Pediatric Feeding Q&A: How to Know If Your Child Is More Than a “Picky Eater” and Tips to Help

Pediatric Feeding Q&A - Mothernova.comWith food allergies and developmental issues on the rise, many parents are finding themselves overwhelmed, especially at mealtime. For the parent with their first child or a child with food allergies, the introduction of solid food can be particularly stressful.

My son’s dairy and egg allergies were not diagnosed until he had a reaction to his first spoonful of yogurt at 10 months old. Add a car accident into the mix that set us back a bit, and his introduction to solids was by no means an easy task.

After meeting Kelly Benson-Vogt, a speech and language pathologist and the owner of Pediatric Feeding & Speech Solutions, mealtime became more manageable. My son’s first bite of solid food was a celebration. With Kelly’s help, it only got easier from there.

I reached out to Kelly so we could share what I know are practical tips for navigating mealtime. Whether your child has significant eating hurdles or is the so-called picky eater, I hope her advice proves to be as helpful to you as it has been for my family.

Q: Over the years and especially lately, there has been such varied advice with regard to beginning solid foods. What tips can you offer to parents and caregivers on when and how to introduce solids?

A: The American Academy of Pediatrics recommends introducing solids between four to six months of age.  Generally, single grain cereals are introduced first followed by other purée fruits, vegetables and meats, but in no particular order.  There is no rule that fruits or vegetables need to be introduced first.  It is recommended that one new food be introduced about every three to five days to allow time to monitor the baby’s tolerance to that food and watch for any signs of possible allergy before another food is introduced.  During the three to five days, you should monitor for significant changes in stools, behavior, vomiting, rashes and/or eczema that may indicate that your baby is not tolerating that food well.

Pediatric Feeding Q&A - mothernova.comSometimes babies will demonstrate a very strong or obvious reaction that they do not like a food by a gag response or a facial grimace.  Even when a child seems to dislike a specific food, as long as there are no other negative responses, I suggest keeping that food in the rotation of that baby’s diet and continue to introduce it in small amounts by itself or mixed with another preferred food to allow the baby time to get used to the new taste or texture.  He or she may never like the food, but don’t give up on it too early.  I think it is important to present that food at least 10 to 20 times before taking a break from it.  If it doesn’t work after these first attempts, take a break and try it again in a few weeks.  We don’t always know if the baby is demonstrating a negative response to the new taste of a food or a change in texture, both which may require some “getting used to” over time.

It is typical for babies to push food out of their mouths during first feedings.

They need time to figure out what to do with this new food and how to respond to a spoon.  If a tongue thrusting motion continues, a parent may try to offer the food/spoon to the side of the mouth so that it stays in better and the tongue is not able to push it out so quickly.  Over time, the tongue thrusting motion should subside.  It is also typical for a baby to demonstrate an occasional gag response during first feedings.  A gag may be a response to a new food flavor and/or texture of a food that the baby is not used to having in his or her mouth.  As with the forward tongue motion, this too should quickly subside with repeated exposure and practice.

With so many kids having food allergies, check with your pediatrician about when he or she recommends introducing foods such as dairy, eggs, berries and peanut butter.   When there is no family history of food allergies, some pediatricians are recommending the introduction of these food much earlier than they used to.

Q: What specific issues are you seeing with regard to the introduction of solid foods?

A:   I think people give up on a particular food too soon sometimes.  Instead of continuing to offer a new food repeated times, as I mentioned before, some parents drop a food when a baby demonstrates first signs of refusal or that he or she does not like the new taste or texture.  When foods are quickly dropped from the rotation of that baby’s diet, the baby then only receives his or her “favorite” tastes (i.e. sweets ) or textures ( i.e. smooth textures), this pattern continues and then these preferences become more ingrained and the refusal responses for new foods or textures become stronger and stronger over time, sometimes resulting in a strong gag and/or vomit response when they are offered.

I think it is important to offer a variety of foods of various colors, tastes and textures from each food group on a regular basis.

A baby is not going to “love” every food that we present, but adults don’t usually “love” every food either.  Sometimes we eat foods that are not our “favorites” because we need specific nutrition, because of convenience or time constraints, or because we are in a particular social situation or maybe because we are constipated. If we only ate our “favorite” foods, I bet our nutrition would really be lacking!

Q: What tips can you offer parents trying to get their kids to eat new things?

A:   When offering first purée foods, as soon as the child is interested in reaching or grabbing for the spoon, let him or her have it.  Give the child the opportunity to play and develop self-feeding skills.  They will start letting you know when they want more, when they are full, and they will begin to demonstrate their independence.  It will probably be a very messy, but hopefully positive and playful time.  This play allows the baby to work on the fine motor skills of holding a utensil, dipping, scooping and trying to get the food to their  mouth.  They may gag themselves occasionally during this learning experience, but it is a trial and error period of learning for the child.  I strongly urge parents to allow their babies to practice and experiment with foods during this time so that these important skills can develop.  The adult will still be the primary feeder through infancy, but I really feel that it is important to allow the baby to have “hands on practice” to develop self-feeding skills even though it will be a really messy process!

Oftentimes, babies will accept and tolerate a new food or texture much better when it is self-fed rather than being fed to them by someone else.

It is typical for toddlers to be picky eaters.  Through this phase I feel that it is important to continue to offer a variety of foods.  I also feel that family meals (as often as possible) are very important.  They provide a great opportunity to model good eating skills and manners, and it provides a great opportunity for speech and language development as family members can ask questions, share information about their day, and engage in activities with the foods that they are eating.

When a child is completely refusing a food you can have them do something with the food such as stirring it, scooping it, touching it, etc… without actually making them take a bite.  The key is to not let the picky eating lead to battles, fights or increased anxiety at mealtimes.  But don’t give in too easily either as this often results in parents making two or three separate meals for the family at a mealtime–becoming a short order cook.

Q: What are some specific red flags parents should watch for?

A:  There are potential feeding problems when children:

  • are omitting an entire food group(s) such as vegetables or meats,
  • refuse or only eat foods that are a certain color (their diet is comprised of all white, cream colored foods),
  • have difficulty biting or chewing foods,
  • chew up and spit out food,
  • pocket food in their cheek,
  • leave food in their mouth after a meal,
  • refuse or gag on a particular texture of food,
  • are very specific or picky about the temperature of foods,
  • cough or choke regularly during a meal,
  • consistently refuse food,
  • have weight loss, difficulty gaining weight or staying on their growth curve,
  • experience sleep disturbance, or
  • have constipation or complaints of stomach pain.

There also can be feeding problems when mealtimes are perceived as stressful by either the parent and/or the child, or when parents feel the need to supplement a child’s diet with something like Pediasure.

Children can be of normal weight or even overweight but still have a feeding problem.  I see children who are nutritionally  malnourished, whose weight is fine, but only because they eat a lot of their restricted diet, which may consist of five foods.

When any of these problems arise, it is a good idea to look into them sooner rather than later.  There is no danger in asking questions about what may be a problem.  There could be a simple solution and no feeding therapy is needed, but if there is a real feeding problem that warrants an evaluation and possible therapy, it is easier to reverse these problems in the beginning versus waiting six months or several years to address and change them.  There are a lot of maladaptive behaviors and family stress that can develop over time as a child tries to avoid foods or mealtimes because of a feeding problem.  It is harder to change these in a teenager versus a toddler or young child.  If you have questions, seek out help and get your questions answered.  Restricted diets can continue to get worse over time.

Q: I often hear moms say their kids are “picky” eaters. How do you know if your child is a so-called picky eater, or if there are more serious developmental issues going on?

A:  Toddlers often go through a picky eating stage.  However, when any of the problems that I mentioned above are seen, there may be an actual feeding disorder.  It is typical for toddlers to have “food jags,” which is when they latch on to a food like chicken nuggets and that is all they want for every meal for a week and then they refuse it the whole next week because they are tired of it.  In a “typical picky toddler,” these food jags are normal and should be short-lived.  After the child gets tired of the food and then takes a break from it for a while, the parent can re-introduce that same food a short time later and the child eats it in a normal way.

A child is more of a “problem feeder” when food jags like this remain.

The child gets stuck on a food, they get tired of it and refuse it, but the parent is not able to successfully re-introduce the food later on.  They continue to reject it and they won’t try it again.  What happens over time as this occurs with  multiple foods is that their diet becomes very restricted.  They continue to drop food out of their repertoire but they don’t pick them back up again, and they either don’t or are very slow or resistant to try new foods.  So their repertoire continues to gradually decrease and eventually they may be rejecting whole food groups or have an accepted repertoire of just a few foods.

A problem may also arise when children become very “brand specific” with foods.  This is when they will only eat fast food nuggets, or they will only accept a certain brand of yogurt.

Q: How do anatomical issues come into play?

A:   Anatomical issues such as large tonsils can affect eating for some children.  For example, children with tongue-tie or a short lingual frenulum can have difficulty with chewing and moving food around in the mouth to prepare it to be swallowed.

Children with hypotonia or low muscle tone can have a difficult time with fatigue during chewing or inefficient chewing/preparation to swallow certain textures of foods.

Some kids who demonstrate a preference for cookies, crackers and over-processed meats may be doing so because these are foods which easily dissolve or breakdown in the mouth.  These foods require much less work than a raw carrot, for example, and may be dictated by an anatomical structure difference, poor oral motor skills or other deficits overlooked.

Kelly Benson-Vogt is the owner of Pediatric Feeding & Speech Solutions in Leesburg, Va. She received her bachelor’s of science degree in Speech Pathology and Audiology from West Virginia University, and a master’s degree in Speech Pathology from Northwestern University in Evanston, Ill. She is certified in Deep Pharyngeal Neuromuscular Stimulation, is a certified VitalStim provider, and presents for lactation training programs on a regular basis.

Is your child a picky eater? Is mealtime a challenge? We’d love to hear about your experiences and any tips you have. Too, if you have any follow-up questions for Kelly, please let us know!

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