The children in this clinic have an unhealthy relationship with food. They drink too much juice and eat too much junk. One patient would eat only madeleine cookies; another roamed the grocery store aisles each morning to choose his breakfast -- chocolate-covered pretzels being a favorite.
But the kids treated by Dr. Maureen Black aren't part of the obesity epidemic that has swept up as many as 18 percent of U.S. children.
They are on the opposite end of the scale, the end that doesn't get the attention. They are the chronically underweight, the malnourished in the land of the increasingly overfed.
The problem is called failure to thrive, but what it means is children weigh so little that they often do not register on the standard growth charts kept by pediatricians. They stop putting on the pounds, then they stop getting taller, and eventually -- if left untreated -- their brains stop growing. They can be left with developmental problems and immune system deficiencies. They can be permanently stunted.
"The bottom line is they're not getting enough food," said Black, director of the Growth and Nutrition Clinic at the University of Maryland School of Medicine. "There's no shortage of these kids."
Exactly how many children fail to thrive isn't known, Black said, but the numbers are as high as one in 10 in low-income communities. The persistently underweight, though, live in the poorest of apartments and the tidiest of McMansions.
Doctors say they are paying more attention to the phenomenon as they see a lack of education about how to properly feed children, isolated single mothers with few places to turn for simple advice on healthy eating and an emphasis on convenience over nutrition when it comes to planning menus, if any planning is done at all.
Some of the patients at the Baltimore clinic have medical conditions that make it hard to eat -- say, food allergies or celiac disease -- but most just aren't getting enough calories. For some, it starts as infants when mothers improperly mix formula, either because they can't follow the directions on the label or because they can't afford to make it full-strength. For others, weight gain starts out strong but begins to lag as meal times become battle times.
The fixes, Black said, are often behavioral.
Alphia Harris brought her daughter to see Black and her colleagues for the first time a few months ago. Harris was worried about her 6-year-old Kaniah's skinny legs and gangly arms, certainly.
But she also knew that her daughter was using dinnertime as a time to pick fights and act up.
Black and her team did what they always do. They examined Kaniah inside and out, studied the East Baltimore family's eating habits, performed a psychological evaluation and videotaped the mother and daughter over a meal.
The Harrises met with Black, who is a psychologist, and a pediatrician and a dietitian.
What they learned is that Harris was leaving Kaniah and her younger brother to eat at the table by themselves. Mom would be busy and tired after coming home from work as a secretary for the state. She would find herself tidying the house or being distracted by some other chore or even trying to steal a few minutes of quiet time on the couch while the kids had their dinner.
It became as simple as spending more time with her daughter, letting her help cook, joining the kids at a set mealtime every night. "It helped her eat more, enjoy the food, that mommy was sitting at the table with her," Harris said.
Harris also stopped rewarding her daughter for good behavior with candy, doughnuts or chips. A few high-fat, high-calorie foods weren't enough to keep the girl's weight on a steady upswing when little else was going in, Black showed them.
The patients in Black's clinic are typically younger than Kaniah; she prefers to see kids from soon after birth through age 3. But it took years before Harris finally admitted that something was wrong with her little girl.
"I was the same way as a child," said a slender Harris. "I figured she'd have the same traits."
After two visits, Kaniah still weighs just 36 pounds and is 3 feet, 8 inches tall -- smaller than nearly all girls her age. Kaniah has more weight to gain.
At her most recent visit, she was given a powdered product made up of fat and carbohydrate calories to add to meals and some Carnation Instant Breakfast packets to use to make calorie-packed smoothies.
More calories is really all that 19-month-old Jenniya Brown seems to need, Black says during her recent appointment. The Northeast Baltimore girl's weight gain started to slow around 9 months. When she came to the clinic in April, at 14 months old, she weighed 17 pounds. On a recent visit, she weighed 19 pounds, 8 ounces. An average 19-month-old weighs close to 25 pounds.
Through a series of interviews, Black determined that the girl's eating seemed fine -- she was having meals with the family, eating a good amount, including the franks and beans, chicken nuggets, french fries and cookies she had for dinner the night before. So jamming in the calories is the focus now.
Dietitian Pam Cureton, pleased with Jenniya's weight gain, still wants to see more.
She gives advice counter to what most Americans receive: Add butter or margarine to everything you can.
Often parents refuse to see that there is a problem, writing off the child's small size as something she'll outgrow.
"They don't want to hear their kids aren't growing," seeing it as an indictment of their parenting skills, said Tiffani Hays, a pediatric nutritionist at the Johns Hopkins Children's Center. The very name, failure to thrive, is pejorative, said Hays, who is not affiliated with Black's clinic.
In most cases, a child won't get better without some kind of intervention. "Fifty, 60 years ago, a lot of these kids would eventually die," said Charles Gulotta, a psychologist who directs the Pediatric Feeding Disorders Unit at the Kennedy Krieger Institute. "With our technology, we're able to change that now. They're not just automatically going to wake up one day and say, 'Hey, I am going to eat a steak.'"
Gulotta said the advice of pediatricians -- don't fight with your child over food; he will eat when he is hungry -- simply doesn't work with those who are falling off the growth chart. The normal cycle of hunger and satiety for some reason isn't functioning properly. Perhaps there is a spot in the brain where appetite has been affected. Or the child could have an allergy that associates food with pain from early on.
"An adult would know, 'I still have to eat. I'll just avoid foods that don't make me feel well,'" he said. "All [children] know is, 'I don't feel well; I don't want to eat.'"
Gulotta supports a method of persistence, of getting past the tantrum and making sure the child takes that bite.
Black takes a different approach. She says never force a child to eat, try to limit negotiating, begging and all of the rest that can go into these fraught mealtimes. She says keeping the child from grazing throughout the day and setting meals by the clock will often push the situation down the right path.
Black has been conducting a long-term study for more than a decade, following children who were failing to thrive from a very young age. One question she wants answered is whether the underweight will stay small or join the obese population. In many cases, the bad habits they have picked up are the same as those of overweight kids. In many cases, even the smallest child has an obese parent. How many will end up on that end of the scale, she wonders.
Hays said she knows that obesity is easier to see. Sometimes children who fail to thrive will often simply look younger than they are. Sometimes you can only see how thin a child is when you lift up his shirt and see his bones.
"It's often overlooked," she said, "which is a little surprising because now these kids really look small because everyone else is so big."
Failure to Thrive
Definition: It's a growth problem in young children, who fall behind in height and/or don't gain enough weight. There are many possible causes, such as poor appetite, poor diet or a medical problem.
Diagnosis: If a child isn't large enough or if his or her growth starts to slow, a doctor will more closely monitor weight and health and may send the child to a specialist.
Treatment: It depends on the severity. There could be an underlying medical condition keeping a child from getting enough calories (an allergy, perhaps) or from absorbing enough nutrients (celiac disease, for example). That should be treated. The goal will be to take in more healthy calories. In more extreme cases, a child may be put on a feeding tube. Later, that child may need to be taught how to eat and drink properly.
Behavioral interventions will also likely be needed to make sure that parents are properly interacting with the child and his or her food. Either extreme - neglect or hypervigilance - can lead to failure to thrive.
Sources: American Academy of Family Physicians; University of Maryland School of Medicine