How Worried Should You Be About Your Underweight Child?

by Naveen Agarwal

in Miscellaneous

News about childhood obesity is everywhere these days. Hardly a day goes by without a screaming headline in the media about this issue. Jamie Oliver has further popularized it by his TV show and even Mrs Obama has taken up this cause via her Let’s Move campaign. There is no doubt that we must address childhood obesity, but what about the problem of underweight and short stature? How worried should a parent be if their toddler falls under the 5th percentile in weight and height?

Recently, registered dietitian Teresa Wagner tackled a reader question in our Ask the Expert column about a toddler not gaining weight. I received a follow up email from another reader who was worried that her 8 month old child was below the 5th percentile and not eating much. The tone of her message reflected her extreme worry and frustration at not knowing what to do.

There is a reason why our media does not focus on this problem. The numbers, when taken as a whole nationwide are not that high. See below a chart based on the 2008 data CDC’s Pediatric Nutrition Surveillance System (PedNSS) on growth indicators. The PedNSS system is a public health surveillance system which monitors the nutritional status of children from low income families under Federal programs. Data comes from public health clinics where these children are seen for routine care, nutrition education and supplemental food.

Percentage of children 2-5 years old who are underweight or of short stature is between 3-5% for Whites, Blacks and Hispanics. These numbers are even smaller for American Indians and Alaskan Natives. Compared to the 20-30% obesity rates, these numbers are too low to capture the attention of mainstream media and policy makers. Besides, the media loves to show extreme images of either very fat kids or severely malnourished starving kids from the third world countries. Anything else does not make the cut for prime time!

As a parent, it is natural to worry. It becomes a personal issue and fancy nationwide statistics do not make a difference. The frustrating part is that it is not always possible to get enough credible information to make informed decisions. The result is that each day becomes a battle to force feed a child in the hope that she will put on some weight. Since children have a natural ability to regulate their food intake based on their current needs, it may seem like they are not eating enough. Anger, frustration and despair are the emotions most parents feel under these circumstances.

Here are 5 questions you can consider to assess the situation and take appropriate actions

Is there a trend in my child’s growth chart numbers?

A single data point on the growth chart, although important, should not cause concern. Take time to understand growth charts and their limitations so you can use them to evaluate the general growth pattern of your child. Another thing to keep in mind is that your child may not be in the normal range for both weight and height. For example, our twins are tall for their age group but lag behind in weight. From this perspective, I like the BMI for age chart because it takes into account both weight and height at the same time. You can use this online calculator for BMI chart or ask your doctor about it.

Is there a medical reason for slow growth?

This is where keeping a close eye on your child’s growth pattern will help you find medical issues that may be affecting her growth. There may be known birth defects or undiagnosed metabolic or digestive disorders. Severe case of reflux like GERD is also a concern. Detecting them early and working with a specialist for corrective action is very important.

Is there a specific reason for poor appetite?

Nearly all toddlers are picky eaters and it is natural for them to frequently show poor appetite. But if it persists over a long period of time, you will need to be extra vigilant so you can find the root cause. Are there food allergies? Special environmental or seasonal triggers? Does a change in menu or feeding schedule help? The important thing is to pay attention to the unique needs of your child so each feeding is most effective. Siblings around the same age, twins or multiples need different treatments based on their individual personalities. Clearly a challenge for most parents, but there is no perfect answer. Practicing the principles of attachment parenting and nutrition can help.

Does my child seem different than his siblings or other family members?

Although it is not always a good idea to compare your children, you have to take into account your family history and genetic makeup. In some ways, a consideration of these factors is probably more important than the growth charts which are based on population averages. If your family ethnicity is not one of mainstream population, it is unlikely that the growth chart standards will be accurate for your child. Evaluate your child’s height, weight and BMI through the lens of your family’s history to determine if there are differences you should be concerned about.

Are there any special circumstances in my family?

Every family goes through ups and downs – financial, emotional or health-related – often over an extended period of time. Assess if you have certain stresses in your personal life or your family situation at the moment. Even toddlers pick on them easily even if they cannot articulate it. If these problems persists over a long period, there may be slow weight gain or even a loss in weight. Recognize these problems early and seek help from family, friends or your doctor to manage them.

One last thing to remember – early childhood height and weight is often a poor predictor of adult height and weight, except in the case of overweight or obesity. You may be surprised how fast your child can grow upon reaching puberty. Keep a close eye on the growth charts, spot the problems early and take appropriate action. No need for excessive worry just because of a couple of low points on the charts!

Most importantly, focus on building healthy eating habits. Offer a variety of foods in healthy balance and moderation.

Are you concerned about an underweight child? Please share your personal story in a comment below.


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  • Cara

    Thank you so much for spotlighting underweight children in this article! As you mentioned, news of childhood obesity is prevalent and children who are having trouble gaining weight are often overlooked. My son is one of those children. Diagnosed as Failure to Thrive (could there be a more AWFUL and guilt inducing label?!) at 6 months merely for poor weight gain (no developmental delays), he has continued to struggle ever since. He is now almost 3 and 21 pounds, and he recently got an NG tube (hopefully a temporary measure) because he just wasn't able to eat enough calories. The cause (or one of them, at least) for my son's inability to weight gain is gastroparesis (delayed gastric emptying). His stomach empties extremely slowly, so he never feels hungry. Some children with GP vomit all the time, but my son's is “silent.” We always just thought he was being picky. In addition to his gastroparesis, my son is also an extremely picky eater, and had allergies to dairy and eggs (thankfully outgrown). As you mentioned, GERD and other metabolic conditions (Crohn's, Celiac, etc) can also cause children to have trouble gaining weight. Getting my son to eat is something that is on my mind constantly. It is an all day, every day battle which can be very trying at times. I've written about our journey with gastroparesis on my blog if anyone is interested. Here's a link to my first post on the subject:

    When you've got a child that won't eat and is underweight, it is so easy to just let them eat whatever they want out of desperation. We're currently working on developing some better eating habits, but I've certainly got a long road ahead!

    Thanks again for spotlighting this often-overlooked issue!

  • TwinToddlersDad

    Hello Cara
    Thank you for sharing your story. My heart goes out to you and your son. Although given his history, 21 lbs at 3 yo is very good progress. I love your positive attitude. I wish you all the best and hope that things will work out for the best.

    Do you know if this is a temporary situation or a lifelong challenge? In your blog post you mention that often the cause is not known. I am intrigued by it and wonder what kind of research exists out there on this topic.

    If you ever want to write a guest article on this subject to highlight research and tips, let me know.

  • Cara

    It is unclear whether this will be temporary or a lifelong challenge. The doctors just don't know. Most adults diagnosed with gastroparesis deal with it for the rest of their lives. Some kids with post-viral gastroparesis outgrow it. My son's has no known cause, so we have no idea what's going to happen. There is limited research on gastroparesis in general, and VERY little information available on gastroparesis in children. Believe me, I've looked! Thanks so much for the guest article offer. I may just take you up on that sometime! :)

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  • Dscott

    I found this article helpful, yet I stil have questions. My son will be 8 in 3 weeks. He eats regularly and likes a variety of foods. No matter what he eats, healthy or not, he won’t gain weight. When he was born the doctors determined that during the pregnancy I had IUGR. This resulted in him weighing 4# 9oz. at birth. He has followed the growth curve to a T. I guess what I don’t get is that I have 2 other children and they are right where they’re supposed to be. My daughter, who is 5 has now passed my son in weight. I am still looking for answers.

  • Angelene Pierce

    Have your child tested for Celiac disease, doctors will say its too rare to bother with, but real statistics show its now very common and can be treated with a gluten free diet. Do an internet search on it and see if you fit the symptoms. I would also get blood glucose checked and a full range blood/hormone test. Immuno A and other similar disorders can mask Celiac disease, so it is imperative to get the testing correct, blood tests by them selves are not always accurate in detecting Celiac, a biopsy is the only fail safe way to be sure.

  • Jove

    My son was born 7 pounds 6 ounces and kept dropping on the growth charts. We was almost 21 lbs at 14 months He is now 17 months and 20 lbs. He has never been a great eater but what worries me more is that as the months go by, things are getting worse – he eats less and less and is losing weight. We are all big and tall people in my family – I’m 5 10 and my husband is 6 1. My older son was 30lbs at age 2. I wouldn’t be so concerned about just the weight. It is the fact that he eats and drinks so little that is so upsetting. I read somewhere he should be getting about 900-1000 calories a day. That seems impossible to get him to eat so much.  His doctor has suggested supplements and different types of food but he hasn’t seen any specialists yet.

  • Jfloyd

    My name is Janice and I have a 2 year old that will not hardly anything maybe one meal a day and she is 22 pd she was 24p her pedetrician said she is fine but I don’t know i am so worried about her I need some advice

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