I am often asked about how to raise children that have positive relationships with food and their bodies. One factor that comes to mind is to consider the messages your children receive about their body from their physician. I recently wrote a post about talking to teachers and coaches about weight-neutral and age appropriate approaches to nutrition and feeding children in school. This post got me thinking about what resources I have collected for pediatricians and that the information I give pediatricians is different than what I give teachers. Pediatric visits may not necessarily be able to be completely weight-neutral, but they can certainly do no harm.
In 2016, the American Academy of Pediatrics published a new statement stating that providers should not focus on weight when talking with young patients. The statement highlights the potential harm that can be caused when pediatricians focus on weight when talking with children and adolescents. However, it is standard practice for a well child visit at the pediatrician’s office to include a review of growth charts. Childhood is a time of growth and development and because of this a health assessment of a child can’t truly be as weight neutral as it can with an adult. It’s important for children’s weight and height to be monitored so that if something is interfering with growth and development it can be addressed, if needed. As parents, how can we advocate for our children to not be harmed by talk about weight and at the same time have these important vitals monitored as part of the health assessment?
Talk with your pediatrician about how weight is discussed in front of your child.
As a parent, I think it's important to support my child in having a positive experience at the pediatrician’s office that does no harm and is free of diet talk. Of course, I’m supportive of each parent handling things how they are most comfortable. Something I have done, when my child reach a certain age, is ask my pediatrician to put a note in their chart to not review growth charts in front of the child. The first time I asked this of my pediatrician, she said “What’s wrong with your child’s weight?” I said, “Nothing is, and I don’t want her ever to think there is.” I asked her to give me the print out of the growth curve at the well child visits and if she ever had a concern she can talk with me privately. I believe this simple request is in line with the American Academy of Pediatrics statement. In case it would be helpful, I've pulled together some resources to share with your pediatrician if you need a little backup when talking to her about how and why talking to children about weight is unhelpful and can cause harm.
Do No Harm Resources for Pediatric Providers:
- American Academy of Pediatrics Statement
- Ellyn Satter Institute
- Online trainings for physicians
- Article on Adolescents that Diet *
If you consider having this discussion and for your provider to give you growth charts without giving in depth information in front of your child, it may be helpful to understand the complexities of growth charts. I have been trained in interpreting growth charts and still find them complex, fascinating, and confusing at times.
Source: CDC Clinical Growth Charts
A few things to know about growth charts:
- Children are always growing and need to be gaining weight. Each year, at a child’s physical, their weight and height are plotted on their growth curve. (Here is a link to the CDC Clinical Growth Charts.) These plot points, mark the weight and height at the child’s current age and gives a percentile. For example, a boy may be at the 70th percentile weight-for-age at age 12. Meaning, that 70% of 12 year old boys weigh less than that child and 30% of 12 year old boys weigh more. This plot point of weight-for-age does not take into account height, genetics, or stage of puberty. It’s only a point comparing the child’s weight to the same aged, same sexed population. These charts can be confusing and quite abstract. Often, the meaning of the information can be construed and taken out of context.
- There is not a right or wrong percentile for your child. We are not all supposed to be at the 50th percentile. Body heights and weights are mostly genetically determined and fall along a wide range, a bell curve. There are individuals whose height-for-age plots along the 3rd percentile their whole life, for example. As long as they are growing and continue to grow along this curve, more or less, this is neither good nor bad. Most likely, a child whose height-for-age is along the 3rd percentile has parents that are shorter in stature. Being shorter, is not different than having brown eyes or a size 10 foot. This is the same for weight-for-age. If a child is at the 20th percentile weight-for-age, we would predict he will continue to plot along this curve. It is neither good or bad, it just is. When we need to become concerned is when height-for-age or weight-for-age begin to drastically cross percentile lines, up or down. This would be a reason to stop and dig a little deeper for information of why this may be happening. It could be a red flag that something is interfering with typical growth and development and there also could be no explanation at all.
- Plot points need to only be compared to that child’s historical plot points, and often that only gives part of the information. If a child’s weight-for-age is at the 90th percentile and always has been since age 2, there is no need for concern. The child is growing predictably. If a child's weight-for-age is at the 10th percentile and has always plotted along the 10th percentile, the child's weight is increasing predictably. We need to only compare these percentiles to that child's historical growth and then look at the larger context. If a child has a big growth spurt and jumps up on their height growth curve they most likely will and, need to, jump up on the weight growth curve. If they go through puberty earlier than their peers, they will cross percentile lines because they are going through a rapid time of growth and development earlier than the average child. Your pediatrician or a pediatric dietitian can review these charts with you in depth, if needed.
- Children, in general, gain and grow predictably without any instruction or interference. This point continues to amaze me. If you know me, you know that I love interpreting growth charts. It’s truly amazing to look at a child’s growth chart and see their weight and height plot points make a curve from age 2 - 17. It’s amazing to me that a child’s body knows what to do, without interference, and plots along a predictable curve. We don't need to do anything or tell them anything,their body knows what to do. Because of this fact, we don’t need to be telling them their plot points and percentiles. That in and of itself is interfering with their growth. They don’t need to hear “you’re doing great you’re plotting along the 50th percentile.” A sensitive child may interpret this as meaning that it would be bad if they veered off. They may think, "what do I need to do to stay on my curve?" Growth isn’t a math test that a child needs to master. They need to do nothing but follow their intuition and giving them this feedback can interfere.
- Growth charts are information for parents. Growth charts are extremely complex and confusing. They give valuable information about how a child is growing which is an important part of childhood. However, because of the complexity of the information, it’s truly adult information, as it can be misunderstood easily by a child. As you may have heard me discuss in the past, children are concrete thinkers. Growth charts and percentiles are certainly abstract concepts. A child may hear, “you’re at the 80th percentile” and misinterpret this information. I’ve heard people think that the 99th percentile is the goal, like a school test. Also, I’ve heard many people believe 50th percentile is the “best” and anything above or below is less than ideal.
The pediatrician or family medicine practitioner is the first medical provider our children have a relationship with. I hope that children have medical providers whose words and actions illustrate that they trust their young bodies. I hope that fear is kept out of medical visits and instead include excitement and amazement for what their bodies can do. I hope that this excitement and amazement translates to them learning to take good care of the body they have and that they know they are in partnership in this task with their doctor. If these foundations can be laid early, then, possibly, they can continue to choose medical providers that listen well and show respect for them and their bodies.
*Newmark-Sztainer et al. "Obesity, Disordered Eating and Eating Disorders In a Longitudinal Study of Adolescents How to Diets Fare 5 Years Later, " Journal of the American Dietetic Asso ciation (2006) 106, 559-568.
I never thought to ask the pediatrician to not discus the child's weight with them in the room. I agree that at such a young age, weight and dieting should not be in the forefront of their minds. I will have to talk to my kids pediatrician and see if he will do this for me.
Yes! Let us know if your pediatrician is receptive.
I like how you said that plot points on our child's growth chart only need to be compared to our child's previous plot points, since the main concern is that our child should be growing predictably. My husband and I have a baby on the way, and I've been trying to learn more about children's health care to help ease my mind about what's to come. I'm glad I read your article because I hadn't previously realized that the percentile doesn't really matter as long as the child's growth is predictable.
Daphne, so glad you found the post helpful.
I like how you said that we should make sure the information from our child's growth chart isn't misinterpreted by them, since they think of the percentiles like they would think of their grades at school. I need to find a new pediatrician soon due to a change in insurance, and I want to help my kids be comfortable with the new doctor however I can. I'm glad I read your article because I never considered that kids could easily misinterpret percentile information.
This is a great article!!! As a clinician (RDN, CDE), I find it challenging to establish a context where I can have a private conversation with parents. (I find I have the opposite problem of parents using judgmental or weight based language I don't want kids to hear). The kids have to be present for the appointment and are often too young to be left alone in a waiting area....ideas?
HI Elizabeth, Thanks for reading! Great question! With young children, I often just meet with the parents. Either way, we encourage the parents to practice being neutral/not commenting about food or weight. Let us know if you have other questions.