To not see why the paediatrician is concerned?

[Purplevioletsherbert]

DS is 7 and has autism and adhd. He has always been very tall and very heavy. Hes quite ‘dense’ so I don’t think he ever looked very fat but was never slim either.

last year he started adhd medication and weighed 40kg at 135cm tall. He had an appointment this week and was 40kg at 142cm tall.

Loss of appetite is obviously normal with his medication, and he often skips breakfast, has a small lunch and then eats a regular meal for dinner. Not huge on veg but will eat a large portion of carrots or cucumber every day and takes vitamins. Lunch at school is a cheese toastie, dinner will be something like chicken and a baked potato. He still has a sweet tooth but we try to limit sweets.

Paediatrician is concerned about his lack of appetite and says I need to make sure he eats breakfast before he takes his medication in the morning so he’s hungry for it. But he has a really good morning routine and he would struggle with this, having not eaten breakfast for over a year. School always offer him a fruit snack or toast when he gets in too and he sometimes has some. He already leaves for school at 7.15am so I don’t want to wake him even earlier to force breakfast down him when there are no downsides to him not having any!

Also, with such a heavy child, the advice is always to help them maintain their weight whilst they grow rather than trying to get them to lose weight. He’s maintaining his weight! And he’s actually looking really healthy for it. Is him skipping breakfast really such a big deal?

He’s also offered breakfast every morning / toast, fruit, yogurt, but he doesn’t want it. He’s offered it all again at school and often still doesn’t want it.

I’d make breakfast something a bit more exciting. Just a mouthful to help his meds.

I don’t think the PP meant you’d ‘put him on’ a diet, more that he’s inadvertently ended up on a vlc diet (in the eating plan sense, not the on a diet sense).

It’s really tricky keeping an eye on so many conditions and requirements at the same time. You have the medication implications, the ADHD condition, his family history and his current build all to keep an eye on and balance the needs simultaneously.

It’s clear you’re doing a fab job. It’s just the paediatrician has seen children lose condition quickly due to the medication.

Both centile charts and BMI can be tricky, particularly in children. They are broadly useful, as in general terms, height and weight should track roughly together as they grow, but they don’t take into account body composition.

They are useful as we have become more and more used to seeing overweight children. When you look at the ‘chubby’ children of my youth, they look normal now.

Being 98th centile doesn’t mean you are very overweight. It just means that (out of 100 normal individuals, you would expect 2 to be heavier than you). I can’t see that you have referred to his height centile, so apologies if I have missed that, but if he is also on the 98th centile for height, then his weight is as you would expect.

As an example, I am 5 foot 2. My friend is over 6 foot. Being on the 98th centile for weight would make me morbidly obese but it would be normal for her.

(There is a slight caveat in children that overweight children tend to grow more generally, so are often also a bit taller than would be expected from parental height)

However, higher weight centile than height or increased BMI doesn’t always mean too fat. My daughter does about 16-20 hours of organised extra-curricular exercise on top of whatever she does at school, with the family and practising her activities outside training. This year, she has significantly changed in physical shape to have noticeable musculature and looks much much leaner. Her ribs and vertebrae are clearly visible. She does not have a six pack, but you can start seeing her abs. She is stronger, fitter, faster and can go further and higher. She has tracked her same height centile, but her weight centile has increased by nearly 2 centiles. In comparison, when her weight centile was less than her height, she did have a little roll of abdominal fat. Her strength, stamina and speed were only just above average. She just seems to have packed on muscle. She is still wearing clothes smaller than her chronological age, except the girth of her quadriceps now makes skinny trousers difficult.

So both measures of growth need to be interpreted in the context of the individual child.

You say that your boy has always been dense rather than fat. Could the paediatrician’s concern be because he remembers that he did not have excess fat last year to explain his weight, and that it was muscle? And therefore he didn’t consider him as having weight to “grow into”? Which therefore has promoted the comment about his lack of increase in weight. His concern may also have nothing to do with his weight, but from a nutritional basis, and he was trying to give well-meaning if a little cackhanded advice, as usually children will eat breakfast, and sometimes find concentration difficult if they don’t. Which might not apply to your son.

Kids with low muscle tone have potentially compromised cardiovascular systems. (The heart pumps blood one way around your body after it has been oxygenated, but it relies on your muscles to squeeze the fluids in between your tissues and cells (the integumentary system) to get blood BACK to your heart. If this doesn’t happen effectively, even children (yes, very rarely) can develop clots where it has pooled. Another issue is that some ASD kids have a higher risk of malnutrition disorders due to their tendencies to minimize or avoid food groups. This can leave them both vulnerable to infection and with a compromised ability to heal. Some kids with malnutrition literally don’t have the energy to feel hungry (think about food, chew, digest, etc…) and thinking about the whole process makes them tired and puts them off eating. Once the issue is resolved they eat again with gusto.

He is very tall for his age but also very heavy. Well above 99.9th centile according to UK charts.
NHS BMI calculator....which takes into account height...has him at very overweight.

Your paediatrician is trying to get a healthier routine.
Breakfast....especially protein, will really help set him up for the day.
A cheese toasie isn't a particularly healthy lunch, and then you said a protein shake but you didn't mention this originally.

It’s really tricky keeping an eye on so many conditions and requirements at the same time. You have the medication implications, the ADHD condition, his family history and his current build all to keep an eye on and balance the needs simultaneously.

This is very true and also just the tip of the iceberg really, he has a wide range of other conditions and difficulties. And we are always getting conflicting information so I’m very used to having to just ignore some of it!

You say that your boy has always been dense rather than fat. Could the paediatrician’s concern be because he remembers that he did not have excess fat last year to explain his weight, and that it was muscle? And therefore he didn’t consider him as having weight to “grow into”?

Completely understand this would be a concern but he’s definitely more muscular now whereas last year was a bit podgy.

@AnxiousRabbit I didn’t mention the protein shake originally because he has it at about 4pm and is irrelevant to the original question about whether or not it’s ok for him to skip breakfast.

I completely agree with this.

He is double the weight of my almost 7 year old.

Helpful comparison.

There can be an issue with meds on an empty stomach being absorbed faster and not lasting the whole day.

I said that you are effectively putting him on a calorie controlled diet which has the consequence of him dropping down the centiles. I did not say it’s deliberate, but you do know it’s happening.

You know he doesn’t feel hungry on the medication and the paediatrician has told you it matters. You can’t expect your child to overcome the appetite suppressing effect of the ADHD meds on his own without your help.

My ds is so adopted as am I.

Can I ask how old he was when adopted? Is there a connection to food and trauma for him? Was he obese when he came to you?

I would potentially try to encourage your DS to eat something small or drink a smoothie (if he will), prior to taking meds.

I take ADHD meds and even though it's not a "must" it's pretty widely recommended that both adults and children on ADHD medication eat before taking it, and eat little but often whilst on them. Speaking from experience, and from what I've read on adult and child groups it make you feel a little rough if you don't, because medication hits you a lot harder on an empty stomach. My psychiatrist also recommends 3 meals and 2 snacks for all stimulant ADHD medications, because it makes you less likely to crash throughout the day.

Also. Your DS portions are quite small now, which is fine, but it's worth thinking about the future. His appetite likely won't increase much as he grows, if medication is a long term thing, but his caloric needs will. Knowing how hard it can be to get food into ASD/ADHD kids and knowing how hard it is to get food into myself whilst medicated, it would potentially be worth introducing the idea of 3 meals and two snacks, with the view that it's then easier to increase those meals/snacks slightly to meet energy needs as your DS gets older, whereas it could potentially be quite overwhelming to have to have to significantly increase the size of two daily meals as DS grows.

I totally understand if my suggestion wouldn't work for you, because I know the change in routine would be huge. But I just wanted to throw it out there as a suggestion for the long term.

Also in case anyone pulls me up for being on child ADHD groups - my daughter has ADHD, so I have reason to be in them.

Its because throughout childhood and into puberty childrens bone and muscle density increases. A 7 year old at the same height and size as a 12 year old should weigh quite a bit less. If they are the same height and weight as a 12 year old its likely a higher proportion of the 7 year olds weight is fat rather that muscle and the weight of their bones.

But he’s also 142cm which is extremely tall for a 7 year old. My dd is 9 next week and 136cm and people say she is tall. So OP’s DS is extremely tall for his age.

OP, I’m not sure what you can do really, you can’t force food into him. He hasn’t lost weight, he’s maintained and is by no means underweight. The main issue is does he have enough fuel in him to concentrate all morning but if he won’t eat his breakfast, I’m not sure what more you can do.

It's really important to understand that the process of digestion itself requires calories. If the body doesn't have enough calories then it won't prioritise digestion, it will prioritise other vital processes. Hence why appetite decreases- the body is saying it doesn't have enough energy to digest food.

Easily fast digestible foods like bananas can help and also some protein like yoghurt, nut butter, an egg which slows the release of sugars from the carbs

I respect doctors hugely for so many reasons, but many have no idea when it comes to nutrition. Kids weight in childhood tends to predict weight long term, so I think you're right to do exactly what you're doing. Leave out breakfast for now. You have a great routine that's working for you and he's slowly losing weight (i.e. Same weight, but getting older) and that's a great achievement - and ultimately a great thing fir his general health.