We have a 28-month-old son who has been small all his life, has a small appetite, and frequently skips meals.


We have a 28-month-old son who has been small all his life. He was born at 7 pound, 9 ounces and began falling off the growth chart at approximately 3 months. He breastfed for the first year with solids introduced at 4 months. He currently weighs 21 pound, 4 ounces.

He has a small appetite and frequently skips meals. He is offered regular meals and snacks. We are at a loss as to how to encourage his eating and weight gain. He is active, alert and is developing normally. Endocrine and genetic testing have revealed normal results. Any advice you can give us would be a great help. Thanks.

Your son was about average weight when he was born. Since now he weighs less than the 5th percentile for a 28 month old, he can’t afford to skip meals or snacks. I would suggest offering small meals more frequently, every few hours. Serve more of his favorite foods even if the variety of foods he eats is limited until his appetite improves. In fact, add butter or gravy to his food to increase calories. He needs to eat more calorie dense foods, not low-fat foods. If he drinks milk, give him whole rather than low-fat milk. Ice cream rather than frozen yogurt.

Children at his age often become picky eaters who refuse all but a few favorites like cheese, hot dogs or peanut butter. Also, most kids growth slows down at this age along with their appetite. I would suggest making an appointment to see a Registered Dietitian who can review your son’s medical chart and food intake in order to make more specific suggestions. The plus is you have a son who is energetic and developing normally.

Height/weight tables for newborns to 2-year-olds used by doctors and dietitians were developed from a single community of Ohio Caucasian, bottle fed babies between 1929 and 1975 who came from families of similar socioeconomic backgrounds. These babies were not measured often enough (every 3 months) yet their data is used to measure every US infant. New data is in the process of being collected by the National Center for Health Statistics, but will still reflect mostly bottle fed infants because of few women breastfeed for 12 or even 24 months. On the other hand, if growth charts were based on breast fed infants, bottle-fed infants would be misdiagnosed as overweight. Weight loss is not recommended in children or infants because it would negatively impact brain development. The World Health Organization infant growth charts contain weight gains more typical of breastfed infants, but WHO growth charts are not used in the United States.

Though they tend to have rounder more developed cheek muscles developed from sucking, breastfed infants gain weight at a slower rate than bottle-fed infants especially after 6 months of age. Breastfed infants weight for height may be 60% below the average (50th percentile) found on commonly used infant growth charts. Their fat stores may be 60% below the average. Breastfed infants tend to be leaner than formula-fed infants from 9 to 15 months of age. This is believed to be due to a lower calorie and protein intake by breastfed infants.

It appears that infants regulate how much breast milk they drink rather than the cause being an inadequate milk production by the mother. The lower calorie intake and weight gain of breast-fed infants is not related to their development, activity or illness either. Breastfed infants calorie intake is usually below the recommended amounts even in optimal environments and even with the addition of solid foods. A mother’s BMI (estimate of percent body fat) appears to determine the mother’s breast milk fat content, but infants seem to compensate for varying amounts of breast milk fat by altering the amount they drink. The amount of calories a breastfed infant consumes is not related to the age that solid foods are introduced as long as the infant continues to breastfeed. So your baby’s weight may be a factor of breastfeeding especially since your doctor has not found any genetic or hormonal (endocrine) abnormality.

Lastly, breastfed infants rate of increases in length and head circumference though does not differ between breast and formula fed infants from 3 to 12 months of age.

There are many positive effects that breastfed infants enjoy. They are less likely to get diarrhea and ear infections. For the mom, breastfeeding improves her weight loss if she continues to breastfeed longer than 6 months and she is less likely to start menstruating again. Though resumption of a normal period also is related to the maternal fat stores as indicated by BMI.

The only risk of nutritional deficiency in breastfed infants during the first 6 months of life are iron (a factor of birth weight and iron drops after 2 – 3 months), vitamin D, (depends on baby’s exposure to direct sunlight and maternal intake), Vitamin B 12 (only concern if mother is a veg*an or has malabsorption of Vitamin B 12).

Without your son’s length, I cannot tell much about his growth pattern because, in children, weight relates not only to age, but also height (length in infants). What a baby eats after birth and illnesses as well as the parent’s height appear to affect infant length gain most. Small for height parents would more likely to have small for height infants and toddlers. But, your son’s current weight is below the 5th percentile for age (i.e. only 5% of children weigh less than this value) irrelative of his length. He should weigh 24 pounds (5th percentile) at least at 28 months. So try my suggestions at the beginning and monitor his weight on at least a bi-monthly basis. Keep his doctor informed of his weight.