People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off‑label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Some weight loss in the first days after birth (referred to in this guideline as the early days of life) is normal and usually relates to body fluid adjustments. Sometimes there may be reason for concern about weight loss in the early days of life, which may need assessment and intervention. For this reason weight loss in the early days of life is dealt with separately in this guideline from concerns about inadequate weight gain in older infants and children, which is often related to nutritional intake.
Be aware that:
it is common for infants to lose some weight during the early days of life
this weight loss usually stops after about 3 or 4 days of life
most infants have returned to their birth weight by 3 weeks of age.
If infants in the early days of life lose more than 10% of their birth weight:
perform a clinical assessment, looking for evidence of dehydration, or of an illness or disorder that might account for the weight loss
take a detailed history to assess feeding (see NICE's guideline on postnatal care)
consider direct observation of feeding
ensure observation of feeding is done by a person with appropriate training and expertise (for example, in relation to breastfeeding and bottle feeding)
perform further investigations only if they are indicated based on the clinical assessment.
Provide feeding support (see recommendations in NICE's guideline on postnatal care) if there is concern about weight loss in infants in the early days of life, for example if they have lost more than 10% of their birth weight.
If infants 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, consider:
referral to paediatric services if there is evidence of illness, marked weight loss, or failure to respond to feeding support (see recommendations in NICE's guideline on postnatal care)
when to reassess if not referred to paediatric services.
If an infant loses more than 10% of their birth weight in the early days of life, measure their weight again at appropriate intervals depending on the level of concern, but no more frequently than daily.
Be aware that supplementary feeding with infant formula in a breastfed infant may help with weight gain, but often results in cessation of breastfeeding.
If supplementation with an infant formula is given to a breastfed infant:
support the mother to continue breastfeeding
advise expressing breast milk to promote milk supply and
feed the infant with any available breast milk before giving any infant formula.
Consider using the following as thresholds for concern about faltering growth in infants and children (a centile space being the space between adjacent centile lines on the UK WHO growth charts):
a fall across 1 or more weight centile spaces, if birthweight was below the 9th centile
a fall across 2 or more weight centile spaces, if birthweight was between the 9th and 91st centiles
a fall across 3 or more weight centile spaces, if birthweight was above the 91st centile
when current weight is below the 2nd centile for age, whatever the birthweight.
If there is concern about faltering growth (for example, based on the criteria in recommendation 1.2.1):
weigh the infant or child
measure their length (from birth to 2 years old) or height (if aged over 2 years)
plot the above measurements and available previous measurements on the UK WHO growth charts to assess weight change and linear growth over time.
If there are concerns about an infant's length or a child's length or height, if possible obtain the biological parents' heights and work out the mid-parental height centile. If the child's length or height centile is below the range predicted from parental heights (more than 2 centile spaces below the mid-parental centile) be aware this could suggest undernutrition or a primary growth disorder.
If there is concern about faltering growth or linear growth in a child over 2 years of age, determine the BMI centile:
using the UK WHO centiles and the accompanying BMI centile 'look‑up chart' or
by calculating the BMI (weight in kg/height in metres squared) and plotting this on the BMI centile chart.
Then:
if the BMI is below the 2nd centile, be aware this may reflect either undernutrition or a small build
if the BMI is below the 0.4th centile, this suggests probable undernutrition that needs assessment and intervention.
Record all growth measurements in the parent- or carer-held Personal Child Health Record.
If there is concern about faltering growth:
perform a clinical, developmental and social assessment
take a detailed feeding or eating history
consider direct observation of feeding or meal times
consider investigating for:
urinary tract infection (follow the principles of assessment in NICE's guideline on urinary tract infection in under 16s)
coeliac disease, if the diet has included gluten-containing foods (follow the principles of assessment in NICE's guideline on coeliac disease)
perform further investigations only if they are indicated based on the clinical assessment.
If observation of eating or feeding is needed because of concern about faltering growth, ensure this is done by a person with appropriate training and expertise.
Be aware that the following factors may be associated with faltering growth:
preterm birth
neurodevelopmental concerns
maternal postnatal depression or anxiety.
Recognise that in faltering growth:
a range of factors may contribute to the problem, and it may not be possible to identify a clear cause
there may be difficulties in the interaction between an infant or child and the parents or carers that may contribute to the problem, but this may not be the primary cause.
Based on the feeding history and any direct observation of feeding, consider whether any of the following are contributing to faltering growth in milk-fed infants:
ineffective suckling in breastfed infants
ineffective bottle feeding
feeding patterns or routines being used
the feeding environment
parent/carer–infant interactions
how parents or carers respond to the infant's feeding cues
physical disorders that affect feeding.
Based on the feeding history and any direct observation of mealtimes, consider whether any of the following are contributing to faltering growth:
mealtime arrangements and practices
types of foods offered
food aversion and avoidance
parent/carer–child interactions, for example responding to the child's mealtime cues
appetite, for example a lack of interest in eating
physical disorders that affect feeding.
Consider asking the parents or carers of infants and children with faltering growth to keep a diary recording food intake (types and amounts) and mealtime issues (for example, settings, behaviour) to help inform management strategies and assess progress.
Be aware that investigations (other than those recommended in recommendation 1.2.6) are unlikely to reveal an underlying disorder in a child with faltering growth who appears well with no other clinical concerns.
If a child with faltering growth develops new clinical symptoms or signs after the initial assessment, reconsider whether investigations are needed.
Together with parents and carers, establish a management plan with specific goals for every infant or child where there are concerns about faltering growth. This plan could include:
assessments or investigations
interventions
clinical and growth monitoring
when reassessment to review progress and achievement of growth goals should happen.
Provide feeding support (see recommendations in NICE's guideline on postnatal care) if there is concern about faltering growth in the first weeks of life. Consider whether such feeding support might be helpful in older milk-fed infants, including those having complementary solid foods.
Be aware that while supplementary feeding with infant formula may increase weight gain in a breastfed infant if there is concern about faltering growth, it often results in cessation of breastfeeding.
If supplementation with an infant formula is given to a breastfed infant because of concern about faltering growth after the early days of life:
support the mother to continue breastfeeding
advise expressing breast milk to promote milk supply and
feed the infant with any available breast milk before giving any infant formula.
When there are concerns about faltering growth, discuss the following, as individually appropriate, with the infant's or child's parents or carers:
encouraging relaxed and enjoyable feeding and mealtimes
eating together as a family or with other children
encouraging young children to feed themselves
allowing young children to be 'messy' with their food
making sure feeds and mealtimes are not too brief or too long
setting reasonable boundaries for mealtime behaviour while avoiding punitive approaches
avoiding coercive feeding
establishing regular eating schedules (for example 3 meals and 2 snacks in a day).
If necessary, based on the assessment, advise on food choices for infants and children that:
are appropriate to the child's developmental stage in terms of quantity, type and food texture
optimise energy and nutrient density.
In infants or children who need a further increase in the nutrient density of their diet beyond that achieved through advice on food choices, consider:
short-term dietary fortification using energy-dense foods
referral to a paediatric dietitian.
Advise the parents or carers of infants or children with faltering growth that drinking too many energy-dense drinks, including milk, can reduce a child's appetite for other foods.
Consider a trial of an oral liquid nutritional supplement for infants or children with continuing faltering growth despite other interventions (see recommendations 1.2.16 to 1.2.22).
Regularly reassess infants and children receiving an oral nutritional supplement for faltering growth to decide if it should be continued. Take into account:
weight change
linear growth
intake of other foods
tolerance
adherence
the views of parents or carers.
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 has been completed and
other interventions have been tried without improvement.
If enteral 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)
the strategy for its withdrawal once the goal is reached (for example, progressive reduction together with strategies to promote oral intake).
If there are concerns about faltering growth (see recommendation 1.2.1), measure the weight at appropriate intervals taking account of factors such as age and the level of concern, but usually no more often than:
daily if less than 1 month old
weekly between 1–6 months old
fortnightly between 6–12 months
monthly from 1 year of age.
Monitor weight if there are concerns about faltering growth (see recommendation 1.2.1), but be aware that weighing children more frequently than is needed (see recommendation 1.2.27) may add to parental anxiety (for example, minor short-term changes may cause unnecessary concern).
Be aware that weight loss is unusual except in the early days of life, and may be a reason for increased concern and more frequent weighing than is recommended (see recommendation 1.2.27).
If there are concerns about faltering growth monitor length or height at intervals, but no more often than every 3 months.
If an infant or child with faltering growth has any of the following discuss with, or refer to, an appropriate paediatric specialist care service:
symptoms or signs that may indicate an underlying disorder
a failure to respond to interventions delivered in a primary care setting
slow linear growth or unexplained short stature (see recommendation 1.2.3)
rapid weight loss or severe undernutrition
features that cause safeguarding concerns (see the NICE guideline on child maltreatment).
Do not admit infants or children with faltering growth to hospital unless they are acutely unwell or there is a specific indication requiring inpatient care, such as a plan to begin tube feeding (see recommendation 1.2.25).
Ensure there is a pathway of care for infants and children where there are concerns about faltering growth or weight loss in the early days of life that:
clearly sets out the roles of healthcare professionals in primary and secondary care settings
establishes and makes clear the process for referral to and coordination of specialist care in the pathway.
Provide community-based care for infants and children where there are faltering growth concerns or weight loss in the early days of life with a team (the 'primary care team') that includes, for example:
a midwife
a health visitor
a GP.
Ensure that the primary care team has access to the following healthcare professionals with expertise relevant to faltering growth:
infant feeding specialist
consultant paediatrician
paediatric dietitian
speech and language therapist with expertise in feeding and eating difficulties
clinical psychologist
occupational therapist.
Consider identifying a lead healthcare professional to coordinate care and to act as the first point of contact for parents of children with faltering growth, for example if several professionals are involved.
Recognise the emotional impact that concerns about faltering growth or weight loss in the early days can have on parents and carers and offer them information about available:
professional support
peer support.
Follow the principles in the NICE guidelines on patient experience in NHS services, babies, children and young people's experience of healthcare and shared decision making in relation to communication (including different formats and languages), information and shared decision making.
Provide information on faltering growth or weight loss in the early days of life, to parents or carers that is:
specific to them and their child
clearly explained and understandable to them
spoken and in writing.
If there is concern about faltering growth in an infant or child or weight loss in the early days of life, discuss with the parents or carers:
the reasons for the concern, and how the growth measurements are interpreted
any worries or issues they may have
any possible or likely causes or factors that may be contributing to the problem
the management plan (see recommendation 1.2.15).
Pre-school children from 1 year of age.
Behaviours sometimes observed in infants or children indicating a persistent unwillingness to eat. Such behaviours, depending upon age, might include signs of distress when presented with food, spitting of food or avoidance behaviour.
A baby up to 1 year of age.
This is the increase in length (under 2 years of age) or height (2 years or older) over time in infants and children.
A high-energy liquid feed designed for enteral use, usually selected and prescribed after specialist advice from a paediatric dietitian.
This is what happens when nutrition is not sufficient. An infant or child with undernutrition may be abnormally thin, may weigh less than expected for their length or height, and if prolonged, undernutrition can lead to stunting (length or height less than expected for age).