The NICE Guideline states that: it is common for infants to lose some weight during the early days of life
NICE thresholds for concern include: a fall across 1 or more weight centile spaces, if birthweight was below the 9th centile
Historically, babies and young children who have not gained weight or not grown at the expected rate, have been termed as ‘failure to thrive’ and various different ways of managing this situation would be tried, depending on the view of the medical professional working with the family, and any the local policies in force to govern this.
Recently the term ‘Faltering Weight’ has been used instead, to describe a baby whose weight gain is less than expected, because the word ‘failure’ was seen as suggesting a judgement on the family. ‘Faltering Growth’ is now used to describe a baby or child whose growth rather than weight was less than expected.
In 2015, the National Institute for Health and Clinical Excellence (known as ‘NICE’), who provide guidance, advice, quality standards and information services for health, public health and social care, commissioned a NICE Guideline entitled ‘Faltering Growth: recognition and management of faltering growth in children’. This guideline was published in September 2017 and covers ‘recognition, assessment and monitoring of faltering growth in infants and children. It includes a definition of growth thresholds for concern and identifying the risk factors for, and possible causes of, faltering growth. It also covers interventions, when to refer, service design, and information and support.’
In the UK, normal healthy term babies are weighed according to the NICE Postnatal Care Guidelines and according to local practice, by the midwifery team at birth, then again by the midwifery team within the first week of life – usually about 5 days – and then again at around 10 days (by the Health Visitor at the ‘Primary Visit’) and around 3 weeks by the Midwife as they discharge the baby and mother from their care. Things may be slightly different for babies who are born preterm or who are unwell, and the timing of later weights is more variable.
Weights are recorded on the electronic systems used by hospitals, in the paper patient records, and in the Personal Child Health Record (PCHR) often known as the ‘red book’ – though in some areas the covers are no longer red. There is a table to record the weight and also other measurements, alongside the date, and there are weight and growth charts to plot the measurements against the age in weeks or months to make a graph showing weight and growth over time.
The weight charts for children from birth to four years of age which are used in the modern ‘red book’ are known as the UK-WHO Growth Charts and were first added to the PCHR in 2009. The new charts are based on the World Health Organisation (WHO) Child Growth Standards, which describe the optimal growth for healthy, breastfed children. Previous UK growth charts were based on data from studies on breast and formula fed children, so did not reflect normal weight fluctuations of breastfed children in the first few weeks – which is what we’re aiming for, of course.
The NICE Faltering Growth Guidance outlines thresholds at which babies are to be diagnosed as having faltering growth and makes evidence-based suggestions about the management of the baby’s feeding from there.
As an Infant Feeding Specialist, I often support families whose babies have been found not to have gained weight as expected. Sometimes this weight issue is picked up at day 3 or 5 when the babies lose a larger than desirable amount of their birth weight, sometimes it is picked up after a few weeks when baby has not got back to birth weight, and sometimes much later.
The NICE Guideline tells the reader that we should be aware that:
If your baby, in the first few days, loses more than 10% of her birth weight, your medical professional should first perform a clinical assessment of your baby, looking for evidence of dehydration, or of an illness or something else which might account for the weight loss. They should then ask you the right questions to gather a detailed feeding history, using the information provided in the NICE guideline on Postnatal Care to guide their questions.
Depending on whether the medical professional found something obvious to explain the weight loss, via either the clinical observation or the detailed feeding history, and whether the medical professional is appropriately skilled to conduct the observation of feeding and make useful suggestions to improve milk transfer from mother to baby, where applicable, they might then do a direct observation of the baby feeding.
If there isn’t an obvious cause for the weight issue from the feeding history or clinical observation, then your health professional should ensure an observation of baby’s feeding is done, crucially this must be conducted by a person with appropriate training and expertise – so if you are in this situation please seek out some expert and experienced breastfeeding support locally if possible, or remotely via telephone or social media if that is not possible. This might be from a –
The guidance says that medical professionals should perform further investigations (for example blood tests or hospital in-patient stays to monitor) only if they are indicated based on the clinical assessment.
The NICE guidance on faltering growth says that the mother of a baby who has been found to be weight faltering should be provided with feeding support, using the information in the NICE Postnatal Care Guideline.
If babies lose more than 10% of their birth weight in the early days of life, or they have not returned to their birth weight by 3 weeks of age, the NICE Faltering Growth guidance asks that the medical professional working with the family consider making a referral should be made to paediatric services (in the hospital), particularly if there is
If no immediate referral if made because the infant is otherwise well, then a decision should be made about when to reassess your baby if she is not referred to paediatric services at this point.
If a baby loses more than 10% of their birth weight in the early days of life, then her weight should measure at appropriate intervals depending on the level of concern, but no more frequently than daily.
Example 1 – 5-day old baby needing improvement in feeding technique
A baby who is weighed by their midwife and found to have a weight loss by day 5 of over 10%, and whose clinical observations are acceptable but feeding history and feeding observations demonstrate that there is some improvement to be made in feeding technique: in this case the mother and baby should be supported to make those changes and the midwife call back in one or two days to check progress by weighing again.
Example 2 – an older baby with slow weight gain
In a situation with an older baby, where weight gain has slowed but clinical observation shows a baby who is otherwise healthy, but the feeding history or observation of feeding show an area for improvement, then again the mother should be supported to improve milk transfer to baby, and perhaps a plan should be to weigh again in a week or even longer, depending on the severity and the age of the baby.
The NICE Guideline for Faltering Growth suggests using the following as thresholds for concern in infants and children (a centile space being the space between adjacent centile lines on the UK WHO growth charts):
The Guidance cautions that we should be aware that supplementary feeding with infant formula in a breastfed infant may help with immediate weight gain, but often results in breastfeeding ending before the mother planned, and sometimes in the allergic sensitisation of the baby.
If supplementation with an infant formula is given to a breastfed infant, we should support the mother to continue breastfeeding, advise her to express her breast milk to promote milk supply and then feed the infant with any available breast milk before giving any infant formula.
In the case of faltering weight in an otherwise healthy baby which does not respond to interventions to improve feeding technique, the NICE Faltering Growth guidance suggests that medical professionals might consider investigating for:
and then perform further investigations only if they are indicated based on the clinical assessment.
Other factors that might be associated with faltering growth include
The NICE guidance suggests that in faltering growth, a range of factors may contribute, and it may not be possible to identify a clear cause, and that while there may be difficulties in the interaction between an infant or child and the parents or carers that may contribute to the problem, this may not be the primary cause.
Input from someone who is expert and experienced in providing evidence-based information and support to breastfeeding families can use the feeding history and any direct observation of feeding to determine whether:
The NICE guidance recommends that you receive help in the community from a tells ‘primary care team.’ A primary care team includes your midwife or health visitor, and/or your GP.
Your primary care team may need access to the following healthcare professionals with expertise relevant to faltering growth,
You may have a lead healthcare professional who coordinates your baby’s care and acts as the first point of contact for you and your baby if several professionals are involved.
In practice this may mean that your midwife or health visitor begins the process by performing a clinical observation of your baby, talking through feeding history and observing a feed, or possibly calling in someone more experienced in supporting breastfeeding issues (or with the time to do it) to observe a feed, then making some initial suggestions to improve milk transfer to your baby which may include
Together you would then agree on a plan for the next day or two, or for the next week if the baby is a little older or issue not as severe, and organise a time and date to return to re-weigh your baby to assess whether the improvements to breastfeeding management have met their target.
There is no justification for automatic re-admission of baby to the paediatric service at the hospital for normal faltering growth when someone competent is managing the case in the community and plans have been made for improvement and reassessment, unless something is on offer in the hospital which cannot be provided in the community, for example, tube feeding the baby straight into its tummy, or an observation or monitoring in a potential safeguarding case.
NICE guidance goes on to say that we should only consider enteral tube feeding for infants and children with faltering growth when there are serious concerns about weight gain and an appropriate specialist multidisciplinary assessment for possible causes and contributory factors have been completed, and other interventions have been tried without improvement.
If tube feeding is to be used in an infant or child with faltering growth, make a plan with appropriate multidisciplinary involvement for the goals of the treatment (for example, reaching a specific weight target), and the strategy for its withdrawal once the goal is reached (for example, progressive reduction together with strategies to promote oral intake).
In most cases, the infant is simply not receiving enough milk because breastfeeding has not got off to a good enough start, either in terms of technique for supporting baby to attach to the breast, or other aspects of management like frequency of feeding and so on, perhaps because the mother has not been equipped with quite the right information and support to prepare her. Another reason for might be that there is some simple reason for the baby not being able to transfer milk sufficient to meet its needs for growth, for example, restricted oral function from a ‘tongue tie’, or some residual damage eg to neck or jaw during birth meaning it cannot get into an effective breastfeeding position.
The crucial messages therefore, are to provide good evidence-based information to mothers about how to feed effectively and the signs that things may not be going so well (signs including nappy output and signs of good attachment at the breast), and to ensure all families can access expert and experienced breastfeeding support if anything does not go as planned, so that they can get back on track properly, without needed to supplement with infant formula as this is not supportive of continued breastfeeding.
It’s a steep learning curve for new mothers, but the hard work is worth it!