Understanding the NICE Approach to Nutritional Decline
NICE, the National Institute for Health and Care Excellence, provides evidence-based guidance for healthcare professionals in the UK. When it comes to the broad concept of 'failure to thrive,' NICE distinguishes between two different population groups: children and adults. For children, the term 'faltering growth' is used, with specific guidelines in place (NICE guideline NG75). In contrast, for adults, there is no specific guideline for 'failure to thrive' as a syndrome. Instead, NICE guidance focuses on diagnosing and managing adult malnutrition, which is often a key component of what is colloquially known as adult 'failure to thrive'. This separation is crucial for understanding how healthcare providers are directed to assess and treat these conditions effectively.
NICE Guidance for Faltering Growth in Children
NICE guideline NG75, published in 2017, provides a clear framework for the recognition, assessment, and management of faltering growth in infants and children. The guidance defines specific thresholds using 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.
- A current weight below the 2nd centile for age, regardless of birthweight.
Assessment for Faltering Growth
Following the identification of faltering growth, a comprehensive assessment is recommended, involving:
- Clinical History: A detailed history is taken, including feeding patterns, medical conditions, and family and social factors.
- Physical Examination: A full physical check-up helps identify any underlying medical causes.
- Multidisciplinary Approach: Collaboration between pediatricians, dietitians, and other specialists is crucial for complex cases.
Management for Faltering Growth
The management plan is based on the assessment findings and may include:
- Dietary Interventions: Simple interventions include feeding support and nutritional advice for parents.
- Nutritional Supplements: If dietary changes are insufficient, a trial of oral nutritional supplements may be considered.
- Monitoring and Review: Ongoing monitoring of the child's growth is essential to ensure catch-up growth occurs without excessive weight gain.
NICE Guidance for Malnutrition in Adults
For older adults, the symptoms associated with 'failure to thrive'—such as unintentional weight loss, poor appetite, and reduced activity—are addressed under NICE's guidance on adult malnutrition. This guidance applies to various care settings, including primary care and care homes.
Screening for Malnutrition
NICE recommends systematic screening for malnutrition using a validated tool, such as the Malnutrition Universal Screening Tool (MUST). Screening should occur opportunistically in primary care and upon admission to new care settings. Key indicators for screening include:
- Unintentional weight loss.
- Body Mass Index (BMI) below 18.5 kg/m².
- Eating little or nothing for more than 5 days.
Assessing Malnutrition in Adults
Following a positive screen, a full assessment is conducted. This involves gathering information on:
- Nutritional Intake: Dietary history, appetite, and any swallowing difficulties.
- Functional Abilities: Assessment of mobility, strength, and ability to perform daily activities.
- Psychosocial Factors: Evaluation of mood, cognitive changes, and social situation, as isolation can contribute to malnutrition.
- Underlying Conditions: Investigation for any medical conditions, infections, or medication side effects that may cause weight loss.
Managing Adult Malnutrition
Management is tailored to the individual and often involves a multidisciplinary team. Strategies include:
- Dietary Advice: Providing food and drink with extra calories and protein, offering fortified foods, and encouraging regular snacking.
- Oral Nutritional Supplements: Prescribing supplements if dietary changes are inadequate to meet nutritional needs.
- Treating Underlying Causes: Addressing any underlying medical, psychological, or social issues contributing to malnutrition.
- Assisted Feeding: In severe cases or when swallowing is impaired, methods like tube feeding or intravenous nutrition may be used.
- Monitoring and Review: Regularly reviewing the patient's nutritional status and adjusting the care plan as needed.
Comparison of Guidance for Children vs. Adults
| Feature | Faltering Growth in Children | Malnutrition in Adults |
|---|---|---|
| Key Term | Faltering Growth | Malnutrition (often linked to adult 'failure to thrive') |
| NICE Guidance | NG75 (2017) | CKS topic on Adult Malnutrition; QS24 on Nutrition Support |
| Screening | Defined growth chart thresholds (centile drops) | Validated tools like MUST, based on BMI and weight loss |
| Assessment | Focuses on growth charts, feeding history, development | Evaluates nutritional intake, function, psychosocial factors |
| Management | Nutritional advice, feeding support, oral supplements | Dietary fortification, supplements, managing comorbidities |
| Context | Pediatric care, growth development, feeding dynamics | Geriatric care, chronic conditions, frailty |
The Role of the Multidisciplinary Team and Care Settings
Both pediatric faltering growth and adult malnutrition require a collaborative, multidisciplinary approach involving several healthcare professionals. For children, this may include pediatricians, dietitians, speech and language therapists, and social workers. In the adult care setting, the team often includes GPs, dietitians, community nurses, physiotherapists, and mental health teams.
Importance in Senior Care
In the context of senior care, the NICE guidance on adult malnutrition is particularly relevant. Elderly individuals are at a higher risk of malnutrition due to factors like chronic illness, poor appetite, frailty, and social isolation. Healthcare providers and caregivers in care homes or providing at-home support must adhere to NICE quality standards regarding nutritional screening and care planning. This includes regular screening for at-risk residents and communicating nutrition support goals clearly between care settings.
Conclusion: A Clear Distinction in Guidance
In summary, while the umbrella term 'failure to thrive' is sometimes used, NICE guidance is clear in its distinct approach for children and adults. For children, the focus is on addressing faltering growth with specific guidelines (NG75), while for adults, the focus is on the assessment and management of malnutrition based on relevant CKS topics and quality standards. Understanding this distinction is crucial for healthcare professionals and caregivers seeking to provide appropriate, evidence-based care. Early identification, comprehensive assessment, and a multidisciplinary care plan are the cornerstones of successful management in both instances. To learn more about the guidelines for adult malnutrition, refer to the NICE Clinical Knowledge Summary: Adult malnutrition.
