Failure to thrive (FTT), now more commonly referred to as faltering weight. It is a common yet complex pediatric condition affecting about 5 to 10% of children in primary care settings. FTT has traditionally been used as a descriptive label instead of a definitive diagnosis. It is linked to growth deceleration or inadequate weight gain. The term carries negative connotations and may lead caregivers to feel blamed for their child’s conditions. Historically, FTT was classified as either organic because of medical causes or nonorganic because of psychosocial factors, but this dichotomy is now considered overly simplistic, as growth faltering is typically multifactorial, which involves medical, nutritional, and social determinants. The absence of clear diagnostic criteria and consistent terminology has contributed to both underdiagnosis and overdiagnosis, variability in research, and inefficiencies in clinical care.
The aim of the updated Clinical Practice Guideline (CPG) is to standardise terminology, diagnosis, and management by replacing FTT with the term faltering weight. This terminology is more neutral and less stigmatizing and aligns with international standards like NICE guidelines. The guideline seeks to establish clear, evidence-based diagnostic criteria, improve the accuracy and reliability of diagnosis, promote efficient and targeted evaluation, reduce unnecessary testing, and support early identification and intervention. It emphasizes a multidisciplinary and patient-centered approach that considers the broader context of the child’s health, including nutritional status, developmental needs, and social environment.
The methods used to develop this guideline were rigorous and evidence-based, which follows the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. A multidisciplinary panel comprising paediatricians, subspecialists, researchers, and caregiver representatives collaborated over several years to review existing evidence. Systematic reviews were conducted using standardized methodologies, and recommendations were formulated based on population, intervention, comparator, and outcome (PICO) questions.
Evidence quality was graded from high to very low. Recommendations were categorized as strong or conditional. The guideline incorporated consensus-building techniques like the modified Delphi process to establish agreement on terminology and diagnostic criteria. Anthropometric assessment was performed using z-scores, which provide a more precise and standardized evaluation of growth patterns across populations.
Diagnostic criteria for faltering weight include low weight-for-length or BMI-for-age (z score < −1.65), poor weight gain velocity (z score < −2 in children under 2 years), or a significant decline in growth parameters (≥1 z score). These criteria are intended as screening tools instead of definitive indicators of malnutrition and must be interpreted within the clinical context.
The treatment and management of faltering weight emphasizes a stepwise, individualized, and multidisciplinary approach. The cornerstone of management is nutritional rehabilitation by increased caloric intake, which is strongly recommended as a first-line intervention. Strategies include the use of calorie-dense foods, fortified feeds, and tailored dietary plans to meet the child’s energy requirements. Oral nutritional supplements may be considered when dietary measures alone are insufficient, although they should not replace regular food intake and must be used judiciously to avoid overdependence or excessive weight gain.
Feeding therapy, which involves speech therapists, occupational therapists, dietitians, and behavioral specialists, is recommended for children with feeding difficulties, as it can improve intake, feeding skills, and overall growth outcomes. The guideline strongly discourages routine laboratory testing and invasive procedures like endoscopy in the initial evaluation unless specific clinical indications are present, as these investigations have a low diagnostic yield. It may lead to unnecessary costs, anxiety, and reduced healthcare equity. Careful history-taking, physical examination, and assessment of feeding practices and social context are emphasized as the most valuable diagnostic tools. The guideline also highlights the importance of addressing social determinants of health, such as food insecurity and access to care, which can significantly impact growth and outcomes.
The transition from FTT to faltering weight represents an important shift toward a more precise, standardized, and compassionate method for pediatric growth concerns. The guideline aims to improve clinical outcomes and healthcare efficiency by introducing clear diagnostic criteria based on z-scores, discouraging unnecessary testing, and emphasizing nutritional and multidisciplinary management. It underscores the need for individualized care that considers the complex interplay of medical, nutritional, and social factors. There are major gaps in evidence that highlight the need for further research to refine diagnostic thresholds, optimize treatment strategies, and evaluate long-term outcomes. Overall, the guideline provides a comprehensive framework to enhance early detection, reduce stigma, and deliver equitable and effective care for children with faltering weight.
Reference: Kersten HB, Goday PS, Abdelhadi R, et al. Clinical practice guideline for diagnosis and management of faltering weight. Pediatrics. 2026:e2025075764. doi:10.1542/peds.2025-075764
