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Column originally published Nov 21, 2006

Small Children Are Often The Healthy Ones

Question: Our nine-year-old son has always been the smallest one in his class. He was 7 1/2 pounds when he was born. After he started walking, he slimmed down and has remained like that until now. He has a good appetite and we always provide nutritious meals at home. He eats all varieties of food, including fruits and vegetables, and our family is not big on fast food. He is not a sick child, but our friends and family are making us nervous. They believe our son is too small and there must be something wrong with him. We took him to our family doctor, who spent a good amount of time examining him and answering our questions. After some additional blood tests, she reassured us that our son is totally healthy. She showed us that although he is small, our son is growing steadily every year along the growth curve. She promised to check him again in a few months. However, our family said that we should have insisted on seeing a paediatrician. We are not sure whether this is necessary or not. Please advise us as to what we should do now.


What you have described tells me that most likely you have a completely healthy, although slim, young son who is smaller than many other boys and girls in his class. There is nothing wrong with that, after all, someone has to be the smallest one!

How big or how small a person is depends on many factors. The greatest one of all is genetics, that is, the genes that parents pass onto their children. If both parents are on the small side, there is a greater chance that their children will be small also. Of course, there are always exceptions to every rule.

Another important factor is nutrition. When there isn’t enough food, especially when a child is growing up, the lack of adequate nutrition can affect a child’s growth. This is the reason why, in many countries, children growing up after the Second World War are taller than their parents because they have had better nutrition.

Just like anything else, there are always exceptions. Children can develop rare tumours which produce too much growth hormone. As a result, they can grow very tall even though their parents may have average height.

On the other hand, there are some children who have medical conditions that make them chronically ill. As a result, they cannot grow and develop like most other children. These conditions include hypothyroidism (not having enough thyroid hormone), severe asthma, cystic fibrosis (a severe lung and intestinal disease), kidney failure, liver disease, as well as other inherited metabolic diseases. In most of these medical conditions, the children are unwell in addition to being small. They fall off the growth curve instead of following it. Most of the time, their illness is so obvious in early life that doctors are able to distinguish them from others who are totally healthy although they are just small.

Another important consideration is that our society has become more overweight and obese in the last few decades. Although we don’t know all the reasons why children are getting bigger and growing faster than ever before, we suspect that this has something to do with their nutrition, and their lack of physical activities. Many families have become too busy and eat out more, often in fast food restaurants, which provide attractive high calorie food that can be ‘super-sized’ with minimal cost.

Many educators have also warned about the danger of reduced physical activities in the school system. In an attempt to cut cost, some school districts have eliminated specially trained physical education teachers. Many elementary and intermediate schools don’t have daily gym classes. Most high schools are listing physical education as an optional course for grade 10 only.

The invention of computers and internet videogames certainly won’t help these children. The amount of time they spend in front of the television, computer, and game console (we call this screen time) far exceeds their body’s need.

The end result of over-nutrition and inactivity is excessive weight gain. Statistics from developed and developing countries around the world show that this phenomenon is everywhere. Because many of the children in your son’s class are likely fairly big (some can be overweight while others can be obese), he would appear to be too small, although he is probably more healthy than many of them.

In over thirty years of medical practice, I have only started seeing children with adult type of diabetes in the last two years. The adult type of diabetes, also called type 2 diabetes, usually occur in children who are overweight or obese.

I want to take this opportunity to warn parents who have overweight or obese children: they have a greater chance of developing diabetes, high blood pressure, kidney disease, as well as heart troubles sooner than other children. You need to reduce their calorie intake and increase their physical activities. Over-nutrition is just as harmful as not having enough food.

Physical activity is as important as your children’s education. Research has shown that children who are active actually learn better. It is important to limit screen time (which includes TV, computer, and games), and send them out to play. Although organized sports are good, walking, running, biking, roller-blading, skate-boarding, throwing a baseball or kicking a soccer ball is just as healthy. Many of us have forgotten about the simple games that we grew up with. May be we can go outside and play with them: this will keep us healthy in our golden years!

Finally, if your doctor is going to follow and monitor your son’s growth and development, he probably won’t need to see a paediatrician, unless if he shows signs of illness or if his growth pattern changes. At that time, your family doctor can certainly refer him to see the paediatrician.