DS11 underweight - how to talk to him about it, or not

[19Bears]

I've put this as a reply to another thread but wanted to make a new one here if that's ok. I had my DS11's height and weight letter from the school nurse just before Christmas. He's on the 1st centile and therefore underweight, and they advised me to contact my GP. He's always been skinny, like me, and doesn't look as 'well' as other kids, in that he can look pale sometimes. He's very active and we have recently been climbing a few hills in the Lakes, so he's not lacking in strength or fitness, he's just thin and fairly fussy with food.

I hadn't mentioned the letter to him as I don't want to make an issue of it, and just want to use a few of the ideas here (peanut butter, croissants, full fat milk) to get him to gradually gain a bit of weight without him really noticing. However, his dad blurted out the other day to him, "this is ridiculous how massively underweight you are! You should be at least 7 stones! You're way too thin!" I felt like pointing out that he is ridiculous for being massively overweight, amongst lots of other ridiculous things, but I bit my tongue...

He's 29kg, which is clearly low, but I don't want him to worry about his weight and feel as if there's something 'wrong' in some way. Equally, I want to encourage him all I can to put weight on and be healthy, and not just let it drift. So my question is, how do you talk to your child about being underweight? What works and what doesn't? Any feedback would be very much appreciated.

Thanks again all. I have made an appointment for 16th Jan. Whilst I feel terrible mum guilt about all of it, both DS15 and DS11 are both top of their classes (for want of a better, less boast-y phrase!) so their brains are ok, despite lack of breakfast (and sleep, for that matter.) My next door neighbour is a riot police officer, if that's the right title, and his mum tells me he lived on cereal til he was in his twenties, so I'm taking that as consolation that things can work out in the end...

I've just played with some numbers, as your child's height and age are similar to my youngest.
If he weighted 32kg, he would be healthy, but in the orange bit. 33kg and he would be totally in the green, healthy, weight category. The "you should weigh 7 stone" is going a long way over what would probably be beneficial for him to weigh.

I think that sort of weight gain would be fairly achievable with small changes - if your son was on board. I think you already know it's a carb heavy det, but it sounds like there are other things at play linked to eating (or not!). Something at breakfast time - it doesn't need to be a traditional breakfast food - would be a great start. Could you link eating breakfast to better concentration and performance at school rather than just weigh gain?

FWIW, my 11 year old is somewhere just below the middle of the centiles, and looks pretty slender compared to many of his peers. His older brother hovers around the 9th centile, looks skeletal compared to most, but equally can out run them.

I really think there is a ridiculous preoccupation with low weight / underweight children among health visitors & GPs for no real reason.

My child is tiny (2nd percentile) but eats healthy food and has loads of energy.

My BMI is technically underweight but i eat whenever I'm hungry and have enough energy. Some people are just like that.

Please don't fall into the trap of giving DS sugary crap just because the GP, who probably knows fuck all about nutrition, doesn't like his position on a chart. I saw a post on MN a while back from a mum who was giving her kid ice cream every night to fatten him up at a GP's suggestion, totally oblivious to any downsides like it may mess up his micro biome and immune system for life. Focus on quality ingredients, wholesome food, and I'm sure he'll be fine. You can add animal fat to veggies and meat if you feel you need to "do something" and provide hummus and nut butters too. Full fat dairy is good but ramping up the sugar is bad.

I do think a PP made a wise comment about food intolerances too. Some people may avoid foods if they subconsciously pick up on a feeling that their body isn't reacting well to them. They may not even know they're doing it.

Red meat is high calorie but best to get quality (organic) if you can afford it.

@19Bears People keep asking you, and you seem to not want to answer them - why is there no evening meal? Do you not eat together in the evening?

Your DS's diet is woefully short of protein, and he needs this to grow/build muscle. A diet so full of carbohydrate and sugar will give him the immediate energy he needs but won't help him to develop physically as he should.

What do you eat? Do you not eat an evening meal?

@19Bears a doctors appointment is a sensible idea if there are issues around food but it’s only going to be of limited help (if they even do a referral!). You’ve avoided answering any questions but based on what you’ve said so far it seems that you are causing these issues by not modelling a healthy relationship with food or providing adequate meals. You really need to make changes, cook dinner and sit with your child to have a family meal at the very least.

I think maybe this has hit a bit close to home and you’re projecting. No one has suggested feeding sugary crap, although that’s pretty much all the child seems to eat now.

@Blondbombsite no I know, it's just a trap I've seen other MN users fall into where they focus on making their DC put on weight to the exclusion of other nutritional considerations so thought I'd mention it.

And I totally agree with you about the current diet which absolutely could be improved.

Fair enough, health is definitely more than just the numbers on the scale 😊

@Lilgamesh2 but being underweight can also cause health problems and with kids being underweight if may be they are not being fed or other health concerns so should always be referred same as for those that are overweight
I say this as someone who has a son on bare minimum of being not underweight as he has severe food restrictions and with him its actually all about calories and not always nutrition as when someone has a limited diet its quite hard to meet the 5 a day etc etc

@Lilgamesh2 its also why I think bmi needs to be used carefuly as what is normal for one is not for another
My other ds if he put on a couple pounds would creep into the overweight , but he is very sporty and muscly and low body fat also very broad shouldered etc and totally different build to ds1

That is barely any food, little substance at all. But if this has been going on for a long time, then it won't come as much of a shock.

I got one of those letters for my skinny y6 boy. He was a fussy eater, but more so as a very young child. He eats anything now but doesn’t have a sweet tooth and isn’t really a snacker. He will have seconds/thirds or normal dinner and eats plenty. He is still skinny as a grown man - around 45kg at 175cm. He has almost no body fat. Incidentally he is also a climber. Your ds sounds like he could do with some support to realise he needs to eat actual meals and not just bread and yoghurt. I think you can increase weight with breakfast, dinner and supper if he only wants a snack at lunchtime. None of mine have ever eaten much at school. Ds had build up type drinks for breakfast and supper for years. I don’t think they made much difference tbh.

I would only be concerned if he has any other symptoms. My 10yo DS has always been small and thin and I had no concerns, but the weight suddenly started to fall off him recently. He's always been a fussy little thing around food but definitely ate plenty to keep him ticking along. Now, though, it turns out he has Inflammatory Bowel Disease - but it was diarrhoea and feeling tired all the time which took us to the GP. He now has a lot of other symptoms. I was shocked when she weighed him as he was on the 3rd centile for weight (25th for height which is normal for him). Anyway, I'm not saying this is what your child has, only that it might be worth investigation if his weight has suddenly dropped and there are other issues.

I also have a 14yo DS who is skinny, but he is visibly healthy (if not particularly fit!) and there is marked difference between his 'type' of thinness and that of his brother.

What evening meals have you prepared over the last 15 years for ds1 and ds2?

What did they used to have for breakfast at primary?
What about toast, cereals, pancakes, muffins, bagels, youghurt and fruit?

You don't surely need a GP to tell you that he eats an appalling diet full of sugary carbohydrates, no protein or fibre and no proper meals at all.

And you wonder why he's underweight...

A GP appointment is a good idea. I posted upthread about my DD who was diagnosed with disordered eating. Since she finds it difficult to eat at school I actually don't send her in until she's eaten something in the morning (~500kcal in some form). If she's finding it difficult to eat she will usually accept a Complan milkshake. She's been late twice in the last term but for me that's worth it because she is motivated to be in school. Often she'll then eat 2 things from her packed lunch at school and the rest when she gets home at 3pm. Then dinner, then an evening snack. We have successfully achieved weight gain with this method even though she doesn't eat much at school.

I really think there is a ridiculous preoccupation with low weight / underweight children among health visitors & GPs for no real reason

It's not for no reason though. You can be perfectly fit and healthy and very very skinny but being underweight can be a sign of all sorts of very bad things. Such as Physical or mental Illness or poor parenting.
Anorexia nervosa is the biggest killer out of all mental health issues. Loads of young people and children receive NHS care for it.
You have to look at the reasons why someone is very underweight. If there is no issue then great but it definitely needs looking at. It's not a ridiculous obsession it's basic healthcare.

Would you talk to him if he was overweight ? I personally wouldn't have told him about the clinically underweight bit.

It does sound like he needs some diet overhaul- even if that means sitting with the family when eating. Is New Year, new eating habits something that you could change as a family ?

My son has been clinically underweight for years. I took him to a hospital appointment when he was a teen and they weighed him and immediately asked him what drugs he was on which annoyed him so much. He is skinny but worked full time on his feet so was fit.

My kids never ate well at school because the sooner you eat, the sooner you can go out to play so I had to make them eat in the morning. They were also ravenous after school but I didn't feed them so much that they couldn't eat dinner later. Is your son veggie ?

What are your own eating habits like? There doesn't seem to be a sitting down dinner at home, is there?

There's no mention of a 'dinner' like spaghetti bolognese.
What are the grown ups eating and where are you eating it?

The fear of eating in front of others is anxiety isn't it?
Was he always like that or is this something that has just happened this year?

Could you mix things up a bit and more of a dinner meal available when he gets home from school?
When you get pizza or something at home or when out, does he eat that in good quantities?

Has he been offered to see anyone in clinic: consultant, nutritionist, dietician, counsellor?

There's not much protein there. Or green veg, broccoli etc.

My 2 have whopping appetites, play a lot sport. Porridge, 4 weetabix, waffles.

Meals:

Sausages and mash
Fajitas
Burgers
Chicken burgers
Quiche and salad
Steak, Chips and salad
Stir fry
Spaghetti and meatballs
Spaghetti Bolognese
Jacket potatoes
Steak/chicken pie and 3 steamed veg with new potatoes.
Chilli
Curry
Chicken and veg kebabs in Pitta
Roast
Pizza
Paella
Chicken fried rice
Fish and chips
Pulled pork
Gammon
Lamb shanks
Cauliflower curry
Shepherds pie
Lasagne
Beef casserole
5 spice pork loin.

Does he like any of the above?

Would he drink a few high calorie shakes every day that would really help you can buy them online in different flavours.

OP, some ideas:
a) some sort of breakfast, building up to a proper breakfast.
b) Speak to school re: lunchtimes. What’s made him too anxious to eat at school? If it’s not easily fixed, then you could see if they’d do something like make him a lunchtime helper for the reception-aged children, with the expectation that part of his job is to sit and eat with them. He’d be much less likely to feel anxious around 5 -year-olds he is meant to be helping. Others could do the same at different tables or different days.
c) have his after-school snack at a table with others (ideally you). He’s then eating “safe” food with a “safe” person, which he might be able to build on - has to be better than browsing in his bedroom in front of a screen.
d) make a proper evening meal. Ideally he’ll eat this at the table with the family. But otherwise in front of a screen, anything so he eats it.
My thinking is that you look at it as two goals - one is to get him eating better quantities and the other is getting him comfortable with food, eg being able to eat in front of others. Presenting him with a meal of foods he’s going to find challenging at a family mealtime is probably going to be too overwhelming.

Dc is 13 on 1st percentile has asd so certain sensory issues but eats good portions. Is currently under gastroenterology and a dietian. So far we've done food diaries and stool charts (could you do one before you go to gp), give 5 meals/snacks a day. Give a vitamin tablet.
Discussion is all about being healthy - eating /good lifestyle habits especially for things that can be seen eg hair, skin, nails or effect how we feel sleep/brain function. Don't ever discuss weight but encourage regular meals and snacks. Adapt food so it is suitable for sensory issues eg no milk on cereal. Add calories where we can such as cream in hot chocolate, side of garlic bread with main, lots of butter on crackers/bread, extra cheese on pizza. Also encourage making new things/trying new recipes and building up a list of safe meals (we now have 14 safe main meals, 7 smaller meals and about 6 snacks plus fruit and vegetables).
It's looking like dc has a medical issue but this has been dismissed in the past due to sensory issues. We're partly proving this by consistent diet and limited weight gain. But without this effort we may have been dismissed again due to sensory issues.