Picky Eater vs. Problem Feeder

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Eating. What’s not to love? Whether it’s a gooey, cheesy slice of pizza or a warm cookie fresh out of the oven (yum!), let’s face it -humans love to eat.  Little humans, ehh not so much. Little ones can be incredibly stubborn when it comes to eating, especially when they’re toddlers. What three year old didn’t go through a phase of just eating her go-to; whether it was mac-and-cheese, hot dogs, or PB&J. Many parents have said the words “picky eater” in reference to their child’s eating habits, but it’s important to know the differences between your run-of-the-mill picky eater versus your problem feeder.

Problem feeding is not a normal part of child development. Feeding problems are estimated to occur in up to 25% of normally developing children and in up to 35% of children with neurodevelopmental disabilities. A common definition for feeding problems is “the refusal or inability to eat certain foods.” Feeding problems can lead to serious medical issues such as malnutrition, dehydration, and impaired intellectual, emotional and academic development. Because of these potential impacts on the child’s development, early recognition and management are critical.

The table below can help you determine if your child’s eating skills are following a normal trajectory or further evaluation is needed:

Picky Eater

Problem Feeder
Eats a decreased variety of foods, usually around 30 foods Eats a restricted variety of food, usually 20 or fewer foods
Foods lost due to “burn out” (i.e. one too many hot dogs = refusal) are typically incorporated back into the child’s diet after about 2 weeks Will eat food over and over again like a picky eater but once they burn out, they will not incorporate that food back into their diet
Can tolerate new foods on their plate, will touch or taste a new food even if they aren’t really excited about it Crying/screaming/melt-down mode if a new food is on their plate and will not tolerate touching or tasting
Eats at least one food from most food group textures (e.g. crunchy, soft, puree, etc.) Refuses entire categories of food textures
Will eat a food after being exposed to it at least 10 times Will not try a new food after 10 or more exposures
Sometimes reported as a “picky eater” at pediatric wellness visits Persistently reported as a “picky eater” at pediatric wellness visits

What to do if you suspect your child is a picky eater:

  • Always eat with your child. Eating is a social experience! If your child is expected to eat alone he may feel left out or neglected. (“Why do I have to eat if no one else is?”)
  • Stick to a routine. Give your child three meals and two snacks at the same time each day (or about the same time each day, let’s be realistic here).  Offer juice or milk with his meals, not in between, to avoid filling up his tummy and decreasing his appetite. Offer water in between meals to quench his thirst.
  • At meal times, always offer him one to two preferred foods (i.e. hot dog, chicken nugget) and one new food. When he sees his preferred food, he will feel more comfortable with his plate. Try to make the new food something you’re eating as well.
  • Always talk positively about food! Even if you don’t like something, do your very best not to talk negatively about it. For example, “Mmm, these sweet potatoes are so yummy!” NOT “Ugh, these potatoes are mushy and gross!”
  • Make it fun! Get some different dips out for his chicken nuggets – ranch, BBQ sauce, ketchup, mustard! Cut sandwiches out with a cookie cutter. Use food coloring. Serve breakfast, for dinner!
  • Have your child help! Let him pick things out at the grocery store. Have him wash the vegetables or fruit. Let him mix up the batter.

What to do if you suspect your child is a problem feeder:

Works Cited:

  1. Sisson LA, Van Hasselt VB. Feeding disorders. In: Luiselli JK, editor. Behavioral Medicine and Developmental Disabilities. New York: Springer-Verlag; 1989. pp. 45–73.
  2. Palmer S, Horn S. Feeding problems in children. In: Palmer S, Ekvall S, editors. Pediatric Nutrition in Developmental Disorders. Vol. 13. Springfield: Charles C Thomas; 1978. p. 107–129.
  3. Feeding problems in infancy and early childhood: Identification and management
  4. Debby Arts-Rodas, Diane Benoit
  5. Paediatr Child Health. 1998 Jan-Feb; 3(1): 21–27.
  6. Toomey, Kay. Copyright 2000/2010. Picky Eaters versus Problem Feeders.

Recipe of the Month: Nutrition Powerhouse Smoothies for Parents and Kids

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Smoothies are a great way to pack a lot of nutrition into something that tastes like a treat. They can be part of a meal or a post-workout snack. These recipes include four of the five components of The Healthy Plate Model:  protein (yogurt), calcium (yogurt), fruits, and vegetables. All of these smoothies promote healthy digestion since they contain fiber (fruits and spinach) and probiotics (yogurt). Kids love drinking something that is colorful and comes with a straw. Plus these are so tasty, they won’t believe how healthy they are! Smoothies are also a healthy option to eat while on the go. Hope you enjoy these!

Berry Blast

1 cup frozen mixed berries
½ banana
¾ cup plain, organic, whole milk yogurt
1 cup loose baby spinach leaves

Put all ingredients in a blender and blend until smooth. If desired, allow berries to sit at room temperature for 20 minutes for easier blending.

Recipe makes 1 serving. Provides approx 245 calories, 8 grams protein, 6 grams fiber, 277 mg calcium.

Green Monster

1 cup frozen mangoes
½ banana
¾ cup plain, organic, whole milk yogurt
1 cup loose baby spinach leaves

Put all ingredients in a blender and blend until smooth. If desired, allow mangoes to sit at room temperature for 20 minutes for easier blending. This smoothie will be green, and giving it a fun name like “Green Monster Smoothie” makes kids more likely to want to try it (it worked with my kid!).

Recipe makes 1 serving. Provides approx 285 calories, 8 grams protein, 4.7 grams fiber, 277 mg calcium.

Immune Booster Digestive Aid

1 cup frozen pineapple chunks
1 clementine orange, broken into individual pieces
¾ cup plain, organic, whole milk yogurt
1 cup loose baby spinach leaves

Put all ingredients in a blender and blend until smooth. If desired, allow pineapple chunks to sit at room temperature for 20 minutes for easier blending. Pineapples and oranges both provide vitamin C. Pineapple also contains a natural enzyme called bromelain that aids in digestion.

Recipe makes 1 serving. Provides approx 242 calories, 9 grams protein, 4.7 grams fiber, 274 mg calcium, 116 mg vitamin C.

Click here for healthy twists on your child’s favorite foods.

Digestive Issues: How to Help with Diet

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Digestive issues are extremely common among kids and adults in our country. So common, in fact, that we often don’t give these issues much thought and accept these feelings as being sort of normal. As a registered dietitian, I can tell you that digestive issues are your body’s way of telling you that some changes need to be made to feel better.

Here are common digestive problems, along with causes and dietary cures:

Acid Reflux

Causes:  Overeating, making the stomach too full and as a result, the stomach contents push up into the esophagus. Reflux can also be caused by food sensitivities or allergies, especially in infants.
Diet Cures:  Eat smaller meals at regular intervals each day (3 meals and 2 snacks). Your stomach is about the size of your two hands cupped together (with two more hands on top to make a sphere), so try eating about this much at meals. Eliminate fried foods. Eat plenty of fruits, vegetables, whole grains and lean meats. Eliminate trigger foods such as caffeine, dairy, and other high fat foods (such as sausage pizza or “loaded” nachos). In infants, rule out food sensitivity or food allergy; common culprits related to reflux in infants are cow’s milk protein (dairy), soy, eggs, and wheat.

General Indigestion

Causes:  Overeating, poor quality of diet, chronic constipation, inflamed enterocytes (cells that line the gastrointestinal tract).
Diet Cures:  Eat smaller meals at regular intervals (see above). Reduce processed foods and focus on whole foods such as legumes, fruits, vegetables, whole grains and lean meats. Drink plenty of water (2+ liters/day). Vary your grain intake (often we eat some form of wheat at all meals and snacks throughout the day). Consume probiotics through quality food sources such as organic yogurt, fermented vegetables (sauerkraut, kimchi, etc), and kefir.

Chronic Constipation

Causes:  A diet that is high in refined carbs, low in fiber, and inadequate in fluids. Constipation worsens with inadequate physical activity and long sedentary periods. Kids may be constipated if they consume too much dairy.
Diet Cures:  Eat fresh fruit at least twice per day and vegetables at least 2-3 times per day. Replace refined grains with whole grains. Other foods high in fiber include legumes, nuts and seeds. Drink 2+ liters of water per day. Limit dairy to 12-24 oz per day. Engage in physical activity throughout the day; even walking and doing house chores are helpful.

Frequent Loose Stools

Causes:  Excessive intake of sugary beverages, including juice, as well as excessive intake of “diet sugars”. Can also be caused by food sensitivity/food allergy. Another cause may be imbalanced gut flora, which can occur after taking antibiotics or with prolonged poor quality of diet.
Diet Cures:  Eliminate sugary beverages and replace with water or milk (given dairy is tolerated). Limit diet beverages to 8 oz per day or less. Trial an elimination diet of common food allergens for two weeks to see if symptoms improve (dairy, wheat, soy, eggs, nuts, fish, shellfish). Consume quality probiotic food sources (see above), as well as soluble fiber which is found in foods such as bananas, oatmeal, applesauce, dried peas as in pea soup, carrots, cucumbers.

Stomach Pain, with Gas and Bloating

Causes:  Food intolerance, sensitivity or allergy. Also these symptoms occur with general overeating of unhealthy food choices.
Diet Cures:  Trial elimination of common culprits for two weeks, including lactose (in dairy), wheat, legumes including beans and nuts, eggs, and soy. Eliminate sugary beverages as well. If symptoms do not improve, investigate fructose intolerance by working with a registered dietitian. Eat smaller meals and regular intervals throughout the day reflecting the Healthy Plate Model.

If you didn’t see your digestive issues listed above, or for more specific questions, leave a comment in the section below. For more guidance on helping your family overcome digestive issues, make an appointment with a registered dietitian at North Shore Pediatric Therapy.

Baby Food Pouches: Bad for Baby’s Health?

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A recent statement from the American Academy of Pediatric Dentistry warns parents of the possible side effects to prolonged usage of baby food pouches. They compare the squeeze pouches to that of giving babies juice in sippy cups and bottles, and they indicate that tooth decay may develop if babies are given frequent access to the pouches.

What Harm Can Baby Food Pouches Cause?

The squeeze pouches, while convenient for families on the go, often contain sugary fruit blends which can reek havoc on developing teeth. Over time, the constant exposure of the foods directly to the teeth may begin to break down tooth enamel. However, further research will determine if there is a true correlation between the squeeze pouches and cavities in young children. It is indicated that if parents do allow for their children to eat from the pouches, that they continue to follow the recommendation  of brushing their children’s teeth 2x per day and giving them water and milk to drink instead of juice.

Should I Allow My Child to Use Baby Food Pouches?

While the jury is still out on the actual effects of the pouches on little teeth, the old adage of “everything in moderation” holds true. Busy parents should not be discouraged from using the pouches in a pinch, but spoon feedings are still preferred. Feeding your child from a spoon not only contributes to functional oral motor development, but increases the social aspects of mealtimes. Parents are able to connect with their children during meals and if children are allowed access to constant drinking from the pouches, they are missing out on opportunities to practice developmental feeding skills when fed via spoon.

Click here to read more about oral motor and feeding difficulties in children.

My Child Is Tongue Tied: What Does This Mean?

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What is Tongue Tie (Ankyloglossia)?

Ankyloglossia, or more commonly referred to as Tongue Tie, occurs when the lingual frenulum (the thin band of tissue that connects the bottom of the tongue to the mouth) is too short and tight. Reports on the prevalence of tongue tie in newborns is conflicting, though current research indicates that this occurs in approximately 1-4% of newborns. Tongue tie may interfere with breastfeeding, and your newborn my present with significant challenges latching, remaining on the nipple when feeding, and fussiness during feeds. Nursing mothers may also experience significant pain when breastfeeding, even after repositioning.  You may notice that your baby has difficulty sticking their tongue out and the tongue shape may resemble a heart, as observed by a “V” indentation in the tip.  If tongue movement is restricted, tongue elevation, lateralization, and protrusion may be negatively impacted.  Tongue tie is not commonly identified at birth, however if you do have concerns, you should speak with a lactation consultant, speech-language pathologist, or your pediatrician.

What are the effects of my baby having Ankyloglossia?

However, it is presumed that long-term effects are not commonly seen in children with tongue tie. As an infant continues to grow, the frenulum in turn stretches and allows for increased tongue movement.  In rare cases, speech development may be negatively impacted by the severity of the tongue tie, as the tongue is unable to coordinate specific movements to produce targeted sounds. In cases where tongue range-of- motion are profoundly impacted by the tongue tie, the child may undergo a frenotomy or  frenulectomy in which the lingual frenulum is clipped to increase tongue movement.  There is continued debate about whether it is beneficial to “clip or not to clip”, as many healthcare professionals disagree on the effectiveness and supposed outcomes of the surgery. Each case is unique however, therefore an extensive oral-motor and feeding evaluation should be completed in order to assess the severity of the tongue tie, in order to determine the best plan of care for the child.

ADHD and Picky Eating

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Attention Deficit Hyperactivity Disorder (ADHD) is a very common diagnosis seen in a pediatric therapy clinic. It is not uncommon for parents to report difficulty with their child with ADHD and picky eating. The most common complaints for parents of children with ADHD who have trouble with mealtimes are distracted eaters, decreased appetites, and picky eaters.

Distracted Eaters

Distracted eaters are attending to external stimuli (e.g., TV, other conversations) or internal stimuli (e.g. lost in own thoughts) during mealtimes. Here are some strategies to help:
  • Decrease the external distractions: Eliminate other distractions like the TV or videogames playing in the background, dogs running around, telephones buzzing, etc. Have your child face other family members and face away from the busy kitchen area to encourage attention in the appropriate direction. Require your child to stay in the room and at the table for the duration of the mealtime.
  • Decrease internal distractions: Use solid placemats, plates, and utensils when eating. Colorful patterns or animated pictures can be distracting. Sometimes having a child engage in motor activities before sitting for a meal can help regulate him to be ready to sit and attend for a period.

Decreased Appetites

An almost universal side effect of stimulant medication used for ADHD is the suppression of appetite. In particular, the dextroamphetamines (e.g., Adderall, Vyvanse) seem to have the highest incidence of suppressing appetite. Here are some tips to manage decreased appetites:

  • Give the morning medication dose after breakfast to ensure an adequate meal is consumed before the side effect of decreased appetite sets in.
  • Provide proteins during lunchtime and small, healthy snacks during the day. Smaller snack-sized portions are often more visually manageable for children than an entire plate of food. Protein shakes are good options during this time.
  • Serve a larger dinner meal at the end of the day when the drug has worn off. Kids will typically make up many of the calories lost during the reduced daytime eating with a larger evening meal.
  • Consider not using the drug on weekends if your child continues to struggle with this side effect. Allowing one or two days of increased calories a week can counteract for a decreased intake during the weekdays.

Picky Eaters

Kids can be picky eaters for a variety of reasons. Evolution dictates children be wary of trying new things in order to survive. They may have a negative association with eating or have sensory issues causing anxiety with certain foods. Cognitive and developmental disorders also may impact the types of food eaten. Similarly, kids with low tone (i.e., decreased strength, coordination, and postural control) may be picky about the foods that are easier for them to eat.

Any of the above issues may co-occur with ADHD.

Here are some strategies to help your picky eaters:

  • Meal Routine: Too much grazing throughout the day may result in a lack of hunger at specific mealtimes. Three meals and two snacks should be offered per day to ensure hormonal balance triggering “hunger”. There should be a beginning, middle, and end to every meal.
  • Exposure: The best role model for food it you! Having family dinners and presenting children to a variety of foods that you, as caregivers, model eating is a critical way to expose your child to the idea that food isn’t scary.
  • Posture: Ideal eating position is hips, knees, and ankles positioned at 90 degree angles. Boosters/chairs should be utilized to ensure the child is at the appropriate table height. If your child has a hard time remaining in a chair, move-and-sit cushions can provide sensory input to help your child stay seated for a longer.
  • Desensitize: For some children, decreasing the sensitivities of the mouth may help with food intake. Using a vibrating tooth brush, a chewy tube or a washcloth tug-o-war are good options to desensitize the child.
  • Get the kids involved: Taking the kids with you when you grocery shop and letting them help pick out the foods will help with compliance. Encourage your child to help with creating the menu, choosing the foods, and preparing the meal are other ways to help your child become involved in mealtimes.

Children with ADHD may have a difficult time with mealtime. Remember to be patient and do the best you can to provide them as many healthy food options as possible. The rest is up to them. For other tips on how to parent a child with ADHD, click here.


5 Ways a Speech Language Pathologist Can Help a Child with Autism

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Having a child receive a diagnosis of Autism Spectrum Disorder can be a scary thing. The best thing you can do for your child is learn as much as you can about what to expect and how you can help in order to be the best advocate that you can.

Here are five areas in which a licensed speech pathologist can help a child with Autism:

  1. Communication – Regardless of whether your child uses sign language, pictures, or words to communicate, a speech pathologist can help a child with Autism learn a functional way to express his needs and wants.
  2. Understanding Language – It can be scary to live in a world where you don’t understand what is said to you. A speech pathologist can aid your child with Autism in comprehending and understanding language.
  3. Social Skills – A speech pathologist can help teach a child with Autism to use communication appropriately with others, whether that means teaching how to touch and look at others when speaking or learning skills to make friends.
  4. Feeding – Mealtimes are a critical part of family and social interaction and a speech pathologist can help your child with Autism eat a wider variety of foods safely and effectively for adequate nutrition.
  5. Safety Skills – Being able to recognize and avoid dangerous situations is a skill that a speech pathologist can help teach your child with autism to keep him safe!

All parents want what is best for their child and a speech pathologist can help your child with autism gain the skills to overcome the daily challenges he may face. To learn more about the steps to take after receiving an Autism diagnosis, click here.

Click here to visit our Chicago Autism Clinic.

Get the Family Healthy in 2014, Part 1 of 2

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The New Year is here, and it’s a great time to make a resolution to get healthy. In order to stick to that New Year’s resolution, be specific about what changes to make. This can help your family execute a plan to ensure positive outcomes. Here are some specific changes that you as a parent can implement to bring about real change for your family’s health this year. I recommend choosing as many of these as you think are realistic to do in your household. Even one real change is better than a handful of half attempts that fail. Good luck!

Easy New Year Health Swaps for the Family:

  1. Replace the refined grains with whole grains. This advice might sound like a broken record, but based on the wide range of clientele I work with, this healthy change is not actually happening in real families. Whole grains maintain the natural fiber, vitamins and minerals that have been stripped from their refined counterparts. Whole grains include whole grain bread, oatmeal, whole grain pancakes, whole grain pasta, brown rice, quinoa, millet, and whole grain cereals. Refined grains are the “white” carbs, such as white bread, white pasta, and the wide variety of processed foods that are made from refined flours. Sometimes it is harder for parents to make this change than it is for the kids, since our generation was raised on refined flours. Trust me, you will get used to it and soon the refined stuff will taste bland and leave you hungry an hour or so after eating. Because whole grains have fiber, they take longer to digest (making you full sooner and longer). Whole grain fiber also plays an important role in binding and excreting fat, both in digestion and circulating lipids in the bloodstream. From the very beginning of feeding your kids as infants and toddlers, remember- kids do not need “kid food”, and they can enjoy whole grain pancakes and whole grain pasta just as much as the white stuff. Be a good example for your kids.
  2. Replace snack foods with fruits or vegetables. And while you’re at it, limit snacks to two per day (one mid-morning or before bed, and one mid-afternoon). This might be the most effective change you can make if you or your family members are big snackers and grazers. Your job is to make sure there are always plenty of fresh, colorful fruits and vegetables available to your kids. When it comes to produce, quality matters. Kids will more readily accept things that look and taste fresh, so choose wisely. Local and organic produce is usually more fresh and flavorful than something that may have traveled half way around the world and then sat frozen in a warehouse for months. Enforce this change by telling the kids what their snack options are, then encouraging them to go play or do homework before the next meal (or bedtime).
  3. Limit eating out to once per week or less. Although it is possible to eat healthy when eating out, often it is easier to make unhealthy choices and overeat when eating at restaurants. It may be even more difficult for your kids to eat healthy when eating out as many kids’ menus are limited to foods high in fat and sodium and low in fiber. This may be a challenge for the busy parent who is not used to cooking. If you choose this resolution, be prepared to plan, grocery shop, and cook. Cut corners by using time-saving and healthy cooking methods such as the slow-cooker and stir-frying lean meats and veggies. It may be a difficult change to implement, but it will be very rewarding from a health perspective (and on your budget).

Check the blog next week for more healthy New Year’s resolutions for your family!

Click here for more advice on how to set achievable goals for the new year.

Infant Feeding: When Your Baby Is Turning One Year Old

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Your baby is a year old- what a milestone! At this time, along with many other developmental changes you’re probably witnessing, baby is ready for some advancement at mealtimes as well.  Here are the next steps as toddlerhood begins:

At one year old, transition to cow’s milk or other milk alternative, if your baby meets the following criteria:

  • Your child does not have any growth or nutrition concerns.*Feeding your one year old
  • Your child does not have history of cow’s milk protein allergy.*
  • You are planning on weaning breastfeeding in the foreseeable future. If not, be sure that your child is getting at least 12 oz of breastmilk at scheduled times (preferably immediately after meals) daily, as well as 1-2 servings of calcium foods. Avoid allowing your child to “snack” on breastmilk at this age since it may decrease appetite for food at meals.
*In these cases, it may still be appropriate to trial cow’s milk at one year old; however, this must be under supervision of your child’s physician or dietitian.

Tips for a healthy one year old diet:

  • To transition to cow’s milk, offer 4-6 oz of milk in a cup at mealtimes. If baby is adamantly rejecting it (presumably because of the taste difference from breastmilk or formula), be patient and do not stress. Stay consistent by offering milk in a cup at meals, but fill it with mostly breastmilk or formula (whichever they are used to drinking) and add a small amount of cow’s milk (ratio of 4 oz:2 oz or even 5 oz:1oz). Every day, make the ratio a little more cow’s milk and a little less of the breastmilk or formula.
  • Limit milk to no more than 24 oz per day to ensure baby has a healthy appetite for meals.
  • Offer milk at meals and water at snack time and throughout the day as needed. There is no need for juice, and in fact, juice can fill baby up with empty calories which decreases appetite for more nutrient-dense foods.
  • Begin phasing out the bottle. Stick to cups at meals and snack times. Often the bottle is most difficult to wean when it precedes a Read more

Infant Feeding Series: How to Transition Your Child from Purees to More Advanced Textures

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It is generally recommended to feed infants pureed foods starting at 6 months old. After a few months of sampling a variety of pureed introducing finger foodsfoods, your child will be ready for other textures. Around 9 months old, your child will develop a “pincer grasp” where they can pick up small objects with their thumb and forefinger. This fine motor skill is acquired around the same time that babies develop the oral motor skill of up-and-down chewing motions. These two skills are both very important and necessary when you think about what your baby needs to do in order to accomplish eating foods that are not pureed.
Therefore, around 9 months is a good time to introduce little finger foods and other soft textured foods. Here are some tips to make the transition:

First and foremost, a few feeding basics:

  •  Always feed your infant in high chair or other belted seat that is pulled up to the kitchen table. Read more