Growth faltering

Last updated: June 13, 2023

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Summarytoggle arrow icon

Growth faltering is defined as a pattern of slow growth in children when compared to the predicted values for their age and sex. It is seen in up to 10% of children in the United States and often occurs secondary to malnutrition, which can be due to a complex interplay between biological and psychosocial factors. The primary mechanisms that contribute to growth faltering and malnutrition are inadequate nutritional intake, inadequate absorption, and increased metabolic requirements. Clinical features may include signs of malnutrition such as muscle mass wasting, minimal adiposity, hair loss, developmental delay, and recurrent infections. Growth faltering is confirmed using standardized growth charts (e.g., weight-for-age < 5th percentile). Clinicians should perform a holistic approach to history and examination to identify risk factors and the underlying etiology. Diagnostic testing is reserved for children with no response to initial management or severe clinical features and can include urinalysis, stool tests, or specific tests depending on the suspected etiology (e.g., HIV test). Management consists of treatment of the underlying cause and nutritional modifications. Most patients can be successfully managed as outpatients. Close follow-up is indicated to prevent relapses or excessive weight gain.

Definitiontoggle arrow icon

  • Growth faltering
    • A pattern of slow growth in children compared to the predicted values for their age and sex
    • Commonly used criteria include: [2][3]
      • Weight-for-age, length-for-age; , BMI-for-age, or weight-for-length < 5th percentile [2][3]
      • A decrease across 2 major percentile lines from an already established growth velocity [2][3]
  • Childhood wasting
    • Low body weight as a result of acute malnutrition, rapid weight loss, or insufficient weight gain
    • Characterized by a z score below 2 standard deviations in BMI-for-age charts or weight-for-length charts
  • Growth stunting

Epidemiologytoggle arrow icon

  • Seen in up to 10% of children in the United States [2]
  • Most commonly occurs in children aged 6–18 months of age [4]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Growth faltering occurs secondary to malnutrition, often due to a complex interplay between biological and psychosocial factors. [2][3][5]

Risk factors [2][3]

Growth faltering is more common in children with multiple risk factors. [3]


Overview of mechanisms of growth faltering [2][3]
Mechanism Common causes
Insufficient calorie consumption Poor oral intake (most common) [3]
Increased requirements [2][3]
Inadequate absorption [2][3]
Defective energy utilization [2]

Clinical featurestoggle arrow icon

Growth faltering is a manifestation of malnutrition and may be accompanied by features of other underlying conditions. [2][3]

Features of malnutrition [2]

Persistent severe malnutrition affects growth parameters sequentially; the first affected is weight, then length, and finally head circumference. [3]

Features of underlying conditions [3]

Features depend on the cause, examples include:

Diagnosticstoggle arrow icon

Approach [2][3]

  • Obtain growth measurements and plot them on growth charts appropriate to age and any underlying conditions. [2][3]
  • Confirm growth faltering by identifying either:
    • Single point measurements in low percentiles
    • OR significant delays in linear growth
  • Perform a comprehensive clinical assessment to identify the etiology of growth faltering.
  • Consider diagnostic studies in patients with: [2][3]
    • Suspected micronutrient deficiencies
    • Severe clinical features (e.g., weight gain velocity < 25% of expected)
    • No response to initial management
  • Concurrently assess for abnormal pediatric development. [3]

Diagnostics studies are not required unless there are concerning features in the history or physical examination. [2]

Clinical assessment [2][3]

Because growth faltering is commonly multifactorial, a thorough clinical assessment is necessary to address the interplay of contributing biological and psychosocial factors. [5][10]

Diagnostic studies

Common studies [2][3]

There is no standard set of blood tests to order; common studies include: [2][3]

Further studies [2][3]

Consider additional studies guided by clinical suspicion, for example: [2]

Managementtoggle arrow icon


Appetite stimulants are not routinely recommended but may be considered in select cases, e.g., children undergoing cancer treatment. [3]

Malnutrition severity

Ensure children are measured correctly, e.g., by a trained professional using a calibrated scale with infants unclothed and older children in undergarments or lightweight clothing. [2][11]

Classification of malnutrition [2]
Mild Moderate Severe

Single-point assessment (z score)

  • Weight-for-height/BMI: -1 to -1.9
  • OR mid-upper arm circumference: -1 to -1.9
  • Weight-for-height/BMI: -2 to -2.9
  • OR mid-upper arm circumference: -2 to -2.9
  • Weight-for-height/BMI: ≤ -3
  • OR length/height: ≤ -3
  • OR mid-upper arm circumference: ≤ -3
Weight gain velocity
  • < 75% of expected weight gain
  • < 50% of expected weight gain
  • < 25% of expected weight gain
Weight loss
  • 5% usual body weight
  • 7.5% usual body weight
  • 10% usual body weight
Deceleration of
weight-for-height or height

Serial measurements allow for dynamic assessment of growth faltering. [2]

Inpatient management of growth faltering

Inpatient management allows subspecialist workup of underlying causes, structured feeding evaluations, and intensive provision of nutritional support and caregiver education (see “Outpatient management of growth faltering”).

Admission criteria for growth faltering

  • Severe malnutrition or dehydration
  • Serious underlying medical issues
  • Extreme psychosocial factors that do not allow for successful outpatient management
  • Need for precise and specific documentation of nutrition
  • Unsuccessful outpatient management

Inpatient management of severe malnutrition

Outpatient management of growth faltering

The majority of children with growth faltering can be managed as outpatients.

Caregiver education on feeding [2][12]

  • Provide a balanced diet with a variety of foods to try.
  • Avoid snacking (and drinks other than water) between meals.
  • Schedule regular mealtimes where everyone eats together.
  • Limit mealtimes to 20–30 minutes.
  • Allow children to self-feed; avoid force-feeding.
  • Provide positive reinforcement.

Nutritional modifications for growth faltering [2]

  • Determine caloric intake required to reach ideal weight-for-height. [2][3]
    • The dietary reference intake for young children is:
      • 0–6 months of age: 108 Kcal/kg/day
      • 6–12 months of age: 98 Kcal/kg/day
      • 1–3 years of age: 102 Kcal/kg/day
    • Catch-up caloric requirement (in Kcal/kg/day) = dietary reference intake (in Kcal/kg/day) × ideal weight-for-height [3]
  • Infants
    • If breastfeeding: Refer to a lactation consultant.
    • Increase the volume of breast milk or formula during feeds (as tolerated).
    • Consider increasing the caloric density of feeds.
  • Children [2]
    • Preferred: increasing calorie-dense foods
    • Alternative: supplemental high-calorie drinks

Follow-up [2][3]

  • Schedule regular appointments.
    • Weekly appointments may be appropriate initially, moving to monthly or every few months.
    • Infants may require more intensive follow-up.
  • Weigh children every few days to one week.
  • Initially, catch-up growth should occur.
    • Rapid growth at up to 2–3 times the normal rate
    • Growth should continue until an acceptable weight-for-length or BMI-for-age z score is attained (usually 4–9 months). [3]
  • Monitor children long-term to ensure appropriate weight gain velocity.
    • Relapse may occur if underlying etiology is inadequately addressed.
    • Excessive weight gain may also occur and should be avoided.

Measure weight every few days on a calibrated scale, at the same time of day with the same clothing on. [3]

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

  1. $Contributor Disclosures - Growth faltering. None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.
  2. Tang MN, Adolphe S, Rogers SR, Frank DA. Failure to Thrive or Growth Faltering: Medical, Developmental/Behavioral, Nutritional, and Social Dimensions. Pediatr Rev. 2021; 42 (11): p.590-603.doi: 10.1542/pir.2020-001883 . | Open in Read by QxMD
  3. Homan GJ. Failure to Thrive: A Practical Guide. Am Fam Physician. 2016; 94 (4): p.295-9.
  4. Mehta NM, Corkins MR, Lyman B, et al. Defining Pediatric Malnutrition. JPEN J Parenter Enteral Nutr. 2013; 37 (4): p.460-481.doi: 10.1177/0148607113479972 . | Open in Read by QxMD
  5. Craig WJ, Mangels AR, Fresán U, et al. The Safe and Effective Use of Plant-Based Diets with Guidelines for Health Professionals. Nutrients. 2021; 13 (11): p.4144.doi: 10.3390/nu13114144 . | Open in Read by QxMD
  6. Littlewood JM, Wolfe SP, Conway SP. Diagnosis and Treatment of Intestinal Malabsorption in Cystic Fibrosis. Pediatr Pulmonol. 2005; 41 (1): p.35-49.doi: 10.1002/ppul.20286 . | Open in Read by QxMD
  7. Daniel M, Kleis L, Cemeroglu AP. Etiology of Failure to Thrive in Infants and Toddlers Referred to a Pediatric Endocrinology Outpatient Clinic. Clin Pediatr (Phila). 2008; 47 (8): p.762-765.doi: 10.1177/0009922808316989 . | Open in Read by QxMD
  8. Norman V, Zühlke L, Murray K, et al. Prevalence of Feeding and Swallowing Disorders in Congenital Heart Disease: A Scoping Review. Front pediatr. 2022; 10: p.843023.doi: 10.3389/fped.2022.843023 . | Open in Read by QxMD
  9. Bouma S. Diagnosing Pediatric Malnutrition. Nutrition in Clinical Practice. 2016; 32 (1): p.52-67.doi: 10.1177/0884533616671861 . | Open in Read by QxMD
  10. Stevens GA, Beal T, Mbuya MNN, et al. Micronutrient deficiencies among preschool-aged children and women of reproductive age worldwide: a pooled analysis of individual-level data from population-representative surveys. Lancet Glob Health. 2022; 10 (11): p.e1590-e1599.doi: 10.1016/s2214-109x(22)00367-9 . | Open in Read by QxMD
  11. Canadian Paediatric Society. A health professional's guide for using the new WHO growth charts. Paediatr Child Health. 2010; 15 (2): p.84-90.doi: 10.1093/pch/15.2.84 . | Open in Read by QxMD
  12. Riley LK, Rupert J, Boucher O. Nutrition in Toddlers. Am Fam Physician. 2018; 98 (4): p.227-233.

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