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 healthcare 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 healthcare 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 healthcare 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 information: Breast pumps (Beyond the Basics)".) For the safety of the infant, this treatment should be undertaken with the supervision of a healthcare 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 polycose or corn oil. As above, for the safety of the infant, this treatment should be undertaken with the supervision of a healthcare provider or dietitian.

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).

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.

Medical treatment — Children who have an underlying medical problem that is limiting weight gain are usually managed by their primary healthcare 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). 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 healthcare 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 information: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)" and "Patient information: 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 ([CSFP] www.fns.usda.gov/fdd/programs/csfp/), Supplemental Nutrition for Women, Infants, and Children ([WIC] www.fns.usda.gov/wic), and food stamps (www.ssa.gov/pubs/10101.html).
• 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 healthcare 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 of the malnutrition, the presence of underlying medical problems, and how successfully the child's weight and medical problems were managed.