My 4-year old daughter is 38 inches tall and weighs 27.5 pounds. She hasn’t been eating much for the last year. Now I’m lucky if I get a meal into her. She has started losing her hair and is not gaining much. At age 4, isn’t she off the charts? What can I do?

Even most very picky eaters get plenty of calories every day, but one of the reasons we follow growth curves is to be sure that is true for an individual child. 27.5 pounds for a girl who is 4 years old puts her below the 5th percentile for girls her age. Her height is about the 25th percentile for her age, meaning she is taller than about 25 out of 100 healthy girls her age. Even though she is shorter than average, her weight for her height is also below the 5th percentile.

Five percent of healthy, well-nourished girls are at or below the 5th percentile. Still, her low weight could indicate that she is not getting the calories she needs or that she is losing calories somewhere (such as protein in the urine) or that she is burning too many calories (from some underlying condition).

A doctor should carefully consider any child who is below the 5th percentile – especially one who is having other symptoms, such as hair loss – to whether this weight is normal for that child or a sign that something needs to change.

Often pediatricians are a great place to begin, but if any questions remain, pediatric gastroenterologists often have a good perspective on this issue. Endocrinologists also look into growth issues, but they are usually best if the height is the first one off the charts. Either way, a visit to a nutritionist may also be wise, both to evaluate what your daughter is actually taking in, and to suggest ideas for increasing her calories, if that is appropriate.

In the meantime, a good chewable multivitamin with minerals can provide a safety net for the major nutrients. I suggest choosing one without added chemical colors or preservatives.