SGEM#523: Everything Grows and Grows…Until it Doesn’t. Clinical Practice Guidelines for Faltering Weight

Reference: Kersten HB, et al; American Academy of Pediatrics and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Clinical Practice Guideline for Diagnosis and Management of Faltering Weight. Pediatrics. 2026. Date: September 15, 2026 Dr. Salina Khushal Guest Skeptic: Dr. Salina Khushal is a Pediatric Gastroenterologist at the Pediatric Specialists of Virginia. She completed her fellowship at Johns Hopkins University School of Medicine and her pediatrics residency at Children’s National Hospital. Her research interests include inflammatory bowel disease, celiac disease, eosinophilic esophagitis, and constipation. Case A 7-month-old infant is sent to the emergency department (ED) for failure to thrive workup (FTT). The parents report that the baby has always been small, but over the past two months, weight gain has slowed. On your exam, the child is not febrile, is smiling, is hydrated, and has normal vital signs. The parents report that feeding has become more difficult since the infant started solids. It has also been difficult maintaining breastfeeding supply after the parent returned to work. They are worried and ask: “Is something seriously wrong? What testing do you have to do? Does our baby have to stay in the hospital?” Background FTT has been around for decades, but the term has always been messy. The term is vague, inconsistently defined, and can feel blaming to families. The word “failure” lands hard when parents are already worried about their child’s growth. It is also not a single disease. It is a descriptive label applied to children who are not gaining weight or growing as expected. While it may seem like this is a more outpatient or subspecialist issue, we are often tasked with evaluating these patients in the ED and determining disposition. The new American Academy of Pediatrics (AAP) and North American Society for Pediatric Gastroenterology, Hepatology, & Nutrition (NASPGHAN) clinical practice guideline updates the language from “failure to thrive” to “faltering weight.” This guideline includes 8 Key Action Statements and 4 Good Practice Statements. The guideline moves away from relying on percentiles and tries to standardize the diagnosis using z scores. That is a major shift. Many previous definitions used weight below the 3rd or 5th percentile, weight-for-length below the 5th percentile, or crossing two major percentile lines. The guideline defines faltering weight as any of the following: Weight-for-length or BMI-for-age less than −1.65 z score, which corresponds roughly to the 5th percentile In children younger than 2 years, weight gain velocity less than −2 z score for age Decline in weight, weight-for-length, or BMI of 1 z score or more Previ0usly, failure to thrive was often divided into organic and non-organic causes. Organic causes meant that faltering weight was attributed to an identifiable medical condition or disease process, such as congenital heart disease, cystic fibrosis, chronic infection, malabsorption, renal disease, or genetic syndromes. Non-organic causes meant poor weight gain was attributed to psychosocial, environmental, behavioral, feeding, or caregiving factors. Examples might include inadequate caloric intake, feeding technique problems, food insecurity, caregiver mental health concerns, etc. The new guideline moves away from that framework because it is too simplistic. Poor weight gain is usually multifactorial, with medical, nutritional, developmental, feeding, behavioral, and social factors often interacting at the same time. Rather than trying to place children into one of two buckets, the guideline encourages clinicians to identify the specific contributors to faltering weight and tailor evaluation and management to the child and family. This clinical practice guideline is primarily intended for pediatricians and other pediatric health care providers in the outpatient setting. The authors defined this group as primary care pediatricians, family practice physicians, subspecialty physicians, other specialty physicians (eg, gastroenterology, genetics), and other members of the team who care for children with faltering weight (eg, dentists, dietitians, feeding therapists, lactation consultants, nurses, nurse practitioners, nutritionists, oral surgeons, physician assistants, social workers, speech and occupational therapists, behavioral and/or functional therapists, feeding therapists, and pediatric psychologists). However, children with poor weight gain are often referred to the ED for urgent evaluation, laboratory testing, or admission. That makes this guideline relevant to pediatric emergency medicine, even if it was not designed specifically for the ED. Clinical Question: In young children with faltering weight living in high-resourced settings, which diagnostic, nutritional and feeding strategies identify important underlying disease and improve growth while minimizing harms, costs, burden and inequity, and should socioeconomic status be used as a diagnostic risk factor? This was built around six prioritized questions.: Whether socioeconomic status predicts faltering weight Whether diagnostic testing should be performed to look for an underlying condition Whether calories should be increased Whether oral supplements or higher-calorie formulas should be used Whether feeding or speech therapy should be provided When endoscopy is useful, including which clinical features predict an abnormal finding Reference: Kersten HB, et al; American Academy of Pediatrics and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Clinical Practice Guideline for Diagnosis and Management of Faltering Weight. Pediatrics. 2026. Population: Children with poor weight gain or suspected faltering weight. The systematic reviews informing the guideline largely focused on children aged 0–5 years in high-resourced countries. Common exclusions were populations from low- and middle-resourced countries, children being fed through a nasogastric tube, studies dominated by older children or adults, and non-English-language reports. Review-specific exclusions also removed case reports, secondary research, reports of tests no longer in routine use and studies that did not provide an outcome relevant to diagnosis or treatment of faltering weight. These exclusions make the population more consistent with North American outpatient practice, but they also narrow generalizability. Exposure/Intervention: The exposure question was socioeconomic status. The diagnostic interventions included laboratory tests, imaging and gastrointestinal endoscopy with biopsy. The treatment interventions were increased calories or energy density, higher-calorie formula or oral nutritional supplements, and multidisciplinary feeding interventions involving dietitians, speech-language pathologists, occupational therapists, home visitors or other members of a feeding team. Comparison: The comparators were no assigned socioeconomic risk factor, no routine diagnostic testing, no endoscopy, no increase in calories, no oral supplementation, no feeding intervention or usual care. Usual care was not standardized across all studies and ranged from ordinary primary care to clinic-based nutritional advice. There was no conventional placebo group for most questions. Outcome: Primary Outcomes. The guideline did not specify one overall primary outcome. Outcomes varied by question and included the frequency of faltering weight, identification of an underlying disease, diagnostic yield and accuracy, endoscopy findings and complications, and changes in growth or weight gain. Secondary Outcomes. Other outcomes included height, calorie intake, development, feeding ability, oral intake, and meeting nutritional needs. The panel also considered potential harms and practical issues, such as false-positive results, additional testing or referrals, hospitalization, procedural complications, excessive weight gain, feeding stress, cost, access, feasibility, and health equity. Many of these outcomes were considered by the panel but were not directly measured in the included studies. Type of Study: Clinical practice guideline using GRADE methodology, systematic reviews, evidence-to-decision frameworks, and expert consensus. Authors’ Conclusions: This CPG renames the condition formerly called “failure to thrive” as “faltering weight.” It also standardizes diagnostic criteria and proposes initial management for this condition as well as an equitable approach. Because this CPG was codeveloped with NASPGHAN, it also provides guidance regarding considerations for endoscopy in children with faltering weight. Challenges remain regarding the adoption of this CPG, and doing so will require changes in EHRs and, potentially, in office procedures. Education of patients, families, pediatricians, and the health care team—along with enhanced information technology solutions—will be needed to help translate these recommendations into clinical practice. Quality Checklist for a Clinical Practice Guideline The study population included or focused on those in the emergency department. No. An explicit and sensible process was used to identify, select, and combine evidence. Yes. The quality of the evidence was explicitly assessed using a validated instrument. Yes. An explicit and sensible process was used to assess the relative value of different outcomes. Yes. The guideline thoughtfully balances desirable and undesirable effects. Yes. The guideline accounts for important recent developments. Unsure. The guideline has been peer-reviewed and tested. Yes and No. Practical, actionable, and clinically important recommendations are made. Unsure The guideline authors’ conflicts of interest are fully reported, transparent,...