Occupational Therapy Consulting, LLC

 

Glass half full

“Picky eater” or “problem feeder”?

I can anecdotally tell you that picky eating is a parenting issue on the rise.  As a therapist, I have multiple opinions as to where this trend comes from and as a parent, I know the stress this pattern can bring to a family.  Thankfully, there are some straightforward things that can be done, both as a therapist or a parent, to begin the process of correcting this difficult pattern.

1) One of the first things I do as a clinician is try to determine severity of the problem.  This means figuring out if the child is a “picky eater” or a “problem feeder”.  Picky eating, while stressful and challenging, is less immediately risky than problem feeding, to the immediate health of a child.  The addage, “They will eat when they’re hungry”, does not apply to kids who are problem feeders.  For both picky eaters and problem feeders, the traditional approach of “de-sensitization”, i.e. forcing kids to take a bite, withholding privileges based on food consumption, and requiring kids to eat all of the food on their plate before offering preferred foods, can lead to increases in food aversions and selectivity, increased power struggles, and overall increased levels of anxiety and upset, not just surrounding food…which for a problem feeder can mean severe nutritional deficit and medical complications.  For kids who are problem feeders, simply engaging them in food preparation and positive interactions with food, is not sufficient.  Problem feeders need a thought out targeted and multi-faced intervention plan that incorporates un-learning negative associations, building foundation skills and physiological processes that are lacking in other physical areas of function, and compensating for weaknesses to facilitate child success.  So what is a picky eater and how does one know when it turns into problem feeding?

Kay Toomey, PhD and author of the SOS Approach to Feeding says that problem feeding is characterized by the following:

  • Restricted range or variety of foods, usually less than 20 different foods
  • Foods lost due to food jags are NOT re-acquired
  • Cries and “falls apart” when presented with new foods
  • Refuses entire categories of food textures
  • Almost always eats different foods than the family
  • Adds new foods in more than 25 steps
  • Persistently reported by parent as a “picky eater” across multiple well-child check-ups

PIcky eating is characterized by:

  • Decreased range or variety of foods that will eat = 30 foods or more
  • Foods lost due to “burn out” because of a food jag are usually re-gained after a 2 week break
  • Able to tolerate new foods on plate and usually can touch or taste a new food (even if reluctantly)
  • Eats at least one food from most all food texture groups
  • Frequently eats a different set of foods than the rest of the family, but usually eats with the family
  • Will add new foods to repertoire in 15-25 steps on Steps to Eating Hierarchy
  • Sometimes reported by parent as a “picky eater” at well-child check-ups
My most recent favorite resource for help with picky eating AND problem feeding is Susan Roberts, MDiv, OTR/L and author of “My Kids Eat Everything”.

2) The next step, once severity of the problem is determined, is to rule out medical cause for the behavior.  Hidden gastrointestinal issues, food allergies & sensitivities, gastroesophogeal reflux (GERD), mineral and vitamin deficiencies, or congenital oral differences such as tongue tie, tongue thrust, and dental problems, may all contribute to, cause difficulty with or changes to eating behaviors.  Even a child without known medical or developmental problems or children with a history of problems from infancy or toddlerhood that seem to have resolved, may still experience any number of the above.  Additionally, children with or without medical diagnosis may still experience physical reasons for food aversion & avoidance.

3) Once medical cause has been ruled out a nutritional consult is imperative, for parents of problem feeders.  A registered dietician and nutritionist (not just a nutritionist) is skilled at establishing the minimum daily nutritional requirements for a child at any given age, based on their individual needs. This information may serve as a baseline, for knowing where to start in establishing an intervention plan for improving eating behaviors.  For parents of picky eaters, a nutritional consult may seem optional vs. imperative, but having a concrete understanding of minimal nutritional requirements, may alleviate stress on the part of a parent and also help to establish realistic expectations for how to approach the problem.  It is important to note, that even a child who eats a large number of foods or eats a large quantity of food, may still be at risk for nutritional deficits and all children need proper nutrition in order to optimize their growth, development, and learning potential.

4) Finally, the next “first step”  is to keep a food journal for a week (including weekends). The food journal should be kept over the course of a typical week, in order to give an accurate snapshot of what a child’s true intake really is.  It is easy to overestimate or underestimate when emotions are involved.  Parenting a child with picky eating patterns or problems in feeding is definitely emotional, and the stress that is caused by prolonged problems in feeding may bias a parent report. The food journal should include:

  • EVERY item a child puts in their mouth (not just what they swallow) and the list may be divided each day according to what is consumed (swallowed) and what is tried (put in the mouth).
  • eating behaviors (i.e. plays with food but doesn’t eat it, throws across the room, screams and cries when said food is presented, threw up 1/2 hr. after eating, took 3 bites, eats only with video playing, etc. The eating behaviors may give clues to the root of the picky eating challenge and also contributes to an accurate picture of what mealtime is like in your house.
  • as many specific details as possible, i.e. include brand names if there are strong brand preferences, if you cut the food into small pieces state that, and if the child only eats a certain food on a certain color of plate or day of the week, state that too!  The more specific the better because it results in a more targeted intervention plan that has more potential for success.

Once these first steps have been completed a parent may begin the process of positive interactions with food (see previous blog post) and seeking professional help (if needed) from an occupational therapist or speech therapist or skilled feeding team!  The more involved in positive interactions with food the child can be, regardless of picky eating OR problems in feeding, the better off EVERYONE in the family will be.  Solving picky eating problems is not easy but is important for both the health of the child AND the well-being of the family!  (next blog…”to cook or not to cook,,,separate meals that is”).

Picky eating not picky reading (2)

The benefits of reading to young children are well documented for literacy development (Kuo et al. 2004) but what about eating development?!  Clinical practice shows that reading books about food may help young children engage in the process of eating or at the very least, increase motivation to interact with food.  Mealtime behavior is directly linked to play behavior (Robertson, 2014) and tapping into a child’s imagination  through stories and books, might just help their picky eating become a little less picky!  Positive interactions with non-preferred food and non-forced gradual exploration of new foods may decrease a child’s aversion to trying a new food.  Reading stories and following them up with playful games that involve those foods, or even pretending to be the characters in the books, might encourage children to be more playful with those food items, thus potentially decreasing the existing anxiety surrounding the perceived threat of being expected to or required to eat them.  by playfully interacting with foods and even the concept of food and eating without the stress of being expected to eat, helps a child relax and learn new responses to the foods being presented and to the concept of mealtime in general.  Changing picky eating behavior can be a long process but if mealtime behaviors are to change the first step is engaging your child in the process.  Below are some suggestions for books about food that just might help: 

1. “Green Eggs & Ham” by Dr. Seuss

2. “I Will Never Not Ever Eat a Tomato” by Lauren Child

3. “The Ugly Vegetables” by Grace Lin

4. “Eating the Alphabet” by Lois Ehlert

5. “Strega Nona” by Tomie dePaola

6. “The Hungry Caterpillar” by Eric Carle

7. “Bread and Jam for Frances” by Russell Hoban

8. “The Monster Who Ate my Peas” by Danny Schnitzlein

9. “Fairy Tale Feasts” by Jane Yolen, Phillipe Beha, & Heidi Stemple

10. “Pete’s Big Lunch” by James Dean (and I CAN first reader)

11. “Cloudy with a Chance of Meatballs” & “Pickles to Pittsburgh” by Judi Barrett, Ronald Barrett

12. “Tops and Bottoms” by Janet Stevens

13. “mmm cookies” & “More Pies” by Robert Munsch

Let us know if you have any other book suggestions to add to the list! Little readers (and mom’s and dad’s) might be “hungry” for more! (wink wink).

 

picky eating (1)

To help a picky eater you do NOT need to become a food artist…

 

 

 

OR creatively disguise veggies to look like the Mona Lisa (or…her brother?)…

 

 

 

In fact…you don’t even HAVE to spend HOURS in the evening prepping your children’s school lunches, perusing Pinterest for “Fun Healthy Lunch Ideas”, or spending gobs of money on cute character containers…

 

 

 

But what you DO have to do is…

Have fun with your food; and show your picky eater that food can be fun!  I don’t mean you literally have to come up with games using food (although that might help too and I recommend it often), but I DO mean one of the most effective means of helping your picky eater is to lighten the mood around mealtime and outside of mealtime as it pertains to food.  You can do this by:

1) Involve your child (of any age) in the food preparation, even if you know full well they have no intention of eating the food

2) Interact with your child while they are eating, whatever they are eating.  Your child wants your unconditional love and support and if mealtimes have become so stressful that nobody interacts except to pressure, prod, encourage, and force the eating issue, then stress gets paired with eating.  Stress is counterproductive to healthy digestion (and motivation to stay at the table).

3) Encourage your child to interact with healthy foods at the grocery store, during play time, at the playground, to feed their favorite toy, or when their favorite friend or family member comes to call.  Building positive associations with food and with the physical sensations involved in foods (sights, smells, textures etc.) will likely decrease sensitivity to the unfamiliarity of that food and/or at least decrease the stress response to that food.  Pairing the positive associations with the unfamiliar or non-preferred food at a time when the pressure to eat is removed, increases a child’s willingness to interact with that food.  Interactions with food ultimately lead to eating that food.  Children with special needs and without special needs but with high sensitivities and/or food aversions, need repeated successful, non-stressful exposure in order to overcome the food aversions.  “Repeated” for typically developing children means more than 21 times…for sensitive eaters it could mean triple or quadruple that number.

4) Continue to present unfamiliar non-preferred foods with food your child enjoys.  Offering a variety of foods ensures that much needed repetition of exposure to new things.   Offering something you know they will eat affords your child some control.  Susan Roberts OTR/L, so succinctly and aptly once stated, “It is a parent’s job to decide what and when their child eats.  It is the child’s job to decide IF and HOW MUCH they will eat.”

5) Seek help from an Occupational Therapist, a Nutritionist, a Speech and Language Pathologist, or your child’s Pediatrician if picky eating persists beyond what is considered typical for their age and/or if it progressively  gets worse; especially if you are concerned about health status and growth and development.  There is a difference between picky eating and problem feeding (new blog post coming), and there could be compounding factors that are impacting your child’s willingness to eat, such as gastrointestinal difficulties, oral motor weakness and/or sensitivities, or other developmental challenges that can make eating or self-feeding more difficult.

Feeding one’s child is an innate drive for many parents and disruptions in a child’s willingness or ability to eat can cause extreme stress for parents and children alike.  There are however, many strategies that can help with picky eating, and positive interactions with food, form the first phase of treatment.  The sooner a picky eating pattern is addressed in a supportive and positive way, the happier mealtime becomes for everyone.

Resources:

“Just Take a Bite”, by Lori Ernsperger

“My Kids Eat Everything”, by Susan Roberts (www.susanroberts.com)