Navigating Relational Feeding in a Medically-Minded World: When Calories Aren’t the Whole Picture

For many families, weekly (sometimes daily) doctor and therapy appointments are the norm rather than the exception. They strive to make everything fit into the schedule, because doing so keeps their child “well”- or at least not sick- and hopefully making medical or developmental gains due to professional, sometimes intensive intervention.  This may be a temporary scenario, or not. For parents of chronically ill or medically fragile children, every day begins with a status check: Is he running a fever? Is she going to hold down her feeds today? Did I give her all of her meds on time? Why is he doing X? Then on to the scheduling and phone calls- to the doctor’s office to sign a request for records to be sent to the out-of-state specialist, to the insurance company to fight yet another battle about payment for the child’s numerous procedures and office visits. For the parents who live this reality, it can be mind-numbing and terrifying all at once. Having a child who is well is the exception rather than the rule. Being truly well, however, is not the same as not being sick. For many kids, they have never been truly “healthy”, as the WHO states: “Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.” What about these situations in otherwise “healthy” children? the baby who screams every time she sees a bottle, but takes a small amount when it is forced into her mouth the toddler who throws up at least once a day after being fed the preschooler who exists on Pediasure because he doesn’t...

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...

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