A.5.1. Who is the focus?

A.5.2. Settings

A.5.3. Activities, services or aspects of care

A.5.4. Economic aspects

We will take economic aspects into account when making recommendations. We will develop an economic plan that states for each review question (or key area in the scope) whether economic considerations are relevant, and if so whether this is an area that should be prioritised for economic modelling and analysis. We will review the economic evidence and carry out economic analyses using an NHS and personal social services (PSS) perspective.

A.5.5. Key issues and questions

While writing this scope, we have identified the following key issues, and key questions related to them:

1. Recognising faltering growth, including defining thresholds for concern

   • What are the growth thresholds for enhanced monitoring or intervention for suspected or confirmed faltering growth in infants and preschool children?
2. Identifying the risk factors for faltering growth

   • What are the risk factors for faltering growth that could inform recognition and management?
3. Assessing infants and preschool children with faltering growth

   • What is the prevalence of specific conditions in infants and preschool children who present with faltering growth and no other symptoms or signs, to help determine appropriate investigations?
4. Growth monitoring in infants and preschool children with suspected or confirmed faltering growth

   • What growth monitoring should be carried out in infants and preschool children with suspected or confirmed faltering growth?
5. Referring to secondary care

   • What factors determine the need for referral to secondary care for infants and preschool children with suspected or confirmed faltering growth?
6. Providing interventions to manage faltering growth

   • What interventions related to breastfeeding are effective in the management of faltering growth?
   • What interventions related to feeding practices other than breastfeeding are effective in the management of faltering growth?
   • What interventions related to dietary advice or supplementation are effective in the management of faltering growth?
   • What family support interventions are effective in the management of faltering growth?
7. Designing services for the management of faltering growth

   • What service configurations are effective for the management of faltering growth in infants and preschool children?
8. Providing information and support to parents and carers

   • What information and support should be provided for parents and carers of infants and preschool children with suspected or confirmed faltering growth?

The key questions may be used to develop more detailed review questions, which guide the systematic review of the literature.

A.5.6. Main outcomes

The main outcomes that will be considered when searching for and assessing the evidence are:

1. measurements of nutritional status (weight, length or height, head circumference, mid-arm circumference)
2. continued breastfeeding
3. increased nutritional intake
4. health-related quality of life
5. parent or carer satisfaction
6. adherence to interventions
7. adverse effects of interventions
8. use of health services.

A.6.1. NICE guidance

A.6.2. NICE Pathways

When this guideline is published, the recommendations will be added to NICE Pathways. NICE Pathways bring together all related NICE guidance and associated products on a topic in an interactive topic-based flow chart.

A draft pathway outline on faltering growth, based on this draft scope, is included below. It will be adapted and more detail added as the recommendations are written during guideline development.

Other NICE guidance that may be included in this pathway is the NICE technology appraisal guidance on human growth hormone (somatropin) for the treatment of growth failure in children.

A.7.1. Key facts and figures

The term ‘faltering growth’ is widely used in relation to infants and young children whose weight gain occurs more slowly than expected for their age and sex. In the past this was often described as a ‘failure to thrive’ but this is no longer the preferred term, partly because ‘failure’ could be perceived as pejorative, but also because lesser degrees of faltering growth may not necessarily indicate a significant problem but merely represent variation from the usual pattern. Estimates of the prevalence of faltering growth in the UK vary widely, depending on the definition used.

The World Health Organization (WHO) has produced growth standards, based on longitudinal studies of healthy breastfed infants. These standards, along with UK full-term and preterm infant growth data, have been incorporated into UK-WHO growth charts for monitoring children’s growth in the UK. A child’s weight, length or height, and head circumference can be plotted to provide a visual representation of their growth over time. Epidemiological studies have shown that healthy children usually progress relatively consistently along a growth centile.

Faltering growth can occur when a child’s nutritional intake does not meet their specific energy requirements. Undernutrition may underlie relatively slow weight gain and movement downwards across weight centiles on a growth chart. Faltering growth in early childhood may be associated with persisting problems with appetite and feeding.

Certain health conditions predispose children to faltering growth (for example, cystic fibrosis or coeliac disease). Specific treatment for such conditions (for example, pancreatic enzyme supplementation for cystic fibrosis and a gluten free diet for coeliac disease) can improve or restore normal weight gain. Simple interventions (such as extra calories and protein) may also be effective in supporting nutrition and weight gain.

The causes of faltering growth in the absence of an underlying condition may be complex and have a variety of causes. In the past, child neglect or socioeconomic and educational disadvantage were often considered to be likely contributors. While neglected children may be undernourished, neglect is now thought to be an uncommon explanation for faltering growth. Similarly, socioeconomic and educational factors have not emerged as important associations in more recent research.

A.7.2. Current practice

Infants and preschool children with faltering growth are often identified by routine growth monitoring. Others may be identified through concern expressed by parents or healthcare professionals. Initial management is often community based and involves providing support and advice to increase calorie intake and manage challenging feeding behaviour. Some children are referred to paediatric dietitians or paediatricians for further assessment and support.

There is variation in practice across the UK in how infants, preschool children and families are supported, referred and investigated where concerns are raised about faltering growth. There is cultural and socioeconomic variation in the rates of initiation and maintenance of breastfeeding, approaches to weaning and choices of weaning foods. Expectations and behaviour at mealtimes, for example whether families eat together, may also be relevant to the risk of infants developing challenging feeding behaviour. These may also influence how readily parents accept feeding support and advice.

A.7.3. Policy, legislation, regulation and commissioning