We have detected you're using an outdated browser. Please upgrade to a major browser for the best experience.

Skip to main content

Faltering Growth and Paediatric-Specific ONS

  By Rachel Sipaul RD    

For many parents, seeing their child ‘grow up’ is a source of delight. This includes seeing their child physically grow, becoming taller and reaching growth milestones.  Conversely however, for children whose growth is slow and not following the ‘normal’ path, it can be an incredibly distressing time, for both the child and parents.  While there are many aspects to ‘growing’, there is no doubt that good nutrition is an essential component. Medical Nutrition also plays an important role, particularly in children whose faltering growth is related to a chronic disease. 

Faltering growth describes when a child fails to achieve adequate growth for their age (to note, the term Failure to Thrive is also used but has now commonly been replaced by faltering growth). Faltering growth is not a disease in itself, but rather describes a condition when a child is not receiving adequate nutrition. Put simply the child is ‘under-nourished’ and is not receiving adequate amounts of energy (protein, fat and carbohydrate) or micronutrients (vitamins and minerals) to meet their requirements. It is imperative that faltering growth is identified as soon as possible, because under-nutrition in children has far reaching complications such as delayed developmental milestones, delayed motor development, learning disabilities, frequent infections, vitamin deficiencies and chronic fatigue (Lissauer, 2007).

While there are varied causes of faltering growth, children with chronic medical conditions (for example; cystic fibrosis; Crohn’s disease; cardiac disease; renal disease; cancer) are often seen as high risk groups. Children with these conditions can have higher nutritional requirements, eating difficulties, poor appetite and malabsorption issues, and as such will often require specialist nutrition support (Lissauer, 2007). NICE have issued guidelines ‘Faltering growth: recognition and management of faltering growth in children’, which detail management strategies (NICE, 2017). NICE strategies include encouraging the child to maximise their dietary intake (e.g. meals and snacks, establishing a feeding routine), moving on to optimising energy and nutrient density by use of food fortification and energy dense foods. If these strategies are not enough, they can be referred to a paediatric dietitian and consider the use of oral nutritional supplements (ONS).

"Consider a trial of an oral nutritional supplement for infants or children with continuing faltering growth despite other interventions" (NICE 2017)

ONS specifically designed for children are available in a range of formats, such as milk based drinks, smoothie drinks or fruit based puddings. Typically paediatric ONS drinks are available in 200ml servings (1.5kcal/ml, 300kcal), though a recent study involving a number of centres across the UK, has looked at the use of a more energy-dense ONS, in a smaller 125ml serving (2.4kcal/ml, 300kcal) (Hubbard, 2020). The smaller, more energy-dense portion size has been used in adults for some years and has been shown to improve compliance and significantly increase energy and protein intakes (Hubbard, 2010). It was therefore hypothesized that in children with smaller appetites, a reduced volume but energy-dense ONS may also be beneficial. The recently published study by Hubbard et al (2020) involved 51 children (mean age 5.8 years) with faltering growth, approximately half (n24) received a standard 200ml ONS and half (n27) received a compact (125ml), energy dense ONS for 28 days. Both ONS were paediatric-specific and provided the same amount of energy (300kcal), just in differing volumes. Use of the compact ONS resulted in significantly greater mean daily intakes of energy, protein and micronutrients over time, due to the high ONS compliance (81% of children consumed >75% of the total volume). Although growth increased in both the standard and compact ONS groups, there was a significant increase in weight and height for those consuming the compact ONS.

The study supports the NICE guidelines and other literature showing that paediatric-specific ONS have an important role in aiding children with faltering growth, helping them improve their dietary intake and ultimately helping them grow.


Lissauer T, Clayden G. Illustrated textbook of paediatrics. 3rd edition. Mosby Elsevier 2007.

National Institute for Health and Care Excellence. Faltering growth: recognition and management of faltering growth in children. NICE guideline [NG75]. Published date: 27 September 2017

Hubbard GP, Fry C, Sorensen K, et al. Energy-dense, low-volume paediatric oral nutritional supplements improve total nutrient intake and increase growth in paediatric patients requiring nutritional support: results of a randomised controlled pilot trial. Eur J Pediatr. 2020;179(9):1421-1430. Doi:10.1007/s00431-020-03620-9.

Hubbard GP, Buchan B, Sanders K et al. Improved compliance and increased intake of energy and protein with a high energy density, low volume multi-nutrient supplement. January 2010. Proceedings of the Nutrition Society 69(OCE2) DOI: 10.1017/S0029665109993600.