ARTICLE
Growth Outcomes of Weight Faltering in Infancy
in ALSPAC
AUTHORS: Zia ud Din, MSc, PhD,a Pauline Emmett, BSc,
SRD, PhD,b Colin Steer, MSc,b and Alan Emond, MA, MB, MD,
FRCPCHb
aDepartment of Human Nutrition, KP Agricultural University,
Peshawar, Pakistan; and bCentre for Child and Adolescent Health,
University of Bristol, Bristol, United Kingdom
KEY WORDS
ALSPAC, failure to thrive, growth, growth patterns, weight gain
ABBREVIATIONS
ALSPAC—Avon Longitudinal Study of Parents and Children
CI—confidence interval
MAC—mid-arm circumference
SDS—SD score
WC—waist circumference
www.pediatrics.org/cgi/doi/10.1542/peds.2012-0764
doi:10.1542/peds.2012-0764
Accepted for publication Nov 19, 2012
Address correspondence to Alan Emond, MA, MB, MD, FRCPCH,
Centre for Child and Adolescent Health, School for Social and
Community Medicine, University of Bristol, Oakfield House,
Oakfield Grove, Bristol BS8 2BN, UK. E-mail: alan.emond@bristol.
ac.uk
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2013 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: Dr Din was supported by a grant from
the Higher Education Commission, Pakistan. Dr Emmett has
undertaken lectures and consultancies and received research
funding from Pfizer Nutrition, Danone, and Plum Baby, who are
involved in the provision of commercial infant foods. The other
authors have indicated they have no financial relationships
relevant to this article to disclose.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found on
page e939, and online at www.pediatrics.org/cgi/doi/10.1542/
peds.2012-0767.
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WHAT’S KNOWN ON THIS SUBJECT: Studies of clinically derived
samples of infants with failure to thrive have reported that
children remain shorter and lighter than their peers at school-
age. Enhanced weight gain (“catch-up”) in small infants has been
linked to subsequent obesity.
WHAT THIS STUDY ADDS: Infants with early weight faltering
caught up in weight by 2 years, but height gain remained
disproportionally slow. Those with weight faltering later in infancy
remained shorter and lighter throughout childhood.
Anthropometric outcomes of both groups were within population
norms at 13 years.
abstract
OBJECTIVE: The goal of this study was to investigate growth outcomes
in term infants with weight faltering.
METHODS: Conditional weight gain was calculated on term infants
from the Avon Longitudinal Study of Parents and Children. Cases of
weight faltering were infants with a conditional weight gain below
the fifth centile. Outcome growth measurements included weight
and length/height (from 9 months to 13 years), BMI, mid-arm
circumference, and waist circumference (at 7, 10, and 13 years).
RESULTS: Weight data were available on 11 499 infants; 507 had “early”
weight faltering (before 8 weeks), and 480 had “late” weight faltering
(between 8 weeks and 9 months). The early group showed enhanced
weight gain from 8 weeks until 2 years, then gained weight at the
same rate as the controls. Gain in height was proportionally slower
than gain in weight through childhood. By 13 years, they had BMI, mid-
arm circumference, and waist circumference similar to the controls.
The late group showed steady weight gain throughout childhood;
enhanced weight gain compared with the controls only occurred
between 7 and 10 years. Gain in height was proportional to gain in
weight. This group remained considerably lighter and shorter than
the controls up to the age of 13 years.
CONCLUSIONS: Children with weight faltering before 8 weeks showed
a different pattern of “catch-up” to those with weight faltering later in
infancy. By 13 years, the anthropometric profile of the 2 groups was
within population norms. Pediatrics 2013;131:e843–e849
e843
Weight gain in infancy has long been
recognized as an important determinant
of subsequent growth trajectory, and
recent attention has focused on rapid
weight gain in the second 6 months of life
as a precursor of subsequent obesity.
Slow weight gain in infancy is often
regarded by parents, and by some
clinicians, as a sign of underlying ill
health, and such infants are expected to
be lighter and shorter as children. The
evidence for this belief is largely based
on clinic-derived samples of infants with
failure to thrive. In early studies of failure
to thrive, slow-growing infants were
found to have poor anthropometric
outcomes in later life,1,2 to have gained
less weight by age 5 years,3 to be
shorter and lighter at age 6 years,4 and
to have lower BMI at age 12 years.5 Many
researchers have identified cases by
using a weight for age below a certain
centile. However, using a centile-based
cutoff for weight will include many
healthy, normal small infants. The pref-
erable approach is to use the criteria of
weight gain below the fifth centile, ad-
justed for age, gender, and initial posi-
tion in the weight distribution to derive
a conditional weight gain.6–8
More recent community or population-
based cohort studies that define growth
faltering on standardized anthropo-
metric criteria of weight gain9,10 have
challenged the traditional view that slow
weight gain is necessarily a marker of ill
health or undernutrition.11,12 Clinicians
working with generally well-nourished
populations face a dilemma between
identifying slow-growing infants to re-
ceive interventions to increase energy
input so that they achieve catch-up in
weight gain, and being aware of the in-
creasing evidence linking rapid weight
gain in infancy with subsequent obesity.13
We have used the Avon Longitudinal Study
of Parents and Children (ALSPAC)14 to
investigate the background factors10,15
and the cognitive,16 psychological, and
educational outcomes of children with
e844 DIN et al
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weight faltering in infancy. In this article,
we report their growth outcomes up to
the age of 13 years.
METHODS
ALSPAC is a United Kingdom–based
birth cohort study designed to examine
the genetic and environmental deter-
minants of child health and develop-
ment.17 The UK Medical Research Council
(grant 74882), the Wellcome Trust (grant
076467), and the University of Bristol
provide core support for ALSPAC.
The study recruited 14 541 pregnant
women resident in the former Avon
Health Authority area of southwest
England with an expected date of de-
livery between April 1991 and Decem-
ber 1992, resulting in a total birth
cohort of 14 062 live births of whom
13 970 were alive at 1 year of age. Avon
has a mixture of urban and rural com-
munities with sociodemographic charac-
teristics similar to the rest of the United
Kingdom at the 1991 census. Methodo-
logic details of the study have been pub-
lished,14 and details of questionnaires
and research clinics can be found on the
ALSPAC Web site.17 Ethical approval for
the study was obtained from the ALSPAC
Law and Ethics Committee and the local
research ethics committees.
Definition of Cases
Weight data collected by health pro-
fessionals as part of routine child
health surveillance were obtained from
the Avon Child Health computer system.
Weights were taken at birth, 6 to 8
weeks (range: 1–3 months), and 9
months (range: 6–12 months) and
converted to z scores adjusted for
gender and age by using the UK 1990
Growth Reference.18 If data were
missing for any of these measures,
children were not included in further
analyses (n = 1292). Infants were also
excluded if they had a major congenital
abnormality likely to affect growth
(eg, cerebral palsy, congenital heart
disease, Down syndrome; n = 89), were
nonsingleton births (n = 184), or were
born preterm (,37 weeks) or post-
term (.42 weeks) (n = 871). For this
growth study, infants with very extreme
weight measurements (#4 SDS or $4
SDS) at birth or 8 weeks were also
excluded (n = 35); these were considered
likely to be measurement or recording
errors. The number of children available
for this analysis was thus 11 499.
Growth was measured by calculating
differences in z scores between 2 time
points and adjusted for regression to-
ward the mean by using Cole’s equa-
tion,19 using regression coefficients
derived from within the cohort. The
resulting weight gain was conditional
on gender, age, and initial weight.
Centiles were produced,20 and as in
previous studies10,15,16 investigating
weight faltering in ALSPAC, cases were
identified as infants with conditional
weight gain below the fifth centile within
the cohort (z score less than –1.645). All
other infants in the cohort with weight
gain above the fifth centile at each time
interval comprised the control group.
Outcomes
Weights and heights measured by
health visitors as part of routine pre-
school surveillance in the community at
ages 18 months to 2 years and 3 years 6
months to 4 years were extracted from
the Avon Child Health computer system.
Weights and heights, mid-arm circum-
ference (MAC), and waist circumfer-
ence (WC) were measured according to
standardized procedures in ALSPAC
research clinics at 7, 10, and 13 years.
All measures were adjusted for age and
gender: weight, height, and BMI were
standardized compared with the UK
1990 reference, and MAC and WC were
standardized by using the internal
means of the ALSPAC cohort as reference.
Different numbers of children were
available for analysis at each time point
depending on whether measurements
were performed on them at that time;

data available on outcomes at different
ages ranged from 100% to 44%.
Confounders
Maternal educational level, housing
tenure, socioeconomic class, and pa-
rental heights were obtained by using
postal questionnaires completed dur-
ing the study pregnancy. Mothers and
partnerswere asked to self-report their
height; data were available for 10 307
mothers and 7165 fathers of the chil-
dren in infancy. Feeding symptoms and
difficulties were captured by parent-
completed questionnaires. Parents
were asked to rate on a scale of 1 to 5
whether their infant demonstrated
specific feeding behaviors, which were
named but not described in the ques-
tionnaire, and no definitions were
provided on what constituted a prob-
lem. We have used specific questions
on feeding from questionnaires com-
pleted at 1, 6, and 15 months of age.
Statistical Analysis
The data were analyzed by using Stata
(Stata Corp, College Station, TX)21 and
SPSS (IBM SPSS Statistics, IBM Corpo-
ration, Armonk, NY).22 The effect of
early growth on anthropometric out-
comes was assessed by running
a general linear model.23 Analysis of
covariance was used in multivariate
analysis to investigate interaction
effects. Major confounders included
maternal anthropometry, socioeco-
nomic characteristics, and infant-
feeding difficulties. Assumption of ho-
mogeneity of variances was tested
by using Levene’s test,24 and the
Pearson product moment correlation
coefficient25 was used to assess cor-
relation among variables. To determine
whether there was a difference between
the expected frequencies and the ob-
served frequencies in $1 category, x2
tests were conducted. All tests were
performed at a significance level of 0.01.
A P value of ..01 was used for stepwise
exclusion of covariates in view of the
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number of outcome variables investi-
gated and the importance of a conser-
vative approach to analysis. We took the
approach of using available data for
each outcome because restricting the
analysis to only those with complete
data for all outcomes would reduce the
numbers substantially.
RESULTS
Ascertainment
From the 11 499 children with complete
growth measurements in infancy, those
with data available at later ages were
more likely to come from families of
higher socioeconomic class, with a
higher maternal educational level, and
secure housing tenure (P #.01 for all),
compared with those lost to follow-up.
However, there were no differences in
the proportion of missing data be-
tween the 2 weight gain groups and the
controls.
Infant Growth
The mean 6 SD birth weight of the
whole sample was 3470 6 475 g.
Weight z scores (corrected for gender
and gestational age) at birth, 6 to 8
weeks, and 9 months were normally
distributed, with a mean just above
0 and an SD of ∼1. Weight gain z scores
were also normally distributed, centiles
were constructed, and infants below
the fifth centile were classified as
cases of growth faltering. A total of 507
children showed slow weight gain from
birth to 8 weeks (early group) and 480
children from 8 weeks to 9 months
(late group). Thirty children (12 boys,
18 girls) were common to both slow
weight gain groups. The tables show
the controls for the early group: the
means and confidence interval (CI) for
the late control group were similar, with
differences ,0.07 SDS. The attained
weights are shown in Table 1, and the
conditional weight gains (weight veloc-
ities) are displayed in Table 2. There
were no differences in the proportion of
ARTICLE
low birth weight infants in the 2 groups
compared with controls.10
Longitudinal Growth
Early Weight-Faltering Group
Infants with early weight faltering
showed an increased weight velocity
compared with controls between 8
weeks and 2 years, resulting in their
weight returning toward the reference
mean for that age (Fig 1). After 2 years,
this group gained weight at a similar
rate to the controls. From 7 to 13 years,
both the early group and the controls
gained weight faster than the refer-
ence, but at all points those with pre-
vious weight faltering remained lighter
than control children; at 13 years, the
mean weight for the early group was
3.3 kg below the mean for controls but
was still above the mean of the UK ref-
erence. Children from the control group
had mean weights parallel to and above
the reference mean at all age points.
The early group was, on average,
shorter than controls at all ages, and
there were proportionally more chil-
dren below the 10th centile (Supple-
mental Appendix 1). Between 8 weeks
and 9 months, the early group grew in
length at a slower rate than controls;
after 9 months, the length/height ve-
locity of the early group was not dif-
ferent from controls (Table 2).
The height velocity of the early group
was slower than their weight velocity up
to 7 years, resulting in these children
being disproportionately short com-
pared with their weight, but these dif-
ferences disappeared after this age,
and there was no difference in mean
BMI, MAC, or WC between the early
group and controls at 13 years (Table 3).
For all these outcome measures, in
multivariate analysis, weight SDS at 8
weeks explained the differences be-
tween the early group and the controls.
The models used in the multivariate
analyses are presented in Supplemen-
tal Appendix 2.
e845
 e846
TABLE 1 Mean (99% CI) Measurements and SDS: Weights, Heights, and BMI for Weight-Faltering Groups and Controls
Weight Gain Group Unit Subject Age

DIN et al
9 mo 2y 4y 7y 10 y 13 y
Early kg 8.51 (8.38 to 8.64) 11.39 (11.20 to 11.58) 15.66 (15.38 to 15.93) 24.61 (23.93 to 25.30) 36.45 (35.12 to 37.78) 52.16 (50.23 to 54.09)
Weight SDS 20.57 (–0.69 to –0.45) 20.21 (–0.34 to –0.08) 20.17 (–0.31 to –0.04) 20.14 (–0.29 to 0.02) 0.12 (–0.04 to 0.29) 0.20 (0.02 to 0.39)
cm 70.86 (70.47 to71.24) 82.66 (82.12 to 83.19) 98.77 (98.20 to 99.34) 123.82 (122.99 to 124.63) 141.69 (140.65 to 142.72) 160.25 (158.93 to 161.58)
Height SDS 20.22 (–0.36 to –0.08) 20.16 (–0.30 to –0.02) 20.33 (–0.46 to –0.19) 20.18 (–0.33 to –0.03) 20.03 (–0.19 to 0.12) 0.04 (–0.13 to 0.21)
w/h2 16.94 (16.87 to 17.02) 16.67 (16.16 to 16.73) 16.07 (15.95 to 16.15) 15.96 (15.65 to 16.27) 17.98 (17.49 to 18.47) 20.19 (19.60 to 20.79)
BMI SDS 20.58 (–0.69 to–0.46) 20.19 (–0.3 to –0.07) 20.99 (–0.01 to –0.21) 20.05 (–0.20 to 0.11) 0.19 (0.008 to 0.37) 0.21 (0.02 to 0.40)
n 451 403 352 284 270 228
Late kg 7.51 (7.38 to 7.64) 10.22 (10.04 to 10.41) 14.44 (14.16 to 14.71) 22.69 (22.03 to 23.37) 33.87 (32.55 to 35.18) 49.18 (47.23 to 51.14)
Weight SDS 21.72 (–1.83 to –1.61) 21.22 (–1.35 to –1.09) 20.85 (–0.98 to –0.72) 20.67 (–0.82 to –0.52) 20.25 (–0.41 to –0.09) 20.10 (–0.29 to 0.09)
cm 69.90 (69.51 to 60.29) 81.02 (80.47 to 81.56) 97.12 (96.53 to 97.70) 121.93 (121.13 to 122.72) 140.03 (139.00 to 141.06) 159.61 (158.27 to 160.96)
Height SDS 20.65 (–0.79 to –0.51) 20.72 (–0.87 to –0.58) 20.74 (–0.88 to –0.60) 20.53 (–0.67 to –0.38) 20.26 (–0.41 to –0.11) 20.06 (–0.23 to 0.11)
w/h2 15.37 (15.27 to15.50) 15.57 (15.50 to 15.64) 15.31 (15.19 to 15.41) 15.19 (14.89 to 15.49) 17.12 (16.63 to 17.60) 19.25 (18.64 to 19.85)
BMI SDS 21.85 (–1.96 to–1.75) 21.05 (–1.17 to –0.93) 20.48 (–0.59 to –0.36) 20.51 (–0.66 to –0.35) 20.20 (–0.38 to –0.02) 20.13 (–0.33 to 0.07)
n 419 385 337 295 275 220
Control kg 9.25 (9.22 to 9.28) 11.94 (11.89 to 11.98) 16.42 (16.37 to 16.48) 25.80 (25.66 to 25.95) 38.16 (37.82 to 38.44) 54.70 (54.29 to 55.12)
Weight SDS 0.19 (0.17 to 0.22) 0.23 (0.20 to 0.26) 0.23 (0.20 to 0.25) 0.20 (0.17 to 0.24) 0.41 (0.37 to 0.45) 0.51 (0.47 to 0.55)
cm 72.50 (72.42 to 72.59) 83.97 (83.85 to 84.08) 100.50 (100.38 to 100.62) 125.74 (125.57 to 125.91) 144.08 (143.86 to 144.30) 163.51 (163.22 to 163.79)
Height SDS 0.48 (0.45 to 0.51) 0.29 (0.26 to 0.32) 0.11 (0.08 to 0.14) 0.19 (0.16 to 0.22) 0.34 (0.31 to 0.37) 0.47 (0.43 to 0.51)
w/h2 17.59 (17.57 to 17.61) 16.96 (16.93 to 16.98) 16.25 (16.23 to 16.28) 16.24 (16.18 to 16.31) 18.25 (18.15 to 18.36) 20.37 (20.24 to 20.50)
BMI SDS 20.09 (–0.12 to –0.07) 0.01 (–0.02 to 0.03) 0.26 (0.24 to 0.28) 0.14 (0.11 to 0.17) 0.33 (0.29 to 0.36) 0.33 (0.29 to 0.38)
n 9773 8675 7799 6474 5925 4887
Control group are the controls for the early growth-faltering group.

the controls (Table 3).

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(Supplemental Appendix 2).

Late Weight-Faltering Group

weight-faltering group and the controls

weight gain similar to the controls
lighter, on average, than the controls
it did not greatly change the effect size
vs 164.1 cm [95% CI: 163.9–166.1, n =

attained at 10 and 13 years, these

weight and height between the late
thus, they were on average both
controls. Compared with controls, at all

shorter and lighter than the controls at

(Supplemental Appendix 1). The late
despite being much lighter, but be-
all age points until 13 years (Fig 1). Up to
163.0 cm [95% CI: 162.2–163.8, n = 453]

complications up to 6 months were

proportional to their gain in weight;
slowly than the controls up to 4 years,

at 10 and 13 years. Although feeding

factor in explaining the differences in
MAC, and WC were lower than those of

months seemed to be the dominant

In multivariate analysis, weight SDS at 9
trols (Table 2). Their gain in height was
group gained length/height more
tween 7 and 10 years, their weight gain
7 years, the late group showed a rate of
and compared with the UK reference at
between 8 weeks and 9 months were
Infants who faltered in weight gain
than control mothers (mean height:
group were on average slightly shorter
Mothers, but not fathers, of the early

statistically associated with the height

all ages. At 13 years, their mean BMI,
gain was at a similar rate to the con-
more were below the 10th centile
ages, children in the late group were

but from 4 years to 13 years, height

remained considerably lighter than the
reference weight for that age, but they
controls. By 13 years, the mean weight
was included in the multivariate model,

of the late group had reached the mean

accelerated and was faster than the
9854]). However, when maternal height

shorter (Table 1) and proportionally

 ARTICLE

TABLE 2 Conditional Weight and Length/Height Gain SDS (Velocity) in Weight-Faltering and Control Groups
Weight Gain Groups Subject Age

8 wk–9 mo 9 mo–2 y 2–4 y 4–7 y 7–10 y 10–13 y

Weight gain SDS
Early 0.52 0.32 20.02 20.11 0.53 0.34
(0.39 to 0.64) (0.19 to 0.45) (–0.18 to 0.13) (20.29 to 0.07) (0.36 to 0.70) (0.13 to 0.54)
n 507 403 292 209 238 215
Late 22.09 0.18 0.01 20.15 0.73 0.27
(–2.24 to 1.97) (0.04 to 0.32) (–0.14 to 0.16) (–0.33 to 0.02) (0.57 to 0.89) (0.06 to 0.48)
n 480 385 286 220 250 209
Control 0.17 0.13 0.09 0.00 0.53 0.34
(0.14 to 0.19) (0.10 to 0.16) (0.05 to 0.12) (–0.04 to 0.04) (0.49 to 0.56) (0.30 to 0.39)
n 10 992 8674 6516 4763 5301 4539
Length/height gain SDS
Early 20.06 20.10 20.19 0.06 0.35 0.28
(–0.22 to 0.10) (–0.26 to 0.05) (–0.34 to –0.04) (–0.11 to 0.24) (0.19 to 0.51) (0.09 to 0.47)
n 394 350 287 210 237 214
Late 20.86 20.46 20.28 0.08 0.53 0.34
(–1.02 to–0.70) (–0.62 to 0.30) (–0.44 to –0.13) (–0.09 to 0.25) (0.37 to 0.68) (0.15 to 0.53)
n 378 337 271 218 249 209
Control 0.20c 20.02 20.12 0.11 0.44 0.38
(0.17 to 0.24) (–0.05 to 0.01) (–0.15 to –0.09) (0.07 to 0.15) (0.41 to 0.48) (0.34 to 0.42)
n 8683 7763 6417 4763 5283 4527
Control group are the controls for the early growth-faltering group. Data are presented as mean (99% CI).

the population reference mean by age

FIGURE 1
Cross-sectional mean weight SDS of early and late weight-faltering groups and controls compared with
UK 1990 reference population.
factors did not attentuate the differ-
ences between the late-faltering group
and controls (see models in Supple-
mental Appendix 2).
Both mothers and fathers of the late
group were shorter, by ∼2 cm on
average, than the parents of the controls.
Mothers’ mean height was 162.0 cm
(95% CI: 161.2–162.9 [n = 410]) vs 164.1
cm (95% CI: 163.9–164.3 [n = 9897]).
Fathers’ mean height was 174.5 cm (95%
CI: 173.5–175.7 [n = 270]) vs 176.1 cm
(95% CI: 175.9–176.3 [n = 6895]). However,
when parental height was included in the
multivariate model, it did not change the
effect size (Supplemental Appendix 2).
Comparison of Early and Late
Weight-Faltering
Although the mean weights of both
groups of children whose weight fal-
tered in infancy recovered to close to
13 years, the pattern of this recovery
was quite different. Figure 1 illustrates
that the early group largely reached
the reference mean for weight by the
age of 2 years, whereas the late group
continued to grow slowly until age 13
years, and remained smaller and ligh-
ter than the early group.
The mean weights and heights of
the boys and girls at 13 years were
not statistically different. No gender
differences were found in the pattern of
weight or height gain in the early- and
late-faltering groups, and no differ-
ences were apparent in the age of
menarche between either of the weight-
faltering groups and the controls.
DISCUSSION
The growth outcomes of children with
poor weight gain in infancy showed that
by age 13 years, they had achieved
heights and weights that were close to
the reference mean but lower than their
peers. The pattern of weight gain in
childhood differed depending on when
the weight faltering occurred: those
with early weight faltering before 8

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TABLE 3 Cross-Sectional BMI, MAC, and WC SDS of Weight-Faltering Groups and Controls at 10 and 13 Years
Weight Gain Group
10 y
BMI
Early 0.19 (0.008 to 0.37)
n 270
Late 20.20 (–0.38 to –0.02)
n 276
Controls 0.33 (0.29 to 0.36)
n 5925
Control group are the controls for the early growth-faltering group. Data are presented as mean (99%).
weeks showed early recovery with en-
hanced weight gain and had almost
“caught up” by 2 years, whereas those
with later weight faltering between 8
weeks and 9 months gained weight
slowly until 7 years, then had a spurt
between 7 and 10 years, but remained
considerably shorter and lighter than
both the normally growing controls
and the early weight-faltering group.
The differences in anthropometric
outcomes between the growth-
faltering groups and controls at 13
years was largely explained by their
weight gain in infancy, re-enforcing the
importance of the first year of life in
determining subsequent growth.
Although the infants who faltered in
weight gain did eventually recover their
weight, their linear growth remained
relatively restricted, with ∼20% below
the 10th centile at 13 years, showing
that slow weight gain in infancy was
associated with subsequent shortness
consistent with previous studies.5,9,26
As both parents of the late weight-
faltering infants were shorter than the
parents of control children, it is likely
that a proportion of these children were
showing growth patterns normal for
their genetic potential. The Millennium
Cohort Study in the United Kingdom has
concluded that both maternal and pa-
ternal height and weight exert in-
dependent and significant influences on
a child’s birth weight and weight gain
between birth and 9 months.27
This study used a large representative
cohort and avoided the biases inherent
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Anthropometric Measurement SDS
WC BMI
20.16 (–0.32 to –0.008) 0.21 (0.02 to 0.40)
270 228
20.51 (–0.67 to –0.36) 20.13 (–0.33 to 0.07)
275 220
0.007 (–0.03 to 0.04) 0.33 (0.29 to 0.38)
5959 4887
in referred samples of children with
failure to thrive. The use of conditional
weight gain, both to identify children
with slow weight gain in the 2 time
periods and to measure their sub-
sequent growth trajectories, adjusted
for the regression to the mean; this
finding would be expected for small
infants at the extreme of the distribu-
tion. However, the study has some im-
portant limitations, especially missing
data: although all subjects selected for
this project had complete weight data
up to 9 months, loss of follow-up took
place from 9 months onward, which
increased as children got older, so that
some of the variables at 13 years were
only available for 44% of the original
cohort. However, it is reassuring that
there were no differences in the pro-
portion of missing data between the
weight gain groups and the controls. We
used the 1990 UK growth reference
because it has data from birth to 18
years derived from British population
surveys, whereas the World Health Or-
ganization growth standards are only
published up to 5 years of age. It must be
acknowledged that much of the data
that contributed to the 1990 UK refer-
ence were collected in the 1970s and
1980s from a British population that
was mainly bottle-fed. However, be-
cause we are comparing slow-growing
groups with controls assessed against
the same standards, the conclusions
would not be changed if we had used
a different standard. A final limita-
tion is that parental heights were
13 y
MAC WC
20.13 (–0.30 to 0.04) 20.15 (–0.32 to 0.02)
228 228
20.38 (–0.55 to –0.20) 20.42 (–0.59 to –0.24)
219 219
0.006 (–0.03 to 0.04) 0.007 (–0.03 to 0.04)
4879 4880
self-reported and not based on clini-
cal measurements. Father’s heights
were only available in 56% of the late
weight-faltering group, and we there-
fore used maternal height rather than
mid-parental height in the final models.
Because ALSPAC is an observational
study, with limited information on use of
health services, we cannot ascertain
which infants showing weight faltering
received nutritional or medical inter-
ventions. It is likely that many of the
infants putting on weight slowly in the
first 2 months would have received
interventions in primary care, such as
management of feeding problems and
increasing energy intake by switching
to formula and providing supplemen-
tary feeds. We have already reported15
that early slow weight gain in ALSPAC
infants was associated with feeding
symptoms, and we speculate that the
infants in the early-faltering group
would have been more readily identified
at the 8-week check, resulting in early
treatment and therefore a more rapid
recovery of weight gain. However, it is
also possible that the differences in
recovery of weight between early and
late weight falterers may reflect differ-
ent underlying causes and mechanisms.
The term catch-up growth can be
defined as increased growth velocity
(rapid gain in weight or height) during
a defined period of time, after a tran-
sient period of growth restriction.
However, catch-up weight gain is not
always beneficial; for example, children
who show pronounced catch-up growth

in the first 2 years can develop central
obesity.28 The early-faltering group,
who showed catch-up by age 2 years,
did demonstrate this tendency with
weight disproportionate to height
during childhood, but by 13 years,
their mean BMI was not different from
controls. In comparison, the catch-up
growth in the late-faltering group was
much later in childhood, and these
children remained shorter and lighter
with a lower mean BMI than their peers,
although the findings were within the
reference norms at 13 years. Further
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e849
 Growth Outcomes of Weight Faltering in Infancy in ALSPAC
Zia ud Din, Pauline Emmett, Colin Steer and Alan Emond
Pediatrics 2013;131;e843; originally published online February 25, 2013;
DOI: 10.1542/peds.2012-0764
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References This article cites 25 articles, 15 of which can be accessed free
at:
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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 Growth Outcomes of Weight Faltering in Infancy in ALSPAC
Zia ud Din, Pauline Emmett, Colin Steer and Alan Emond
Pediatrics 2013;131;e843; originally published online February 25, 2013;
DOI: 10.1542/peds.2012-0764

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/131/3/e843.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on January 11, 2015