NICE vs RCPCH: Management of Failure to Thrive (2025)
Failure to Thrive (FTT), more accurately described as Faltering Growth, is a common clinical concern in paediatric practice. In the UK, two key bodies provide guidance: the National Institute for Health and Care Excellence (NICE) and the Royal College of Paediatrics and Child Health (RCPCH). While their overarching goals are aligned—ensuring child wellbeing—their approaches in guidance documents differ in scope, detail, and practical application. This comparison analyses the NICE guideline Faltering growth: recognition and management of faltering growth in children (NG75, September 2017, last updated February 2025) and the RCPCH resource Faltering Growth: A practical guide (2017, with ongoing relevance for 2025).
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Key Distinction: NICE provides a formal, evidence-based guideline for the NHS in England, Wales, and Northern Ireland. The RCPCH offers a practical guide and toolkit, reflecting consensus and expert opinion, designed for UK-wide use by paediatricians.
Diagnosis and Assessment
NICE (NG75)
NICE adopts a systematic, population-health focused approach. It emphasises using standardised growth charts (UK-WHO) and objective centile-based criteria to identify faltering growth.
- Definition: A fall across one or more weight centile spaces, where birthweight was at or below the 9th centile. For children whose birthweight was at or above the 75th centile, a larger fall (across two or more centile spaces) is significant.
- Assessment: Stresses a structured history and examination. Key areas include feeding history (duration, frequency, technique), psychosocial factors (family stress, parental mental health), and a thorough physical exam for underlying medical causes.
- Red Flags: Explicitly lists concerns warranting urgent specialist referral: vomiting, dysphagia, developmental delay, signs of neglect, or abnormal neurological findings.
RCPCH
The RCPCH guide provides a more nuanced, clinical-judgement-led framework. It acknowledges the limitations of strict centile-based definitions.
- Definition: Focuses on a child's growth deviating from their expected trajectory. It highlights the importance of serial measurements and clinical concern, even if centile criteria are not strictly met.
- Assessment: Offers highly detailed, practical tools. The "ABCD" approach is central: Anthropometry, Burden of disease/nutrition, Child-centred factors (development, behaviour), and Determinants (parenting, social, environment). This provides a holistic biopsychosocial model.
- Red Flags: Similar to NICE but embedded within the broader ABCD assessment, encouraging a comprehensive rather than checklist-based approach.
Key Difference & Practical Takeaway
NICE offers a standardised screening definition useful for primary care and community settings to ensure consistent identification. RCPCH provides a comprehensive diagnostic framework for paediatricians, integrating quantitative and qualitative factors to understand the "why" behind the growth pattern. In practice, use NICE's criteria for initial recognition and the RCPCH's ABCD tool for in-depth assessment.
Treatment and Management
NICE (NG75)
NICE guidance is principle-based and focuses on the multidisciplinary team (MDT).
- Primary Care Focus: Strong emphasis on initial management in primary care and by health visitors. Advises on responsive feeding, positioning, and addressing common feeding problems.
- Dietary Strategies: Recommends increasing the energy density of food and drink (e.g., adding healthy fats) as a first-line dietary intervention.
- Referral Pathways: Clearly outlines when to refer to specialist services (dietetics, paediatricians, speech and language therapy) if initial strategies fail or if red flags are present.
RCPCH
The RCPCH guide is more prescriptive regarding specific interventions and the role of the paediatrician.
- Intervention Hierarchy: Proposes a stepped approach: 1) Management of underlying disease, 2) Dietary manipulation, 3) Behavioural feeding strategies, 4) Consideration of oral nutritional supplements, 5) Rarely, enteral tube feeding.
- Detailed Advice: Provides specific, practical advice on managing behavioural feeding issues (e.g., food refusal, aversions) and the cautious use of high-energy supplements.
- MDT Coordination: Positions the paediatrician as the central coordinator of the MDT, which may include dietitians, psychologists, and social workers, particularly for complex cases.
Key Difference & Practical Takeaway
NICE outlines the "what" (principles and pathways) for the broader healthcare system. RCPCH details the "how" (specific interventions and hierarchy) for the specialist clinician. For a GP, NICE provides the management roadmap; for a paediatrician, RCPCH offers the clinical toolkit.
Special Situations
NICE (NG75)
NICE includes specific considerations for:
- Breastfed babies: Highlights that faltering growth is not a reason to stop breastfeeding and advises seeking support from a breastfeeding specialist.
- Disabled children: Notes the higher prevalence of faltering growth and the need for individualised assessment, considering factors like difficulty swallowing or physical challenges with eating.
RCPCH
The RCPCH guide delves deeper into complexity, reflecting its specialist audience.
- Complex Co-morbidities: Provides extensive guidance on managing FTT in children with neurological impairment, cystic fibrosis, cardiac disease, and other chronic conditions, where nutritional needs are altered.
- Social Complexity & Neglect: Offers a robust framework for assessing and managing cases where safeguarding is a concern, integrating closely with social care.
- Transition to Tube Feeding: Discusses indications, decision-making processes, and management plans for enteral nutrition support.
Key Difference & Practical Takeaway
NICE covers common special situations encountered in general practice. RCPCH is essential for managing complex, co-morbid, or high-risk cases under paediatric care, providing the depth required for specialist decision-making.
Practical Clinical Flow
A synthesis of both guidelines for a UK clinician:
- Identification (Using NICE): Plot weight on UK-WHO chart. Identify a significant fall in centiles as per NICE criteria. Trigger assessment.
- Initial Assessment (Using RCPCH ABCD):
- Anthropometry: Confirm growth pattern, review height and head circumference.
- Burden: Screen for medical signs/symptoms (red flags).
- Child: Assess development, feeding behaviour.
- Determinants: Detailed feeding, social, and family history.
- Initial Management:
- If no red flags and simple cause: Implement primary care advice (NICE) – feeding support, dietary energy increase.
- Monitor closely (2-4 weekly weight checks).
- Referral & Specialist Management (Using RCPCH):
- If no improvement, red flags present, or complex case: Refer to paediatric services.
- Specialist MDT follows RCPCH's stepped intervention model, managing underlying conditions, behavioural issues, and considering nutritional support.
Frequently Asked Questions (FAQs)
1. Which guideline takes precedence in clinical practice?
For NHS organisations in England, Wales, and Northern Ireland, NICE NG75 is the formal standard. The RCPCH guide is a complementary, expert-led resource that provides the practical detail to implement the NICE guideline effectively within paediatric practice. They should be used together, not in isolation.
2. How should I define Faltering Growth for a clinical letter?
Use the NICE definition for objectivity (e.g., "fall across two centile spaces since birth"). Then, contextualise it with the RCPCH ABCD findings to give a holistic picture (e.g., "...in the context of reported feeding difficulties and parental anxiety").
3. What is the single most important investigation?
Both guidelines agree: Serial, accurate weight measurements plotted on the correct chart is the cornerstone. Extensive routine blood tests or other investigations are not recommended initially; they should be guided by the history and examination findings.
4. When should I refer to a paediatrician?
Refer based on NICE's red flags (e.g., vomiting, developmental concern) or if structured primary care management fails over 2-4 weeks with no improvement in weight gain velocity. Early referral is also indicated for significant parental concern or complex psychosocial factors.
5. How do the guidelines address safeguarding?
Both emphasise that faltering growth can be a sign of neglect. NICE lists it as a red flag. RCPCH provides a more detailed framework within its "Determinants" domain, guiding the clinician on how to assess parenting capacity, home environment, and when to involve social services following local safeguarding procedures.
Source Links
- NICE Guideline NG75 (Feb 2025 update): Faltering growth: recognition and management of faltering growth in children
- RCPCH Practical Guide (2017): Faltering Growth - a practical guide (Includes downloadable assessment tools and flowcharts).
- UK-WHO Growth Charts: RCPCH Growth Chart Resources