Doctors: Support Parents of Children with Picky Eating (from Typical to Extreme)

We were so excited to see this recent article, A Practical Approach to Classifying and Managing Feeding Difficulties (Kerzner et al. 2015) from the Journal of Pediatrics. It does a great job of providing an overview of feeding challenges: underlying factors, screening, red-flags, and a user-friendly format for primary care providers who are the front lines on this issue— most of whom receive little to no training in feeding challenges. This paper provides an excellent overview. Here are our summary points for clinicians: 1) Take every worry and complaint about picky eating seriously before jumping to reassurance. “…pediatricians must take all parental concerns seriously and offer appropriate guidance.” Parents may do well with reassurance and a handout, or they may need a referral to specialist care. You can’t reassure parents without listening to and addressing their concerns. 2) History, physical exam, potential lab tests, and red flags are discussed and help determine severity and what general category challenges fall under: misperceptions of typical variants, low appetite, medical/organic, selective, sensory, fear of feeding, and feeding style. This helps guide referral and treatment. Some sample red flags: using distraction to increase amount eaten, prolonged time at the table, gagging or coughing/choking, significant conflict, history of choking, or forceful feeding. “When it is apparent that a potential feeding difficulty exists, a complete history and physical examination, including carefully done anthropometrics and a brief dietary assessment, are necessary with special attention to serious red flags…” 3) Assess parents’ feeding style by asking parents how feeding is going, what they worry about, what they do if they think a child needs to eat more...

Milk is Food: Improving Appetite for Toddlers with Picky Eating

Lately, we’ve been getting questions from parents whose toddlers are struggling with poor appetite for solid foods but eagerly take a bottle or want to nurse around the clock. Cow’s milk (or a milk alternative) is a recommended part of a toddler’s overall diet, and many toddlers continue taking formula or breast milk into the second year of life. Some children may need a more fortified liquid supplement like Pediasure if growth has been poor. The American Academy of Pediatrics recommends that low-fat/reduced-fat milk not be started before 2 years of age, and at age two, toddlers need approximately two cups of dairy per day. (And if your child prefers whole fat dairy, serve what he likes. There is no compelling evidence that low fat dairy reduces the risk of being overweight down the road.) A common problem with milk occurs when the amount he consumes or the timing of consumption interferes with appetite for other foods. Not only can nutritional variety suffer, but crucial early experiences eating a variety of foods can be missed. Whatever type of milk we are talking about, it is digested in the same way as food, and contains filling fat and protein. There’s only so much room in that toddler tummy! Let’s be honest. We all prefer the path of least resistance, and children are no different. Drinking most of their calories is just easier for some children. The comfort of being in mom’s arms, the soothing nature of sucking, and the ease of just swallowing- and not having to chew- are all reasons why some toddlers can have trouble transitioning to a more...

Chew on This: Considerations for Development of Oral Skills in Extreme Picky Eaters

When I evaluate a toddler that hasn’t made the transition to table food, one of the first questions I ask is “Did he mouth on toys/hands/lovies as an infant?” If the answer is yes, I always ask how much and how that child compared to other children in the home with regard to mouthing and early acceptance of oral play. However, more often than you would think, I hear from parents that these children with extreme aversion to texture in their food did not mouth at all. They blithely say “We didn’t have to baby-proof!”, unaware that their well-behaved infant’s choice to leave that paperclip on the floor is at least part of why he hasn’t moved on from pureed foods. I recently saw an older toddler who fit this description exactly—to the extreme. When observing her oral motor skills without food, there were no noticeable deficiencies. Lateral tongue movement was present, she could open and close her mouth in mock chewing, was able to blow a kiss, and kept her tongue in her mouth where it is supposed to be. No outward signs that this child had never had one bite of actual food. Not one bite swallowed. Theirs was a successful breast feeding dyad, but that was the only sustenance she got, and not from lack of trying on the parents’ part. So why couldn’t this child learn to eat? Interestingly, the family had many older siblings who had mouthed as infants, accepted spoon feedings of purees without incident, and had no trouble learning to eat the family foods. So it wasn’t what the parents had or...

The Art of the Pile-On: Family-Style at It’s Finest

I learned about the “pile-on” from friends at work many years ago—the modern version of a pot-luck, where everyone brings 1-2 ingredients to put together a meal. We usually enjoyed the Mexican Pile-On, with tortillas, chips, ground beef, shredded chicken, beans, tomatoes, lettuce, sour cream, cheese, olives, etc. The “pile-on” is the fun part: everyone gets to choose from all the separate items to build their own taco, burrito, or nachos. With my own kids, the pile-on dinner has become an easy way for me to serve family-style in a manner that suits the very different feeding temperaments of my children. I have expanded this to the “Potato Pile-On”, “Pasta Pile-On”, and “Pancake Pile-On”. I get out lots of toppings and put them all on the table, and am continuously surprised at the “inventions” that my boys make from the offerings. The pasta night includes spaghetti, tortellini, or some other pasta, pesto and tomato sauce, cut up tomatoes, bell peppers, onions, and avocados, Parmesan and mozzarella cheese, and diced chicken or ground turkey. Pancake pile-on is made up of sweet potato or apple pancakes (I add sweet potato puree or applesauce), various fruit cut up in bowls, yogurt, turkey bacon or apple-cinnamon sausage, gouda or goat cheese, and scrambled eggs. The other night, we had baked potatoes, and my oldest came up with this: My younger son went a completely different way (no surprise there) but ended up with quite the food sculpture! Mine was a more traditional stuffed baked potato with cheese, sour cream, broccoli, and turkey bacon, with the tomatoes and avocados on the side as a...

Moving from GET to LET: Supporting the Child with Picky Eating

“I couldn’t get him to eat anything.” While reviewing the progress of the children in my feeding program with my graduate student clinicians, I hear this type of statement all the time. There is sometimes so much ‘get’ that I have to stop the discussion and tell the students to remove that word from their vocabulary during feeding therapy. Why? The words we say out loud, and even in our own heads, can make a huge difference in how we think and feel about others, ourselves, and our actions. How we behave is influenced by what we’re thinking . . . and words are a direct reflection of our thoughts. Words matter. They shape our thinking and other’s perceptions of our message. They can color a conversation, and can change someone’s mind. Words can drive a wedge between partners or support someone so they can go on to change the world.   Henry Ward Beecher said “All words are pegs to hang ideas on”. If we view words in that way, it can help us to see how our language can make a huge difference in not only how our children react to us, but how WE react to THEM. If you have an agenda and the child isn’t cooperating, your instinct is to do something to GET them to play along. So many parents I work with say the following types of things: “How do I GET her to eat more?” “I can’t figure out how to GET him to drink.” “His doctor said we need to GET 24 ounces in him.” “I just can’t GET him to...

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