What is the assessment and treatment plan for a 3-year-old presenting with decreased appetite?

Assessment and Management of Decreased Appetite in a 3-Year-Old Child

The assessment and treatment plan for a 3-year-old with decreased appetite should focus on ruling out medical causes, evaluating growth patterns, and implementing behavioral strategies to improve food intake while avoiding pressure tactics that may worsen the situation.

Initial Assessment

Medical Evaluation

• Rule out acute illness (fever, respiratory symptoms, gastrointestinal issues)
• Check for signs of dehydration (abnormal capillary refill, abnormal skin turgor, abnormal respiratory pattern) 1
• Assess for chronic conditions that may affect appetite:
  • Gastroesophageal reflux
  • Food allergies/intolerances
  • Constipation
  • Oral-motor issues

Growth and Nutritional Assessment

• Plot height, weight, and BMI on CDC growth charts
• Compare current measurements with previous growth patterns
• Evaluate weight gain trajectory over time 2
• Calculate daily caloric requirements based on age, weight, and activity level

Behavioral Assessment

• Categorize the eating behavior under one of three patterns 3:
  1. Limited appetite (overall reduced food intake)
  2. Selective intake ("picky eating")
  3. Fear of feeding (anxiety around eating)
• Assess parental feeding style (responsive, controlling, indulgent, or neglectful)
• Evaluate mealtime environment and routines

Management Plan

For Normal Growth Despite Decreased Appetite

If growth parameters are normal:

1. Reassure parents that appetite fluctuations are common in toddlers 4
2. Implement structured meal and snack schedule (3 meals, 2-3 snacks daily) 2
3. Limit milk intake to 16-24 oz per day (excessive milk can decrease appetite) 4
4. Avoid pressuring child to eat, which may worsen feeding problems 2
5. Encourage family meals with parents modeling healthy eating behaviors
6. Offer a variety of nutrient-dense foods at each meal
7. Allow child to determine how much to eat (division of responsibility)

For Poor Growth with Decreased Appetite

If growth parameters show faltering:

1. Increase caloric density of foods:
   • Add healthy fats to meals (avocado, nut butters if not allergic)
   • Offer nutrient and calorie-dense foods first
   • Consider nutritional supplements if indicated
2. Implement more frequent, smaller meals
3. Consider referral to pediatric dietitian for individualized nutrition plan 2
4. Schedule follow-up in 1-2 months to reassess growth

For Selective Eating ("Picky Eating")

1. Continue to offer rejected foods alongside preferred foods
2. Avoid food battles and negative mealtime interactions
3. Involve child in food preparation when possible
4. Use "food chaining" - gradually introducing new foods similar to preferred foods
5. Praise attempts to try new foods, regardless of amount consumed

Red Flags Requiring Immediate Attention or Referral

• Weight loss or crossing downward of two major percentile lines
• Signs of malnutrition (muscle wasting, poor skin turgor)
• Persistent vomiting or diarrhea
• Dysphagia or odynophagia (difficulty or pain with swallowing)
• Severe food selectivity affecting multiple food groups
• Suspected food allergies or intolerances
• Family distress around feeding issues

Follow-up Plan

• Schedule follow-up in 1-3 months depending on severity
• Monitor growth parameters at each visit
• Adjust management plan based on response
• Consider multidisciplinary referral (dietitian, feeding specialist, developmental pediatrician) for persistent issues despite intervention

Common Pitfalls to Avoid

• Forcing child to eat or using punishment/rewards around food
• Allowing grazing throughout the day rather than structured meals
• Offering only preferred foods to ensure some intake
• Excessive focus on the child's eating, creating anxiety
• Overlooking the impact of parental anxiety on feeding dynamics
• Failing to recognize that toddler appetite naturally fluctuates with growth spurts and developmental phases 2, 4