or more centiles with more than one weight;

    Indicates a likely problem therefore investigation may be necessary.
  1. Children: weight <9%

    A fall through 1 centile with more than 1 weight. Indicates a likely problem therefore investigation may be necessary;

    N.B This is for guidance only. (See Appendix 1: Faltering Growth/ Failure to Thrive (FTT) Guidelines for Health Visiting Teams, Flowcharts).

The holistic picture of the health and welfare of the infant or child needs to be taken into account when action is considered. Young infants are particularly vulnerable. A fall off in weight centile usually exceeds and precedes any fall off in height centile. A fall off in head circumference centile usually only occurs in children with very severe

FTT. An equivalent fall off in weight and height centile or a fall off in height centile in excess of weight centile may suggest an organic cause. See Appendix 2: Suggested Agenda for FTT Professionals Meeting.

Other Growth Patterns which may Indicate FTT

Weight centile two or more centiles below height centile (more than 1 centile if height below 9%) or Height/weight centile below 0.4%.

Height/weight centile below target centile range (based on accurate parental heights). A fall of more than 1 centile in height with a continuing fall at next measurement in children over 2 years.

Catch Down Growth

Children under 2 years may show catch down growth to their genetic centile making interpretation of growth charts more difficult. Birth weight is mainly determined by how well nourished they have been in utero. After 6 months of age genetic factors become more important and the rate of growth may slow until the baby/child reaches the centile where they are genetically "destined" to be (usually achieved by 2 years) Typically in catch down growth both weight and height will fall through centiles at the same rate or, if the weight centile is more than height centile then the weight centile alone may fall to match the height. Similarly catch-up growth may occur if infants are poorly nourished in utero. Catch down growth is unlikely to be the cause for a fall through the centiles if:

  • This occurs rapidly;
  • Fall in height centile is preceded by a significant fall in weight centile;
  • There is a fall outside the target centile based on parental heights;
  • History suggests an underlying cause.

Good Practice for Weighing and Measuring

For children where there are concerns about growth, length/height measurements should be taken and recorded with each or alternate weights. Head circumference should be measured and recorded with each or alternate weights in the first year of life. Height measurements should be taken. and recorded both in the parent held record book and the child's notes (paper record or computerised) In children where there are no concerns about growth, follow the child growth foundation assessment recommendations (Dec 2009).

Role of the Health Visitor

To monitor and record the growth of children under 5 years in line with national and local parameters, using equipment and techniques specified by the Child Growth Foundation. Take the lead in closely monitoring under 5 children with FTT. NB children should be weighed naked up to 2yrs old and then in vest and nappy/knickers up to 5yrs old and on the new WHO Charts we should be recording in ink and plotting in pencil. To record and plot weight, height and head circumference in the parent held child health record, (PHCHR) if there are concerns about FTT then a separate record should be kept within the health visiting records.

Any baby born before 32 weeks should have a pre term 32 week growth chart which will be administered by the neo natal unit. This should continue for the first two years of life. Babies born 32-36 weeks should be plotted on the pre term section until 42 weeks and then transferred to the main charts. Corrections should continue until 1 year using the drawn back method to indicate that the professional is correcting for prematurity.

Where there are concerns over growth the Growth Faltering Protocols should be followed and in addition in the case of breast-fed babies the Best Practice Guidelines should also be referred to.

The GP/ Paediatrician should be asked to see the child to liaise on case management and if there is a rapid falling below the centiles.

Recommended guidelines for the monitoring of infants as part of the CONI programme should be followed.

Inform parents about concerns and recommendations and obtain consent for referral and information sharing as per Common Assessment Framework (CAF) consent procedures.

Ensure that all parents and carers receive professional advice and appropriate literature on dietary, feeding and behavioural problems. Being mindful that the appetite may be suppressed due to an iron deficiency.

To be proactive in encouraging interaction with health professionals, other agencies who may be working with the family, ensuring due account is made of cultural differences.

Where a child has been seen in hospital there should be liaison with hospital professionals.

Make appropriate referrals according to the flow chart in agreement with the parents and carers.

Maintain Health Visitor records and Parent held record, including any responses from other health professionals to whom the child may have been referred. Parental awareness and concerns must be addressed.

If there is no significant improvement and /or FTT in the child is thought to be caused by neglect, then further action should be agreed with other professionals taking into account safeguarding issues (speak to Safeguarding Nurse). Record all contacts in accordance with health visiting policies.

At school entry, where there is on-going concerns liaison with School Nurse should be made and records including growth charts should be verbally transferred.

Measuring Growth Accurately

  1. Weight

    Modern scales are accurate, so long as they are regularly calibrated;
  1. Length

    Accuracy to 0.5 cm is sufficient because children are growing rapidly under the age of two years. A good device is the Raven Rollameter (£55.90). The Starters Measure Mat (CGF) is satisfactory;
  1. Height

    Please use the Leicester Height Measure. This is an accurate inexpensive portable device (£47) and one should be available in every clinic. It is superior to the Raven Microtoise or Minimetre, which has to be accurately attached to the wall and is more appropriate when portability is vital (i.e. use at home). The Raven Magnimetre is also well designed. Tape measures, books on the head, sliding rulers and wall charts are very inaccurate!

Technique of Measurement:

(See also the front of the Child Growth Foundation CGF A4 charts).

Length: The infant should be measured supine by two people with equipment featuring both a head and footboard. One person holds the head in the Frankfurt plane (ear hole in line with lower border of eye socket) against the headboard and the other the heels against the footboard. The downward pressure on the knees will not endanger the hips.

Height: The child should stand with bare feet, back against the vertical of the measure. The head is held in the Frankfurt plane (see above) and the Leicester's sliding device is brought down to touch the head. Gentle but firm pressure is applied under the mastoids by the measurer to help the child stretch (make sure the child does not rise onto his toes, it is usually helpful for another adult to press on the feet). The sliding device moves upward slightly as the child stretches. Record the height to the last mm.

Flowcharts

Click here to view Growth Faltering Flow Chart

Click here to view Outline of Possible Causes of Growth Faltering Flow Chart


Appendix 2: Suggested Agenda for FTT Professionals Meeting

  • Introductions;
  • Background and presentation;
  • Questions for health:
    • GP:
      • Has weight fallen through 2 percentile lines (since 6 week baseline);
      • Have medical causes for FTT been sought;
      • Have medical causes for FTT been excluded;
      • Are there known risk factors for abuse in the family:
        • Failure to attend appointments;
        • Substance abuse;
        • Mental illness;
        • Learning difficulties;
        • Domestic abuse.
    • HV:
      • What is the house like;
      • Have you observed:
        • Food available;
        • Meal times/feeding effective.
    • Paediatrician;
    • Dietician;
    • SALT.
  • Questions for Children's Services:
    • Are there known risk factors for abuse:
      • Substance abuse;
      • Mental illness;
      • Learning difficulties;
      • Domestic abuse;
  • General:
    • Chronologies of weight and feeding;
    • Chronologies of interventions tried:
      • Are there records of these assessments and interventions.
  • Risk Assessment:
    • Is the child safe;
    • Risk of cot death;
    • Risk of other forms of abuse;
    • Risk of medical problems.
  • Plans:
    • Are there simple interventions still likely to help:
      • HV support;
      • Dietician;
      • Referral to Hospital OPD.
    • Is there need for more complex intervention;
    • Referral to Children's Services:
      • Admission to hospital;
      • Period in foster care.
    • Will the parents co-operate or will legal intervention be needed.
  • Who will talk to the parents next with the plans;
  • Timescales;
  • Date of Next meeting.


Appendix 3: Children's Failure to Thrive Integrated Care Pathway

Click here to view this appendix

End