I think there are three very important clues to what might be going on
here which also will guide one's response to a very real concern about
FTT.

> Baby hasn't gained any weight in the past 3 months. He had gained a  > little last month but lost it during a severe ear infection episode.

One of the most useful reasons to keep infant growth charts is to chart
more than growth on them. All potentially growth-impacting episodes in a
child's life (infections, surgery, vaccinations, etc) should be noted by
writing them vertically at the corresponding age. Recuperation from such
episodes can often take 2 or 3 months. Under such circumstances, the
child's own, individual growth curve should only match, or mimic the
closest printed curve. In this case, as long as his overall curve
matches the "bend" of the 5%, he is doing okay. Achieving an accelerated
curve - or "catch-up" growth - requires an enormous caloric intake and
good health sustained over time.

> they have 2 months before she starts doing tests to
> see why he's so small (he's also growing slowly in height although his head is growing at a normal rate)

The fact that his head is growing at a normal rate is reassuring
information that his poor health (and genetics) has not been permanently
damaging to him. When malnutrition (whether due to illness or lack of
food or any other reason) has affected head circumference growth, the
effects are often permanent. This is to say that monitoring weight and
length are important as screening tools...to guide us into evaluation,
which includes head growth, and quick management of the underlying
cause.

There are three basic reasons why children don't gain weight. From the
University of Pennsylvania Pediatric Nutrition Assessment Guidelines,
they are:

1) Decreased food intake (i.e. eating disorders, child neglect or abuse
resulting in failure to thrive)

2) Malabsorption states (i.e. cystic fibrosis, short bowel syndrome,
irritable bowel disease, malabsorption, dumping syndrome, pancreatic
insufficiency, liver disease, celiac sprue),

3) Catabolic states (i.e. fever, infection, trauma, surgery, malignancy,
burns, diarrhea, vomiting)

In this case, it seems the reason(s) for his weight and length growth
lags were/are the ear infections, placing him in a catabolic state
category. The management approach would be to minimize catabolic states,
as is being done. Medical tests will rule out any unobserved or unknown
malabsoprtive states (for which breastfeeding protects and sometimes
hides diagnosis until weaning).

Incidentally, my approach would also include, in addition to improving
his caloric intake and nutrient absorption, education about infection
control and management for this family, starting with handwashing and
staying away from crowds until his immune system recovers and matures
more.

> father is opposed--he's worried it
> won't sit well on the little Chinese stomach.
> (Father is Chinese, mother is not)

This is important that genetics are accomodated. First, obtain Chinese
growth charts for him. There are at least 2 sources of Chinese Growth
Charts on the Internet:
for mainland Chinese: http://fwcc.org/growthchart.html
for Hong Kong/ Southern Chinese: http://mmlab.csc.cuhk.edu.hk/index.htm

Additionally, the Preliminary Growth Charts for Breastfed Babies from
the World Health Organization Working Group on Infant Growth can be
found at: http://www.clark.net/pub/activist/bfpage/growth.html

The Hong Kong Growth Chart page also includes an excellent link called
Food and Nutrition which includes suggestions for Chinese ethnic food
sources and portion sizes of calcium, protein and fat:
http://mmlab.csc.cuhk.edu.hk/gs_food.htm
These should "sit well on a Chinese tummy". The page is written by Dr.
Sophie S. F. Leung, Department of Paediatrics, The Chinese University of
Hong Kong.

(I don't know if advocado is acceptable, but it is an excellent source
of hypoallergenic medium-chain-triglycerides which require minimal
digestive effort and are great for increasing calories in an easy,
palatable way for babies. I know of at least one NICU that adds
blenderized advocado to bottles in certain circumstances.)

Unless it was a typo error, this baby is extremely short for weight. An
immediate concern must be calcium intake - How is mom's diet and does
she need calcium supplements? I'm not sure I'd wait two months on this
one!

I hope it goes without saying that BFing should by all means continue.

For more information on evaluating growth, WHO publishes 2 items:
An Evaluation of Infant Growth: WHO Working Group on Infant Growth,
1994, 83 pages

The Growth Chart: A Tool for Use in Infant and Child Health Care, 1986,
33 pages [Ar, E, F, S] ISBN 92 4 154208 X

Katharine West, BSN, MPH
Sherman Oaks, CA