“Help! My Child Isn’t Eating at School!” 8 Fuel-at-School Tips for Picky Eaters

School has started for some of us, and will start for the rest of the country soon! A big worry for parents of picky eaters, especially those with more extreme picky eating and anxiety, is what happens at school around food. We get emails with a variation on this theme all the time: “My son is six, we’ve struggled to get him to eat enough his whole life. It’s all worse at school where he is already anxious. He has twenty minutes, and lunch staff try to make him eat which makes him upset. They threaten to take away recess time. He comes home with his lunch untouched most days and is understandably crabby when I pick him up.” Government programs address child hunger, often through schools: from breakfast in the classroom to free and reduced lunches, millions of children are getting fuel for their day. But what about the “hidden hungry”? The kids these programs can’t help? There are hundreds of thousands of kids heading to school every day from homes with enough food and resources. But they are too distracted, anxious or scared to eat.     Helping Your Child with Fuel at School Gather information How much time does your child have to eat? Can he open containers on his own? Is temperature an issue? Does he prefer foods hot, warm or very cold? Is lunch right before recess, so he’s eager to get outside to maximize playtime? Is he eating in his snowsuit or carrying gloves, or has a hat that gets in his way? Are adults or other children pressuring him to eat? Ask him...

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...

The Lonely Kitchen Island: Physical Obstacles to Family Meals

This post isn’t specifically about the spectrum of picky eating… but it is. One of the major goals of our STEPS+ approach is for families to enjoy eating together again— or perhaps for the first time. We wrote a whole chapter on rehabbing family mealtimes, and one often overlooked piece of the puzzle is the physical space where meals happen. Consider the kitchen island. Other than just being a place to throw keys and homework, the kitchen island in many houses and apartments has replaced the kitchen table. Granite countertops sell homes— humble tables don’t. Growing up in the ’70s and ’80s, most Midwestern middle class kitchens I dined in did not have elaborate islands or counters with stools. I remember sitting around tables. As homes generally got bigger over the last 30 years, it seems the kitchen island became standard and the eat-in kitchen disappeared. On house-calls and play-dates over the years as a childhood feeding specialist and mom, I’ve watched the parent or childcare provider standing behind the island counter preparing food and serving children. By design, the island makes line-cook/wait-staff the easiest option— and there’s nothing wrong with this on occasion. But if it mostly or always happens, it robs children of the most important mealtime ingredient—a loving adult providing company and eating from the same foods (including at least one item the child generally enjoys). So, did form follow, or dictate function? Were parents already standing and serving meals and needed a more efficient way to do so, or did the changing design of modern homes assist the slide of communal family meals?  Moms  (both...

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...

What is ‘Extreme’ Picky Eating?

It’s a hot topic at the playground and preschool pick-up; parents commiserating over their child’s sudden refusal of long-time favorites, or yearning for all foods “beige”. There is a lot of talk and worry around picky (fussy, finicky, choosy…) eating. Then there is the mother not saying much, wishing if only she had a child who would eat macaroni and cheese, or cucumbers with Ranch while other parents complain about the ubiquitous white sauce. Then there are the few moms and dads in the bunch who enthuse that if you only knew how to crisp kale chips properly, all the children would surely love them like theirs do. These discussions mirror what research tells us about the experiences of parents of young children: various studies suggest that between one and two-thirds of parents will describe their young child as “picky” at some point. Most will grow out of it and expand their tastes, but about 10-15% of children will become “persistent” picky eaters and many in that group have what we call “extreme” picky eating.   What’s in a name?   Researchers are still trying to agree upon consistent language and definitions. Clinicians and health insurers try to define ‘pathology’ that needs treatment and billing codes for reimbursement. Many of the labels and diagnoses we see include: feeding disorder, failure to thrive, infantile anorexia (outdated term), problem feeder, ARFID (avoidant restrictive food intake disorder), feeding aversion, selective eating, and selective eating disorder… Parents have also heard “spoiled”, or themselves been labeled as “neurotic”, “neglectful” or even “abusive” for letting their children eat foods not up to nutrition police standards....

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...

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