Patient education: Poor weight gain in infants and children (Beyond the Basics)
- Kathleen J Motil, MD, PhD
Kathleen J Motil, MD, PhD
- Section Editor — Pediatric Nutrition
- Professor of Pediatric Nutrition
- Baylor College of Medicine
- Teresa K Duryea, MD
Teresa K Duryea, MD
- Section Editor — General Pediatrics
- Associate Professor of Pediatrics
- Baylor College of Medicine
- Section Editors
- Jan E Drutz, MD
Jan E Drutz, MD
- Section Editor — General Pediatrics
- Professor of Pediatrics
- Baylor College of Medicine
- Carolyn Bridgemohan, MD
Carolyn Bridgemohan, MD
- Section Editor — Developmental and Behavioral Pediatrics
- Assistant Professor of Pediatrics
- Harvard Medical School
POOR WEIGHT GAIN OVERVIEW
During infancy and childhood, children gain weight and grow more rapidly than at any other time in life. However, some children do not gain weight at a normal rate, either because of expected variations related to genes, being born prematurely, or because of undernutrition, which may occur for a variety of reasons. Undernutrition is sometimes called a growth deficit or failure to thrive.
It is important to recognize and treat children who are not gaining weight normally because it may be a sign of undernutrition or an underlying medical problem that requires treatment. Undernutrition can have complications, such as a weakened immune system, slower than expected linear growth, shorter than expected height, or difficulties with learning. These complications are more common in children who are undernourished for a long period of time.
HOW IS POOR WEIGHT GAIN DEFINED?
Poor weight gain is defined as gaining weight at a slower rate than other children who are the same age and sex. "Normal" ranges for weight are based upon the weight of thousands of children. Standard growth charts are published by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO); these charts are available for boys and girls and are appropriate for all races and nationalities.
For children less than two years old, the WHO growth standards are used. Charts are available here for boys (figure 1) and here for girls (figure 2). For children two years and older, the CDC growth charts are used. They are available here for boys (figure 3) and here for girls (figure 4). Children with particular genetic syndromes may require special growth charts. As an example, a growth chart for children with Down syndrome is available from the CDC.
Weight gain normally follows a predictable course from infancy through adolescence. However, some children do not gain weight normally from birth, while other children gain weight normally for a while, then slow or stop gaining weight. Weight gain usually slows before the child slows or stops growing in length.
A child is said to have poor weight gain if he or she does not grow at the expected rate for their age and sex.
POOR WEIGHT GAIN CAUSES
Poor weight gain is not a disease, but rather a symptom, which has many possible causes. The causes of poor weight gain include the following:
●Not consuming an adequate amount of calories or not consuming the right combination of protein, fat, and carbohydrates
●Not absorbing an adequate amount of nutrients
●Requiring a higher than normal amount of calories
Poor weight gain can occur as a result of a medical problem, a developmental or behavioral problem, lack of adequate food, a social problem at home, or most frequently, a combination of these problems. Common causes of poor weight gain for each age group are described below:
●Prenatal – Small for age at birth (called intrauterine growth restriction); prematurity; prenatal infection; birth defects; exposure to medications/toxins that limit growth during pregnancy (eg, anticonvulsants, alcohol, tobacco smoke, caffeine, street drugs)
●Birth to six months – Poor quality of suck (whether breast- or bottle-fed); incorrect formula preparation; breastfeeding problems; inadequate number of feedings; poor feeding interactions (eg, infant gags or vomits during feedings and parent assumes child is full); neglect; birth defects that affect the child's ability to eat or digest normally; underfeeding (sometimes associated with poverty or not understanding dietary needs of infants); milk protein intolerance; problems with child's mouth/throat; medical problems that affect absorption of nutrients (cystic fibrosis); medical problems that increase the number of calories needed (congenital heart disease), gastroesophageal reflux
●Seven to 12 months – Feeding problems (eg, struggles between the child and parent about what will be eaten; problems with the child's mouth that make it hard to adapt to textured foods; delayed introduction of solid foods; refusal to eat new foods when first offered so the parent does not offer again; parent does not offer enough quantity or variety of solid foods); intestinal parasites; food allergies
●Over 12 months – Behavioral (eg, the picky eater or the child who is easily distracted at meal time); illness; new stress at home (divorce, job loss, new sibling, death in the family, etc); social factors (underfeeding related to fear of overfeeding, limiting food choices, poverty); sensory-based feeding disorders in children with developmental disorders (eg, autism spectrum disorder); swallowing dysfunction; excessive milk or juice intake; not offered enough calories or the right combination of healthy foods; celiac disease; food allergies
POOR WEIGHT GAIN DIAGNOSIS
If an infant or child slows or stops gaining weight, it is important to try to determine and treat the underlying cause. The first step is a complete medical history and physical examination. Most children will not require blood testing or imaging tests, although testing may be recommended in certain situations.
The parent(s) should mention if the child has any of the following:
●Vomiting, diarrhea, or rumination (swallowing, regurgitating, then reswallowing food).
●Avoids foods with particular textures (eg, hard or crunchy), which may be a sign of a problem with chewing/swallowing.
●Avoids types or groups of food (eg, milk, wheat), which can be a sign of a food allergy or intolerance.
●Drinks large amounts of low-calorie liquids or fruit juices. Drinking these beverages may prevent the child from eating solid foods, which contain more calories.
●Follows a restricted diet (eg, vegetarian, lactose free, wheat or gluten free).
●Behavioral rigidity or sensory aversions that result in self-imposed feeding restrictions.
Parents should also mention if they have eliminated foods from the child's diet due to concern about the effects of these foods (eg, abdominal pain, diarrhea, "hyperactivity").
The provider may also ask about the child's household, including who lives in the child's house, if there have been recent changes or stresses (eg, divorce, illness, death, new sibling), or if anyone in the house has a medical or psychiatric illness, including history of feeding/eating disorder. The provider may also ask about the food supply (eg, if there have been days when anyone in the family went hungry because there was not enough money for food). Although these questions can be difficult to answer, it is important to be honest.
In some cases, the provider will ask the parent(s) to keep a record of everything the child eats and drinks for a few days (form 1). This can help to determine if the child is eating an adequate number and type of calories.
POOR WEIGHT GAIN TREATMENT
The goal of treatment is to provide the child with adequate nutrition so that he or she can "catch up" to a normal weight. There is a range of normal weights for a particular age. Catch-up growth may require changes to the child's diet, feeding schedule, or feeding environment. The parent and health care provider should work together to develop a plan that meets the needs of both the child and the family.
The type of treatment needed depends upon the underlying cause of poor weight gain, any underlying medical problems, and the severity of the situation.
●Most children who are mildly to moderately malnourished can be managed at home with help from the child's health care provider, and in some cases, other specialty providers (eg, dietitian, occupational or speech therapist, social worker, nurse, developmental specialist, child-life worker, psychiatrist).
●Children who are severely malnourished are usually hospitalized initially. While in the hospital, the child's diet and weight can be monitored closely.
Nutritional therapy — Nutritional therapy is the primary treatment for children with poor weight gain. The goal of nutritional therapy is to enable "catch up" weight gain, which is usually two to three times the normal rate of weight gain for the child's age. The best way to increase calories depends upon the child's age and nutritional status; individual recommendations should be determined by the child's health care provider or dietitian. A multivitamin supplement may be recommended in some cases.
For infants — The number of calories in breast milk can be increased by pumping the breast milk and adding a predetermined amount of formula powder or liquid concentrate. This combination is called fortified human milk (see "Patient education: Pumping breast milk (Beyond the Basics)"). For the safety of the infant, this treatment should be undertaken with the supervision of a health care provider or dietitian.
The number of calories in infant formula can be increased by adding less water to powder or liquid concentrate or by adding a calorie supplement, such as maltodextrin or corn oil. As above, for the safety of the infant, this treatment should be undertaken with the supervision of a health care provider or dietitian.
Plant-based milks (eg, soy, almond, rice, coconut, etc) are not suitable for infants. With the exception of soy-based infant formulas, plant based milks are deficient in protein, calcium, vitamin D, and other nutrients.
Infants between zero and four months require frequent feedings, typically 8 to 12 per day; older infants typically require four to six feedings per day.
In older infants, calorie intake can be increased by adding rice cereal or formula powder to pureed foods.
For older children — In older children, calorie intake can be increased by adding cheese, butter, or sour cream to vegetables, or by using calorie-enriched milk drinks instead of whole milk. Other ideas are provided in the table (table 1).
Nondairy milk alternatives are available for children with poor weight gain who are unable to tolerate dairy milk (ie, milk from animals, most often cows and goats). Nondairy milk alternatives are not "milk" per se, but extracts derived from plant sources. Common alternative milks include soy, almond, rice, coconut, and hemp milks. Newer milk alternatives include quinoa, oat, potato, and mixed grain milks. Soy milk has a nutrient profile that is most like cow's milk. It usually is fortified with calcium and vitamin D. Other plant-based milks generally are lower in protein, calcium, vitamin D, and calories than cow's milk or soy milk. They also may be lacking in other vitamins, minerals, and fatty acids that are found in dairy milk. If alternative milks are necessary for children with poor weight gain, other foods must be chosen wisely to provide the nutrients that are missing from the alternative milk.
Yogurt may seem like a nutritious option for children with poor weight gain, but it is important to read the nutrition facts label to make sure that it is high in calories, protein, and calcium. An increasing variety of yogurt products are available, and the nutrient profiles vary widely. Greek yogurt is a good choice because it may contain up to twice as much protein and calories as regular yogurt. Low-fat and nonfat yogurt should be avoided.
During catch-up growth, the amount of calories and protein that a child eats is more important than the variety of foods eaten. For example, if a child is willing to eat chicken nuggets and pizza, but refuses all vegetables, this is acceptable. At meal and snack time, solid foods should be offered before liquids. Fruit juice should be limited to four to eight ounces of unsweetened 100 percent juice per day.
The older child should eat often (every two to three hours, but not constantly). The child should have three meals and three snacks on a consistent schedule. Snacks should be timed so that the child's appetite for meals will not be spoiled (eg, snack time should not occur within one hour of meal time; snacks should not be offered immediately after an unfinished meal). Examples of healthy snacks include crackers, peanut butter, cheese, hard boiled eggs, pudding, yogurt, fresh fruit or vegetables, or pretzels. A multivitamin and mineral supplement may be recommended in some cases.
Eating environment — Changes to the area where the child eats may help the child to eat more. All members of the child's household should be aware of the importance of these changes.
●The child should be positioned so that the head is up and the child is comfortable. The child should be allowed to feed him/herself (eg, by holding a bottle or eating finger foods) but may need to be fed soft foods with a spoon. A certain amount of messiness is to be expected as the child learns to feed him/herself. Allow the child to finish eating before cleaning up.
●Meal time distractions, such as television, phone calls, and loud music, should be minimized.
●Make meal time routines consistent, no matter who feeds the child.
●Meal time should be relaxed and social; eating with other family members and pleasant conversation (not related to how much the child eats) are encouraged. Eating with others allows the child to observe how others make food choices, hopefully encouraging healthy eating habits.
●Do not be discouraged if the child refuses a new food. New foods may need to be offered multiple times (even up to 10 or more) before they are accepted. Among children with behavioral rigidity (eg, those with autism), new foods may need to presented up to 30 times before they are accepted.
●Meal time should be free of battles over eating; caretakers should encourage, but not force, the child to eat; food should not be withheld as punishment. In addition, food should not be offered as a reward.
●The child should be praised when he or she eats well but not punished when he or she does not.
Additional tips are provided in the table (table 2).
Medical treatment — Children who have an underlying medical problem that is limiting weight gain are usually managed by their primary health care provider (eg, pediatrician, family practitioner). On occasion, a specialist may need to be consulted (eg, an allergist/immunologist for a child with food allergies, a gastroenterologist for a child with gastroesophageal reflux, or a dietitian for nutritional guidance). These specialists can provide guidance regarding the need to eliminate certain foods. Foods and groups of food (eg, milk products) should not be eliminated without the advice of a knowledgeable health care provider because this can further increase a child's risk of undernutrition.
Children who are undernourished are at risk for complications, including an increased risk of developing common infections. Normal infection prevention techniques, such as handwashing and avoiding exposure to sick friends or family, are encouraged. However, it is not usually necessary to take additional precautions (eg, by preventing the child from attending day care or school).
Childhood vaccinations should continue to be given on schedule; immunizations that have been missed should be updated. (See "Patient education: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)" and "Patient education: Vaccines for children age 7 to 18 years (Beyond the Basics)".)
Developmental and behavioral treatment — Developmental and behavioral problems can increase a child's risk of being underweight. For example, if a child has difficulty chewing or swallowing food, he or she may not be able to consume an adequate number of calories.
In the United States, early intervention programs can provide developmental stimulation and physical and occupational therapy when needed. Some children also benefit from seeing a developmental behavioral pediatrician or behavioral psychologist for further assistance. These clinicians have specialized training in the medical, psychologic, and social aspects of childhood developmental and behavioral problems.
Psychosocial issues — In some situations, the child's poor weight gain is related to issues at home, such as not having an adequate amount of food in the house, parental concerns about feeding the child certain types of food (eg, foods with fat), or medical or psychiatric problems in the parents (eg, alcohol/drug abuse).
In these situations, treatment includes measures to improve conditions at home, ensure that there is enough food for all family members, and educate parents about the importance of adequate nutrition. This may involve:
●Home visits by a nurse, social worker, or other clinician to provide education, support, and guidance to parents.
●Referral to programs that provide supplemental food, eg, Commodity Supplemental Food Program www.fns.usda.gov/csfp/commodity-supplemental-food-program-csfp), Supplemental Nutrition for Women, Infants, and Children www.fns.usda.gov/wic), and food stamps (www.ssa.gov/pubs/EN-05-10101.pdf).
●Referral to programs for parents, including assistance locating child care, housing, job training, or alcohol/drug abuse treatment. A social worker can usually help to connect a family with these programs.
POOR WEIGHT GAIN FOLLOW-UP
Children who are underweight are usually seen by their health care provider on a regular basis after treatment begins; the frequency of visits (weekly to monthly) depends upon the individual situation. During these visits, the child will be weighed and measured and the provider will talk to the parent(s) (and child, if applicable) about any new or ongoing questions or concerns. These frequent visits are usually continued until the child's weight is near normal and increasing regularly. If the child is able to take in an adequate amount of calories, catch-up weight gain is usually complete within three to six months.
Many parents wonder how poor weight gain will affect the child's height and weight as an adult. A child's size as an adult depends upon several factors, including genetics, the age at which the child was underweight (eg, as young infant versus toddler), the severity and duration of the malnutrition, the presence of underlying medical problems, and how successfully the child's weight and medical problems were managed.
WHERE TO GET MORE INFORMATION
Your child's health care provider is the best source of information for questions and concerns related to your child's medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Pumping breast milk (Beyond the Basics)
Patient education: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)
Patient education: Vaccines for children age 7 to 18 years (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Failure to thrive (undernutrition) in children younger than two years: Etiology and evaluation
Failure to thrive (undernutrition) in children younger than two years: Management
Management of isolated ventricular septal defects in infants and children
Poor weight gain in children older than two years of age
The following organizations also provide reliable health information.
●National Library of Medicine
(www.nlm.nih.gov/medlineplus/ency/article/000991.htm, available in Spanish)
●The Nemours Foundation
(http://kidshealth.org/parent/food/weight/failure_thrive.html, available in Spanish)
●The Academy of Nutrition and Dietetics
- American Academy of Pediatrics Committee on Nutrition. Failure to thrive. In: Pediatric Nutrition, 7th ed, Kleinman RE, Greer FR (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2014. p.663.
- Zenel JA Jr. Failure to thrive: a general pediatrician's perspective. Pediatr Rev 1997; 18:371.
- Gahagan S. Failure to thrive: a consequence of undernutrition. Pediatr Rev 2006; 27:e1.
- Carruth BR, Ziegler PJ, Gordon A, Barr SI. Prevalence of picky eaters among infants and toddlers and their caregivers' decisions about offering a new food. J Am Diet Assoc 2004; 104:s57.
- Hasemann A. Yogurt: Nutritious food or sugary treat. Pract Gastroenterol 2014; 38:37.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.