During the first 2 years after birth, growth charts are typically used by health care providers to ensure adequate and proportional growth with respect to weight, length, and head circumference, but information is usually communicated to parents without significant explanation so long as the child does not (a
) raise concern for failure to thrive or (b
) demonstrate disproportionate or very excessive growth on 1 of the 3 measurements. The results of this study suggest that improved communication between health care providers and parents about normal infant growth is necessary. These data suggest that many parents are averse to their children growing in the lowest quartile for weight. In contrast, many parents have a preference for their child’s weight to show progression toward the higher percentiles on the growth chart despite evidence that during infancy, weight in the higher percentiles and rapid patterns of growth elevate the risk for obesity and its comorbidi-ties.4–7,13–23
Parents’ bias in favor of higher percentiles may reflect their response to the use of percentiles as a way of presenting their infant’s growth relative to others because in nearly every other life circumstance, higher percentiles are better, as for example, in the case of academic achievement.
Overall, parents tended to have negative perceptions of patterns of early life growth in the lower percentiles. These negative perceptions may have negative consequences; parents who perceive their children as too thin are more likely to pressure them into eating.24
This hinders children’s ability to recognize internal cues for hunger and satiety.25
Furthermore, parents often perceive their children as picky eaters even when their weight gain is progressing normally,26
and infants and children perceived as too small are often given developmentally inappropriate nutrition, including the early introduction of solids and/or table foods.27,28
This, combined with findings that parents tend to underestimate rather than overestimate their child’s weight, might create a major obesogenic force.17,29–35
Many parents believe that greater infant weight is an indicator of good infant health and higher levels of parenting competence.27,28,36–40
Furthermore, parents may not value their child’s weight status as a health indicator but, rather, may refer to their ability to perform activities accomplished by their peers or the lack of chronic medical illness.41
Whereas in the past these findings have been shown in low-income or minority populations where there is often an association of food with love,42
the current results show general preferences for higher weight infants in a mostly white, well-educated, middle class community.
The results of this study are limited by several factors. First, the participants were from a single, suburban, outpatient office, and the population was homogeneous, with limited minority group representation. This is important to note because ethnicity has been demonstrated to play a significant role in parental assessment of child weight status.27,28,40,42
Nonetheless, the current data suggest that the phenomenon of “more is better” regarding infant weight is not limited to minority groups. A second limitation is that the results rely solely on weight percentiles, not weight-for-length percentiles, which may better represent infant adiposity.43
Despite this, weight-for-length percentiles are much less commonly used by clinicians in day-to-day practice and may be a more difficult measurement for parents to understand. Furthermore, the accuracy of length measurements in the clinic setting may be questionable.44
Whereas weight measures can be obtained accurately if proper quality control is practiced, length measures are more difficult to obtain accurately.
In conclusion, this sample of parents perceived infant and toddler growth at lower percentiles on the weight-for-age growth chart more negatively than growth in the upper percentile range. In the midst of a childhood obesity epidemic, the reasons for such parental preferences require further exploration, as does study in differing population groups. Because early life overweight and obesity are increasingly common, children currently considered “normal” may include infants and toddlers who are larger than those in the past. Clinicians must recognize that parents may have potentially unhealthy preferences for their infant’s weight as well as perceptions of normal that are different from those in previous generations and educate families on what constitutes a healthy growth pattern.