When Ashley Boyd's daughter Autumn Greer was about 3 months old, she stopped growing and gaining weight despite what appeared to be a healthy appetite.
"It was scary because it seemed like I was doing the right things that I usually did with my other kids," said Boyd, 26. "She was eating normally; it was just like she didn't grow."
Boyd took Autumn to see her pediatrician, who referred them to the University of Maryland Growth and Nutrition Clinic in downtown Baltimore, where Boyd met Maureen Black, a pediatrician and the clinic's director.
Black's treatment method involves inviting a family to the clinic and videotaping them eating breakfast together. The video is played back to the parents later to help them see what might be affecting their child's eating habits. Black uses a strategy called motivational interviewing to gently help parents realize how their behaviors may be influencing the child.
Sometimes, for example, the parent will ignore the child while texting through the meal, not noticing that he or she was trying to get their attention.
"Mealtime is supposed to be not only around food, but it's also a social exchange," Black said. "We use it to try to show parents that their child is trying to get their attention."
Snacking on junk food throughout the day or drinking too much juice can disrupt the child's eating habits, too, she said.
"Children are smart, and from a very, very young age they'll recognize the parent will give them junk food, and they'll hold out for it."
Black's research on the impact of childhood and household risk factors on children's weight was published in December in The Journal of Pediatrics. The study was based on data culled from five years of treating underweight children. Black and her co-authors found after studying nearly 300 children under age 5 from the Baltimore area that those with multiple household risk factors — such as crowding, single-parenthood or poverty — gained weight more readily after the intervention than children with fewer risk factors.
In other words, Black said, the worse off kids were the better they were able to recover.
In motivational interviewing, Black asks the parents questions — "Why do you think your child is eating better today?" or "Is this how mealtime usually goes?" — to help them figure out a solution on their own.
"No one likes to be told what to do," Black said. "If I were to say to the family, 'Turn off your cellphone,' families may feel like, 'Who are you?' But if they see themselves on the cellphone, then see the child looking at them or making overtures at them, they come up with the intervention, 'Maybe my cellphone should be turned off.'"
Sometimes, the parents will beg the child to eat or threaten them, and, in some cases, hit the children. Mostly, Black said, the parents ignore the child during mealtimes.
The clinic has a multidisciplinary team that helps evaluate the child and determine whether the feeding problem has a medical cause, for instance, celiac disease or acid reflux. More often though, behavioral changes are enough to help the child eat better.
"Sometimes we have moms who say, 'I don't really eat, I just grab,'" Black said. "It's really unhealthy for a mom but very unhealthy for a child to not have eating habits."
The doctors at the clinic also give parents advice on what to eat, such as more vegetables, and how to add calories to meals using butter or cream cheese, until the child's weight increases.
An estimated 3.5 percent of U.S. children and adolescents ages 2 to 19 are underweight, according to the Centers for Disease Control and Prevention. Malnutrition in childhood can lead to lifelong problems, including stunted growth and impaired cognitive function.
Some 17 percent of children and adolescents in the same age range are obese, according to the CDC. Black believes her techniques can also be used to help overweight children, and hopes to start working with them at the clinic soon.
Marina Chaparro, a dietitian and spokeswoman for the Academy of Nutrition and Dietetics who has a private practice in Miami, uses the same videotaping technique. She said that if there's no underlying medical issue, the problem is often the child struggling with different food textures or tastes.
"It's very rare to just have a kid that's not eating enough to gain weight," Chaparro said. "Kids are very intuitive and they're not going to go hungry."
Chaparro said that sometimes parents won't bring the problem up with a doctor or get professional help because they think it is a phase and instead cope by making the child special meals. Sometimes parents don't seek help until the children are teenagers.
"It's really important that if your kid is struggling to eat or meals are taking more than an hour, I think you need to seek help because then it becomes a problem," Chaparro said.
Boyd's daughter Autumn, now about a year old, has gained about 12 pounds and now weighs nearly 24 pounds after several visits to the nutrition clinic. Boyd started adding butter to her foods and feeding her and her sons, ages 3 and 6, more vegetables, which she said they enjoy. Autumn's favorite foods are broccoli and green beans, Boyd said.
"I feel very confident," Boyd said. "I haven't had any issues with her weight since. She's playful, she's healthy, and she's at the right size for her age."