Safeguarding Children at Risk Due to Faltering Growth

The term faltering weight has now been accepted as the term for infants, children and young people that show a fall in weight or poor weight gain. It is most often associated with infancy but can affect any child up to adulthood - if it is unrecognised and untreated it can have adverse consequences for a child’s health and development. For the purposes of this procedure, faltering growth includes faltering height and development delay.

Faltering growth affects approximately 5% of all children. 5% of these children are abused or neglected thus 0.25% of all children have faltering growth and abuse or neglect.

Of all children with faltering growth approximately 5% of these will have an underlying organic cause: i.e. a medical condition that increases nutritional requirements, affects the body’s utilisation of nutrition, decreases appetite or affects the body’s ability to take in adequate nutrition.

Approximately 95% of children with faltering growth will have no known organic cause. These children would thus be classified as having non-organic faltering growth. Poor growth would thus be attributed to inadequate food intake/nutrition.

Factors that contribute to inadequate food intake can include but are not limited to: early feeding difficulties, poor appetite (following illness or dental problems), parental attitudes to food and feeding (including cultural practices), behavioural difficulties and coercive feeding, limited or rigid parenting skills, parental ill health (e.g. depression), family characteristics (e.g. chaotic household and lack of routine), poor housing/facilities and neglect.

Children with faltering growth can have underlying issues that are both organic and non-organic in nature. Therefore even when there is known organic disease, other non-organic contributing factors should be explored, including abuse and/or neglect.

Although neglect and abuse only accounts for a small percentage of children with faltering growth all practitioners must remain mindful of neglect and abuse at all times, especially when there is no known organic cause and despite support and advice there is no improvement in growth.

Practitioners should be mindful that faltering growth occurs in children from all socio-economic groups and there is no evidence to suggest that rates are higher in poorer / low income families.

Recognition that a child is not growing appropriately depends upon regular monitoring of the child’s growth and recognition by professionals, carers and family that growth is not progressing normally. This is usually assessed using standardised growth charts. Guidelines on the 2009 UK-WHO growth chart suggest that a sustained drop of weight through 2 centile or more spaces is unusual (fewer than 2% of infants) and should be carefully assessed by the primary care team.

Professionals need to be mindful that health assessments for older/school age children are less frequent and therefore professionals need to be very alert to growth problems in this age group.

Faltering weight is identified in the main from the interpretation of standardised growth charts and this remains the most reasonable marker for diagnosis.

Faltering growth can thus be defined as:

• Insufficient weight gain to maintain growth along a centile line with weight or height falling through more than 2 centile channels;
• No signs of catch up growth.

Although growths charts are the most common way to identify faltering weight, the following features may also be linked with poor weight gain and practitioners should be mindful of these:

• Muscle wasting;
• Poor skinfold thickness;
• Thin wispy hair;
• Visible or prominent bones;
• Pale complexion;
• Poor sleep pattern;
• Developmental delay (particularly in communication skills);
• Emotional and behavioural issues (ranging from withdrawn/passive to active/chaotic with poor concentration);
• Low Body Mass Index (BMI) indicating potential eating disorder.

A child who displays some indicators of faltering growth may come to the attention of a professional following recognition of some of the indicators above. The professional should consider, after discussion with the parents, consulting with a health professional such as a health visitor or school nurse.

The health visitor/school nurse should undertake a primary care assessment which should include:

• Observing feeding;
• Checking chart height/length and head circumference;
• Checking BMI;
• Conducting a brief food and drink diary with parents;
• Compiling a social background and developmental history;
• Checking for symptoms – e.g. cough, vomiting, stools;
• Undertaking a developmental assessment;

If they are concerned, consideration should be given to referring the child to their GP for medical assessment. The GP will arrange to see the child and assess from a medical point of view whether there is any obvious cause for the child’s faltering growth. This will include an assessment of the child’s growth and development, and may involve a referral to the dietician who can evaluate feeding practices/dietary requirements and offer support to the family or to specialist paediatric assessment.

For more information, see Guidelines for GPs - to follow and Weight Faltering: Primary Care Management.

If a child is referred to a Paediatrician with faltering growth, they should undertake an assessment of the child, including assessment of the child’s growth and development, to determine whether there is any obvious cause.

If the assessment by a GP or Paediatrician confirms that the child has faltering growth, they will determine the next course of action. This might include referral to a Multi-disciplinary health team so that specialist services such as occupational therapist or CAMHS can be involved.

For more information, see Weight Faltering: Secondary Care Management - to follow.

The course of action might include additional medical investigation in the community or hospital admission as a last resort. The purpose of admission to hospital is to:

• Exclude organic disease by history taking, examination and investigations as appropriate;
• Observe parental behaviour and compliance with treatment (this is not a parenting assessment);
• Record if the infant or child is hungry and gains weight in hospital which the child has not gained at home;
• Discuss any suspected organic cause with the relevant experts.

When a child is admitted to hospital because of safeguarding concerns regard should be given to the relationship between the child and their parents/carers. For more information, see Contact between Parents and their Children in Hospital where there are Safeguarding Concerns Procedure. A Discharge Planning might be appropriate – for more information, see Discharge Planning from Hospital when there are Safeguarding Concerns about a Child Procedure.

If the GP or paediatric assessment finds no obvious cause for concern, they should consult with the referrer to agree a process for monitoring.

If at any time there are concerns that the child has suffered or is likely to suffer Significant Harm the situation should be discussed with the relevant Children’s Social Care Team Manager if the case is open to Children’s Social Care. If the case is not open a referral should be made to the Multi-Agency Safeguarding Hub (MASH) under the Referring Safeguarding Concerns about Children Procedure. Consideration should be given as to whether the threshold for Significant Harm has been met and a Strategy Discussions/Meetings convened (see Strategy Discussions/Meetings Procedure).

If medical opinion is that the child’s weight or development is due (wholly or in part) to the behaviour of the parents or there are concerns about the parent’s capacity to care for the child, a referral should be considered.

Concern about the parent’s behaviour or capacity to care for the child could include:

• The parents are hostile to professional concerns; this includes resistant and avoidant behaviour, disguised compliance, manipulation and non-engagement (including missed, cancelled or changed appointments) - for more information, see Reluctant and Hostile Families Procedure;
• The parent’s needs are too great to allow them to focus on the needs of the child (e.g. Parental Mental Health, Domestic Abuse, Parental Alcohol Misuse, Parental Substance Misuse, Children of Parents with Learning Disabilities);
• The parents fail to follow professional advice, either passively (e.g. due to lack of understanding or education) or deliberately (e.g.Management and Safeguarding Children Where there are Perplexing Presentations (including Fabricated and Induced Illness/ FII) Procedure);
• The parents insist on a diet for the child without medical diagnosis that is inappropriate for the child’s age, development or nutritional needs and this impacts on the child’s growth and development.

A referral to Children’s Social Care may be progressed via a Strategy Discussion to a Multi-Agency Assessment. All practitioners involved with the family should contribute to the assessment and any resulting intervention, including a Child in Need Plan, Early Help Assessment or Child Protection Plan.

Where it is considered that a child’s faltering growth is not putting a child at risk of significant harm, advice to the parents or carers regarding diet and support to the family should result in an improvement in the child’s growth. A referral to Early Help should be considered with the consent of the family. For more information, see Early Help Guidance: Integrated Working With Children, Young People and Families With Vulnerable or Complex Needs Procedure.

If parents fail to engage with the Early Help process, and the child's welfare continues to cause concern despite support and intervention at early help level, then a referral to MASH is appropriate.

The weight and development of the child who has faltering growth should be monitored by primary health professionals. Progress must be monitored within an agreed timescale appropriate to the child’s age, needs and circumstances.

The younger the child (especially below 12 months of age), the more critical the timescales - as brain growth is occurring at a significant rate, and therefore, longer timescales may not be adequate to safeguard and promote the child’s welfare. If no significant progress is being made, the situation should be escalated to the Paediatrician.

When continued monitoring of a child’s growth and development takes place because of concerns about faltering growth, there must be effective sharing of information amongst all professionals involved with the child and family. For more information, see Information Sharing Procedure.

Multi-agency discussion should take place appropriate to the threshold of the risk of significant harm to the child, e.g. Strategy Meeting, Child Protection Conference, Child in Need Meeting, Early Help or Team around the Family Meeting.

Ongoing monitoring of the plan should be agreed as appropriate to each of the services involved with the child or family. The role of each professional should be clear. The roles of health professionals are to diagnose and treat any organic disorder, consider any safeguarding concerns and report unexplained faltering growth. For example, a Paediatrician may wish to review the child in 6 weeks’ time, the Health Visitor will check the weight at intervals in between and the Dietician will advise the family so that they can implement the advice at home. The school and children’s centre staff should also participate in the monitoring and feedback process.