Worried About Your Underweight Child? Here’s What Helped Mine.
Inside: If you have an underweight child (or a child who takes medication that affects her appetite), here are 10 tips to help you!
When my son was in middle school, we were told by the pediatrician that he was borderline underweight.
He’d been battling stomachaches, and there were many nights when he didn’t feel well enough to eat dinner. While everyone around me seemed to be going on and on about the vast quantities of food their tweens and teens were inhaling, I was asking my child if he’d eaten at all–and clearing away his barely-touched plates.
As a registered dietitian and a mom, I was worried.
As parents, we all have an instinctive drive to feed and sustain our kids. When something gets in the way of that–whether it’s picky eating or an illness–it’s hard not to stress.
A few doctor’s visits, a trip to a specialist, some lifestyle changes, and many months later, I’m happy to report that his stomach pain is mostly a thing of the past. But that year taught me a lot about the day-to-day practicalities and challenges of feeding a child who needs to gain weight but doesn’t have much of an appetite.
I’ve heard from some of you that you have a child who is underweight and/or takes medicine that affects appetite and weight. So I wanted to share some lessons I’ve learned about feeding an underweight child and encouraging weight gain in a healthy way.
10 Tips for Healthy Weight Gain
1. It’s not just about calories
It would be easy to throw a bunch of cookies and potato chips at the issue. But I’m a dietitian, so I can’t help but focus on the quality of those calories too.
As children are growing and developing, they need nutrients like iron, protein, and calcium–and just as important, they’re forming ideas and habits around food and eating that can stretch into adulthood.
So during the year of stomachaches, I kept serving healthy meals and made sure most snacks were calorie-dense but also nutrient-dense, which meant things like nuts, dried fruit, and cheese sticks. That being said, I also didn’t worry about daily dessert (I still don’t) or the liberal use of real butter (still don’t).
2. Presentation Presentation Presentation
I firmly believe that when it comes to kids and food, presentation is key. But this is especially true for kids who have small appetites.
I tried to make those healthy, nutrient-rich foods look especially appetizing, whether it was putting yogurt and berries in a fancy glass or pulling together an after-school Snack Platter. I also used white plates for his meals–which, as I know from doing food photography, make food really pop. These were small and easy things for me to do but made a difference for him.
3. Switch your dairy
Switching from low-fat to full-fat dairy products like whole milk and full-fat yogurts is a great way to snag a lot of nutrients and extra calories (read about why full-fat milk shouldn’t be feared: Is Whole Milk Healthier?).
I buy full-fat cheese and pick up tubs of full-fat yogurt and individual cups for lunch boxes. (Though low-fat and non-fat yogurts still dominate shelves, more companies are making full-fat versions too. My kids like full-fat cups made by Dannon, Stonyfield, and Annie’s.) I also buy a half-gallon of whole chocolate milk every week.
4. Focus on favorites
You know I’m all about making just one meal for the whole family (read The Dinnertime Rule That Will Change Your Life). But when my son’s appetite was down, I did make sure to regularly serve meals I knew he especially enjoyed–and tried not to show my disappointment if he didn’t want to eat that evening. Some of his favorites are this Whole Wheat Chicken Pot Pie and this Whole Wheat Spaghetti Carbonara.
5. Watch out for drinks
Yes, hydration is important. But some kids can fill up on drinks like juice and milk and not have room left for actual food at mealtime. I tried to pour him a smaller drink with meals, obviously allowing for refills! Read: What Are The Best Healthy Drinks For Kids?
6. Don’t fear fat
I came of age in the 80s and 90s, when we were taught to fear fat. But it’s high time to let that go–especially where underweight kids are concerned. That’s because fat is the most calorie-dense nutrient, and can go a long way in helping children get enough calories.
Here are some ways to add it in: Toss pasta in olive oil before adding other sauce, butter bread under peanut butter on PBJs, sprinkle cheese on pastas and rice dishes, and add avocado to a smoothie (sounds weird, but it adds a great creaminess!).
7. Compromise
In my ideal world, my son would be craving quinoa salads and butternut squash soup. In the real world, he’s a regular kid who likes chicken wings and soda. Thankfully there is a middle ground with foods we both feel good about (like whole wheat spaghetti and meatballs, guacamole and chips, and Caesar salad), and there’s wiggle room too (like the beef jerky he loves).
8. Serve small portions
At mealtime, either had my son serve himself or gave him very small portions (with seconds and thirds readily available). I learned this from my rotation through a nursing home while in school to become a dietitian: Large portions are overwhelming and unappealing to someone with a small appetite, but small portions may actually encourage that person to eat more. That was also my approach when packing his lunch (read How Much Should You Pack In Your Child’s Lunch Box?).
9. Include calorie-dense foods
There are certain foods that are both calorie-dense AND nutrient-dense–and they can help your child get more calories, as well as more nutrients. I tried to include some of these at meal and snack times:
- Dried fruit
- Nut butters (such as peanut butter and almond butter) and seed butters (such as sunflower butter)
- Nuts and seeds
- Full-fat milk and yogurt
- Cheese
- Avocados
- Trail mix and granola
- Salmon
- Beef
10. Avoid Pressure
Nagging kids about food is never a good idea. It was tempting to grill my son about what he’d eaten that day or sigh with dismay when he barely ate his packed lunch. But I tried to have the same relaxed, accepting attitude I recommend all parents strive for at the table (full disclosure: I didn’t always succeed!). I also tried to have faith that things would get better. (And luckily they did!)
FAQ About Underweight Kids
What can cause poor weight gain in kids?
Poor weight gain can be caused by things like medications that lower appetite (such as some ADHD medicines), food allergies that limit the number of “safe” foods they can eat, illness, and and certain medical issues. Stress and anxiety can also cause poor appetite.
Can protein powders be helpful for underweight kids?
Maybe. Most kids get enough protein, since many foods beyond meat contain it, including milk, cheese, and grains like pasta. But powders can be an easy way to get protein, especially for picky eaters who are underweight.
Protein powder can be pricey and contain a lot of extra ingredients, like artificial sweeteners or even herbal supplements. So while a protein shake once in a while is fine, you can also make your own protein-rich shakes from regular ingredients. Here’s are recipes for a Peanut Butter Protein Shake and Protein Pancakes that don’t contain any protein powder.
How do I know if my child is underweight?
Your child’s doctor is the best resource for this, because they track your child’s weight and height on a growth chart at each visit.
Technically, underweight means below the 5th percentile for BMI (Body Mass Index) for age, gender, and height. But BMI isn’t a perfect measure and doesn’t account for things like frame size and muscle.
Keep in mind that some children are just naturally thin, and a “skinny kid” isn’t necessarily something to worry about. A sudden growth spurt where a child shoots up in height first before gaining weight can also look like underweight.
What’s more important is your child’s growth pattern: Is their weight increasing predictably on their growth curve, or is it flattening out or falling off? Has their weight suddenly dropped? Are they having a decreased appetite or issues with eating?
What foods are “empty” calories?
This term is typically used to describe foods that don’t contain many nutrients–things like pretzels and candy come to mind. Yes, nutrients are important. But in my opinion, a well-balanced diet also contains some foods that are eaten simply for “fun”. (And things like cookies, ice cream, and chips do provide calories too.)
Does my underweight child need a multi-vitamin?
Maybe. Talk to your child’s pediatric or pediatric dietitian to see if your child is getting enough of a variety of foods to supply the nutrients they need. Underweight kids who are very picky eaters may especially benefit from a supplement.
Where can I go for more help?
Ask your child’s doctor about a referral to a pediatric dietitian, who can help guide you. You can also call a local children’s hospital and ask whether they have pediatric dietitians who do outpatient counseling.
Do you have any experience feeding an underweight child–if so, what works/worked best for you?
Yes! After choking over spring break, our youngest stopped eating solid foods for six weeks. With a few months of therapy, she’s back to eating about 70% of what she used to. She’s now very slow and very selective. Smoothies got me through those first six weeks. I could use high-quality protein powder, whole milk, and add things like spinach, avocado and pumpkin and she’d happily drink them. I too offered snacks and not once said “no” to dessert. Thanks for the post, it’s nice to know we’re not alone!
Lisa–I’m so sorry to hear that happened to your daughter, and I’m glad you got her help to get over such a scary experience. Sounds like she’s making good progress. Wishing your family all the best!
What do you do when they still refuse to eat what you have made and ask to have something different? My underweight kiddo is also my pickiest kiddo. He will refuse things I make for dinner and then want to fill up on cereal all night long. Suggestions?
Hi Jill–
Not knowing all the details of your situation, I’d start by suggesting that you make sure there’s something on the table he likes, even if it’s just rice or bread. Then if he doesn’t want the main dish, there are still foods on the table he likes. You will also want to make sure he’s hungry at dinner (some kids snack before dinner and come to the table seeming picky but they’re actually just not hungry).
I also have a variety of posts that might help you:
This post is about what can be at the root of Extreme Picky Eating (I don’t know if your son’s picky eating is extreme but this post may still help): https://www.realmomnutrition.com/5-common-problems-at-the-root-of-extreme-picky-eating/
Here’s a post about what to do about after-dinner snack requests: https://www.realmomnutrition.com/help-my-child-eats-hardly-any-dinnerthen-wants-a-snack-10-minutes-later-sound-familiar/
I also have a free course about picky eating that includes my best advice on the topic if you’re interested: https://www.realmomnutrition.com/help-for-picky-eating/
Hope these help. Feel reach to reach out again!
I hear you! I have a son who is doing a lot of sport (5 days a week and sometimes more than 3 hours a day) and he is bordering on underweight – he is also our most difficult to feed (he doesn’t like potatoes, go figure). Where I struggle most is getting snacks into him on the go – we use yoghurt snacks called “Breaker”, because it allows him to get some full-fat dairy into himself quickly and in situations (like someone else’s car on the way to training) where he is embarrassed to get a lunch-box out and eat something messy, but I have to say that this feels like a compromise which I want to try and change – they have sugar and preservatives and other stuff that I’d rather not put too much of into him. I also notice that if he has a match at snack time, it’s hard to get snacks into him before – he’s 10, but if he’s not hungry he finds it difficult to eat, even if, intellectually, he knows that he needs the energy for his tennis match.
Because he doesn’t have a huge appetite, lunch is small (our lunch-boxes look like yours, Sally) but I try and send him with pasta and with other things rather than just bread every day. The struggle is made worse by school having a strict rule that the children all have to be outside 15 min after lunch time has begun, no matter whether lunch was started late for any reason…
Any suggestions from people for easy to eat snacks on the go which are not filled with sugar or preservatives?
Hi Claire–Thanks for your message. If you don’t like the ingredients in the Breaker yogurts I suggest looking for the Stonyfield, Dannon, or Annie’s whole milk yogurt cups. They have pretty simple ingredient lists. Here are some posts I’ve written about snacks: Here is one about packaged snacks https://www.realmomnutrition.com/healthy-school-snacks/
And here is one about snacks you can make yourself but many of these can be grab-and-go as well: https://www.realmomnutrition.com/24-healthy-after-school-snacks/
I wonder if a drinkable snack (like a homemade smoothie in a thermos or a yogurt/kefir drink) might be more palatable if he’s not hungry but needs a little boost? Even some whole grain crackers would provide some carbs for energy before a game. Good luck and keep me posted!
Great post Sally. There’s so much concern about overweight and obesity in kids that the issue of kids who are underweight and struggling to maintain a high enough weight doesn’t get the attention it needs. These are all great tips – even for parents just trying to deal with the day to day of feeding kids regardless of weight. Glad your son is doing better.
Thanks Jessica!
As always i appreciate your perspectives Sally thanks for sharing. I am very interested in the food psychology aspect of feeding my kids as well. I have written you before about my sons poor appetite and his being underweight. I suffered with it a lot in the past and I notice my attitude really affects his. I am a huge lover of gastronomy and I find it very easy to find new inspiration all the time and my son helped me learn one of the things I always judged other moms for, having kids who were poor eaters (before I had kids) , had nothing to do with their habits. Sometimes kids are just born that way! My son started saying to me when he would be angry at me that he isn’t going to eat any dinner tonight. Thats when I realized I’m doing something wrong if he realizes it holds this power over me. I try not to give it importance but when I see how little variety and quantity he eats, its hard for me not to worry especially considering I have two other great eaters who I have practiced the same habits with!
He often complains of stomach pain but i’m really not sure it’s just to get out of eating. I had him tested for everything wondering if it was some kind of intolerance. He doesn’t consume any dairy, (his choice not mine), he hates all fruit even though I have it out constantly. He only occasionally likes meat. I feel so limited in what he likes its a constant surprise when we have a good day and his appetite seemed to open up.
Anyway, if you don’t mind me asking what the solution to the stomach problems was for your son? Just tweaking his diet? I’m curious. My doctor told me not to force my son to eat cheeses or milk if he didn’t want it because maybe his body was telling him not to eat it. But thats just the opinion of one doctor i’m not sure what to do about it all…..
Hi Tania–Feel free to email me directly at sally@realmomnutrition.com or DM me through my Real Mom Nutrition Facebook page.
Oh and I liked the eating small quantities of things they like tip. I never thought of it that way I’m definitely going to try that. Thanks
tania
Hi Sally,
This post is a very good idea.
My toddler is on the low weight limit since she is born, and is a picky eater with some food allergy.
Since she is born I try to make her take weight. As you say, it is necessary to cook regularly what they like. For my daughter, pastas are almost always welcome.
So here is my trick : I buy every kind of Pastas: Ravioli, Whole wheat Spaghetti, buckwheat tortellini, lentil spaghetti, lentil lasagna… so it looks like I am cooking 6 time a week pastas, but I am offering a more varied meal plan. I also mix veggies like mushroom or Butternut squash with cream to make creamy sauces, or I cook Bolognese sauce with beef and veggies hidden in the tomato sauce.
She likes fresh and dried fruits too, but for meat and veggies it is more difficult. Cheese or yogurt sometime.
Anyway, as you said, it is going better than 1 year ago. At the beginning, if she was eating something at one meal each day, it was already a victory. Now she eats 4 time a day. It makes a big change!
Feeding my underweight child with sensory issues and medicication induced appetite suppression, I’ve learned that you cannot trick a child into eating more than they want to, but you can offer dense nutrition when they are hungriest. My son is hungry at breakfast so I feed a full meal with protein, veggies,etc. (It may be an omelet, it may be a hamburger.) Lunch is a snack at best, so I pack a smoothie (usually PB, banana, and whole milk) and some crackers. He’s never been much of a dinner eater but will have some fruit at the family dinner table, and he has a small meal for bedtime snack (sandwich and carrot sticks or cereal and fruit.)
Thanks for your post! My son is underweight, he was recently diagnosed with celiac disease, but it took us a while to figure it all out. He is also a very picky eater and the gluten free food isn’t helping. Anyway, I’m a NDTR and getting a master’s degree in dietetics now, but even with all of my knowledge it still feels challenging to feed him. I really appreciate the post, and it confirms that I’m on the right track. I’m excited to read the rest of your related posts you linked to here. I’m so desperate for ideas!
Sally,
My daughter is 10 and is also having mysterious stomach aches for the past 6 months her pediatrician hasnt been able to pinpoint the cause. Her appetite has never been great but she is also a long distance runner and it pains me to see her so thin and after a hard workout she barely picks at her dinner (even her fav meals… she says her stomach hurts and/or not hungry) Id love to hear more about your son if youre willing to share. If not i understand, its just nerve wracking. What are your thoughts on Ensure and other calorie drinks.
Just reached out to you via email, Monica!
I wish I had tips. My 2 year old is underweight. We use all full fat, add butter, avocado, peanut butter, pediasure, look for the highest calorie options, eat at least 2 snacks a day and still she won’t gain enough. I feed her with way more attention to calorie content than my older 3 who are a healthy weight, and it doesn’t seem to matter what I do she just won’t put on weight.
I appreciate these suggestions. My guy isn’t picky and he eats a fair amount of food, but he’s just really lean (at 11 years) and always has been. I’ve been trying more of these tips and I feel like he’s filling out a little. I am going to see if you have a post on butter (you mentioned it here). We use butter and I’m happy to let him eat it (and he likes it) but I always feel nervous about it, given all I’ve heard/read over the decades. I recall Ellyn Satter (sp?) recommended up to 2tbsp a day or something but I would love to see a well-informed and up-to-date article on it, just so I have the latest in my mind.
Hi Desi–I don’t have a specific post about butter. When it comes to fats/oils, I try to use a few different kinds instead of relying on one. I primarily use olive oil for cooking, but butter for buttering bread or toast, etc. Sometimes I use avocado oil if I have it, sesame oil if I’m making a stir-fry or similar dish. Butter has more saturated fat vs. unsaturated, which is why you’ll sometimes see cautions around it. I try to take a moderate approach. There’s nothing like butter on a slice of sourdough or in a cookie. 🙂