• When considering weight loss, consider the possibility of an error in recorded weights.

  • Obtain a thorough dietary history. Consider inaccuracy, especially if an eating disorder is possible.

  • A basic workup should be performed before attributing the loss to mental health. Consider the following assessments: complete blood cell count, comprehensive metabolic panel, C-reactive protein, erythrocyte sedimentation rate, tuberculin test, rapid plasma reagin test, HIV test, tissue transglutaminase plus immunoglobulin A, thyrotropin plus free thyroxine, stool guaiac test/culture/ova/parasites, and urinalysis.

  • Close follow-up is mandatory. Admission criteria if an eating disorder is considered can include less than 75% of the ideal body weight, a supine heart rate less than 50 beats/min, a temperature less than 35.6°C, a systolic blood pressure less than 90 mm Hg, arrhythmia, and orthostatic vital signs.

  • If findings from the workup are negative, attempts to increase caloric intake are insufficient, and an eating disorder is not suspected, refer the patient to a registered dietitian and/or a gastroenterologist.

  • The definition of significant weight loss varies by the child’s age and includes acute and chronic causes.

  • Clinically significant weight loss depends on age.

    • Newborns may lose 5% to 10% of their birth weight in the first few days after birth; losses greater than 12% are concerning.

    • In children, unintentional weight loss greater than 5% from baseline may be concerning.

    • In adolescents, in addition to weight relative to baseline, consider body mass index (BMI) percentile.

  • As many as one-half of adolescents with disordered eating do not meet the Diagnostic and Statistical Manual of Mental Disorders criteria.

    • These individuals remain at risk for developing both physical and psychological complications from their altered eating habits.

  • In general, weight loss occurs when caloric intake does not meet caloric expenditure.

    • In breastfed infants, actual intake may be difficult to ascertain, given dependencies on both maternal milk production and effective feeding.

    • In children, even if enteral intake seems sufficient, there may be issues with absorption and ability to metabolize the nutrition.

  • Weight loss may result from excessive fluid losses.

  • For all patients, records of previous body weights, allowing for differences in weighing technique, can be helpful.

  • Obtain a complete history, including

    • Diet and consumption history of child and family, with caloric assessment.

    • Assess parental expectations.

    • Obtain a careful birth, family, past medical, and medication history.

      • Assess sick contacts/exposure to illnesses and immediate history of febrile or other illnesses.

      • Determine the number of urinations and bowel movements per day.

      • Review gastrointestinal/malabsorption symptoms, such as vomiting, constipation, and diarrhea, and amount, frequency, and character of stools.

      • Assess other indications of feeding intolerance, including rashes.

      • Compare caloric intake with estimated caloric needs.

    • For infants,

      • In general, an infant should gain 25 to 30 g each day in the first 3 months after birth.

      • Assess feeding effort and coordination.

      • If the infant is formula-feeding,

        • Discuss the proportions in which formula is constituted.

        • Estimate total caloric intake from the volume of formula and caloric density of formula (standard is 20 kcal/oz).

      • If the infant is breastfeeding, assess

        • Perceived adequacy of maternal milk production.

        • Ability of infant to breastfeed.

        • Typically, birth weight is regained in 14 days; consider interventions if it is unlikely to be regained in the first 3 weeks, especially with new parents.

    • For children and adolescents,

      • Discuss whether eating leads to symptoms, such as pain, vomiting, diarrhea, or fatigue.

      • Discuss quantity and type of stools.

      • Assess body image, social context (including family function and patient’s emotional well being), and stressors.

      • Consider HEEADSSS (home environment, education and employment, eating, peer-related activities, drugs, sexuality, suicide/depression, safety) examination

      • Does the patient participate in sports in which weight loss is a goal?

        • Such as wrestling, gymnastics, ice-skating, running, swimming,diving, and dancing.

        • If yes, obtain a thorough dietary and supplement history.

      • For girls, obtain a menstruation history.

  • Subjective impressions of weight loss should be verified objectively before an evaluation is undertaken.

    • True weight loss may sometimes be difficult to differentiate from factitious weight loss.

    • Errors occur in the recorded weight of 5% to 20% of all children because of faulty equipment or poor technique.

    • Weigh the patient and plot that weight onto a growth chart; consider serial weight measurements for computing growth velocity.

    • Consider weighing a breastfed infant before and after a feeding.

    • Measure length/height.

      • For children 2 years and older, compute BMI and BMI percentile.

  • For vital signs,

    • Assess temperature, supine heart rate (HR) (if an eating disorder is possible), blood pressure (BP), and orthostatic vital signs.

  • For physical examination,

    • Assess mental status.

    • Assess volume status and for anemia (eg, pale conjunctivae).

    • Examine oral mucosa for thrush and ulcerations.

      • Oral aphthous ulcers may be related to Crohn’s disease.

      • Discoloration of teeth may be related to purging behaviors.

    • Assess cardiorespiratory status.

    • Assess abdomen and for organomegaly.

    • Look for signs of malnutrition or vitamin deficiencies (eg, lanugo).

    • Assess for toxidromes in adolescents.

  • In breastfed infants, in which weight loss is suspected because of inadequacy of feeding, observe the mother breastfeeding the baby.

  • The differential diagnosis for weight loss is broad and varies somewhat with age.

  • Of note, poverty is the greatest single risk factor for developing failure to thrive in the United States.

  • Psychosocial factors (eg, poor parent-child interaction, depression, rumination) often underlie poor growth and development.

    • Actual weight loss is much less common in this setting than slowdown or cessation of weight gain and linear growth.

    • Psychosocial dysfunction resulting in a child’s weight loss requires a prompt and thorough evaluation.

    • Eating disorders have been described in prepubertal children as young as 7 years.

Newborns and young infants

  • Difficulties in establishing breastfeeding

  • Inappropriate dilution or choice of formula

  • Inadequate intake

    • In breastfed infants, inadequate intake at the breast is the most common reason for weight loss.

    • In formula-fed infants, consider unsuccessful feeding related to parental inexperience; if this is not the case,

      • Search for an organic problem.

      • Evaluate family dynamics, support mechanisms, and adjustment to the newborn.

  • Excessive losses from vomiting and/or diarrhea

  • Child abuse

  • Infection

  • Metabolic abnormality

  • Craniofacial abnormalities

  • Central nervous system (CNS) dysfunction

  • Somnolence from maternal medications/substance use disorder

  • Maternal depression, inexperience, or lack of knowledge

  • Congenital heart disease

  • Polyuria (ie, diabetes insipidus, renal disease)

Older infants, preschoolers, and school-aged children

Adolescents

  • Dieting behavior

  • Adolescent eating disorders

    • Anorexia nervosa

      • Suspect when the adolescent is unwilling or unable to maintain body weight over a minimally normal weight for age and height.

      • Attitudes and behaviors about eating or body image are distorted; amenorrhea, emaciation, and overactivity may be described.

      • Concurrently, may have hypothyroidism, bradycardia, hypothermia, growth of lanugo-like hair on body and extremities.

    • Bulimia nervosa

      • Binge eating, followed by self-induced vomiting, self-starvation, overactivity, and use of cathartics or diuretics to reduce weight

        • These behaviors are practiced in secret, and the adolescent often denies them.

    • Other eating disorders

  • Psychiatric affective disorders, especially depression

  • Malignancy, especially lymphoma

  • Inflammatory bowel disease

  • Diabetes mellitus

  • Hyperthyroidism

  • Tuberculosis

  • Celiac disease

  • Sports-related weight loss

    • Adolescents may engage in unhealthy weight-control practices to seek advantage in their athletic activities.

      • These may include food restriction, vomiting, overexercise, diet pills, stimulants, insulin, nicotine, and voluntary dehydration.

  • Evaluation is guided by clinical suspicion.

  • For infants, ensure that a newborn screening has been performed.

  • Studies may include:

    • Comprehensive metabolic panel

    • Complete blood cell count, blood smear

    • Erythrocyte sedimentation rate, C-reactive protein

    • Tuberculin test, rapid plasma reagin, HIV test

    • Tissue transglutaminase plus immunoglobulin A

    • Thyrotropin plus free thyroxine

    • Stool guaiac test/fat/culture/ova/parasites

    • Urinalysis, including specific gravity; urine culture

  • Imaging is guided by clinical suspicion.

  • Diagnostic procedures may be performed as guided by clinical suspicion.

    • Upper endoscopy with biopsy

    • Colonoscopy

    • Sweat test (for chloride)

    • Esophageal motility testing

    • pH probes

  • In addition to diagnostic testing, serial evaluations of weight and intake are the cornerstones of assessing weight issues.

Infants

  • In breastfed infants with inadequate weight gain, support and education are appropriate interventions.

  • Appropriate weight gain in the following few days provides evidence that the infant is well and confirms the diagnosis of initial underfeeding.

  • Prematurely recommending discontinuation of breastfeeding is inappropriate.

    • The mother’s motivation to breastfeed and her positive or negative feelings about the experience should be discussed.

    • Encouragement and support should be given for continued breastfeeding.

    • Do not reinforce parental perceptions that the mother’s milk supply is insufficient or less nutritious than formula.

    • Lactation consultants or community organizations (eg, La Leche League) may be helpful in supporting lactation efforts.

    • Infants who fail to thrive while breastfeeding require more intensive nutritional rehabilitation, while breastfeeding is still preserved.

  • If, however, the situation requires supplemental formula, counsel the family that this formula will not negate the positive benefits of human milk and should be used only for a short time (ie, until the next weight check), while they are awaiting milk supply and/or breastfeeding to improve. Supplemental formula should be provided only after breastfeeding.

Children/adolescents

  • For admission criteria, see When to Admit below.

  • Obtain urine for a dipstick urinalysis to be performed in the office if this type of analysis is available.

  • Perform the workup indicated above, plus any additional workup that seems indicated.

  • Obtain a dietary history.

  • If findings from the dietary history indicate insufficient caloric consumption and there are no concerns for eating disorders (ie, a patient who had no issues with weight previously, in whom a stimulant was started for attention-deficit/hyperactivity disorder, and who is now not eating much), provide guidance regarding how to increase this consumption. Simple tips include

    • By using a blender, create a weight-gainer shake with milk, peanut butter, fruit, and ice cream. (The child can try different ingredients/recipes until they create one that is palatable.) Then drink this shake after meals.

    • Add olive oil or extra cheese to foods.

    • Parents, allow more judicious use of snacks/desserts after eating a nutritious meal.

    • For kids who typically graze throughout the day, switching to 3 meals plus 2 snacks daily can be helpful.

    • If needed, start consuming PediaSure or Ensure after meals (if picky eating has led to weight loss, though, this approach can exacerbate the picky eating).

  • Refer when there is evidence of or suspected

  • If findings from the workup are negative and insufficient caloric intake is still suspected, refer to a registered dietitian and/or a gastroenterologist.

  • A newborn, when

    • Weight loss cannot be managed in the outpatient setting.

    • Weight loss is greater than 12% to 15% of birth weight.

    • Excessive fluid loss (from vomiting, diarrhea, or polyuria).

    • Evidence of infant hypernatremic dehydration.

    • Suspected infection, metabolic abnormality, congenital heart disease, or other conditions requiring evaluation.

    • Extreme passivity of the infant, which may require tube feeding.

    • Need for intensive maternal education and support.

  • At any age, when

    • Weight loss is excessive (>5%–10% of previous weight).

    • Excessive fluid loss from vomiting or diarrhea.

    • New-onset diabetes mellitus (usually).

    • Evidence of severe febrile illness (eg, pneumonia, pyelonephritis, osteomyelitis, meningitis, septic arthritis).

    • Evidence of dehydration.

    • Physiological instability.

    • Severe bradycardia.

    • Hypotension.

    • Hypothermia.

    • Orthostatic changes.

    • Electrolyte abnormalities (eg, hypernatremia, hypokalemia).

    • Evidence of significant psychosocial dysfunction.

  • An adolescent, when

    • Eating disorder cannot be managed in the outpatient setting.

    • Severe malnutrition, with weight less than 75% of ideal body weight.

    • Supine HR less than 50 beats/min while adolescent is awake (<45 beats/min while adolescent is sleeping).

    • Temperature less than 35.6°C.

    • Systolic BP less than 90 mm Hg.

    • Arrhythmia.

    • Orthostatic vital signs (BP >10 mm Hg or pulse >20 beats/min).

      • Given that many adolescents have orthostatic vital signs, not all centers follow this guidance; please consult the center adolescent medicine team.

    • Evidence of dehydration or electrolyte abnormalities.

    • Acute food refusal.

    • Uncontrollable binge eating and purging.

    • Acute medical complication of malnutrition (ie, syncope, seizures, cardiac failure, pancreatitis).

    • Suicidal intent or ideation, or psychosis.

BMI Percentile Calculator for Child and Teen: English (interactive tool)
,
Centers for Disease Control and Prevention
.
Breastfeeding Handbook for Physicians, 2nd Edition (book)
,
American Academy of Pediatrics
.
Growth Charts (web page with charts)
,
Centers for Disease Control and Prevention
.
Pediatric Nutrition Handbook, 8th Edition (book)
,
American Academy of Pediatrics
.
American Academy of Pediatrics Section on Breastfeeding
.
Breastfeeding and the use of human milk
.
Pediatrics
.
2012
;
129
(
3
):
e827
e841
Carl
RL
,
Johnson
MD
,
Martin
TJ
;
American Academy of Pediatrics Council on Sports Medicine and Fitness
.
Promotion of healthy weight-control practices in young athletes
.
Pediatrics
.
2017
;
140
(
3
):
e20171871
. doi:10.1542/peds.2017-1871
Gidding
SS
,
Dennison
BA
,
Birch
LL
, et al;
American Heart Association
.
Dietary recommendations for children and adolescents: a guide for practitioners
.
Pediatrics
.
2006
;
117
(
2
):
554
559
. AAP endorsed
Rosen
DS
;
American Academy of Pediatrics Committee on Adolescence
.
Identification and management of eating disorders in children and adolescents
.
Pediatrics
.
2010
;
126
(
6
):
1240
1253
. Reaffirmed November 2014
Carl
RL
,
Johnson
MD
,
Martin
TJ
;
American Academy of Pediatrics Council on Sports Medicine and Fitness
.
Promotion of healthy weight-control practices in young athletes
.
Pediatrics
.
2017
;
140
(
3
):
e20171871
. doi:10.1542/peds.2017-1871
Rosen
DS
;
American Academy of Pediatrics Committee on Adolescence
.
Identification and management of eating disorders in children and adolescents
.
Pediatrics
.
2010
;
126
(
6
):
1240
-
1253
. Reaffirmed November 2014