What All Parents Can Learn from a Feeding Therapist

By Beth

This post is the second in a series from an interview with Dr. Ramasamy Manikam, PhD, a clinical psychologist and top expert on feeding disorders with over 20 years of practice. Dr. Manikam is the Director of the Center for Pediatric Feeding Disorders at St. Mary’s Healthcare System for Children.

Compared to most of us parents, Dr. Manikam has experienced far more challenging situations at mealtime than what we face at our own tables. He is also a parent and grandparent. In this post, he shares his experience and perspective for all parents, including how to deal with “picky” eating issues such as color, texture, food jags and other common food concerns.

First, the most important message for all of us parents is that minor food issues — such as typical “picky” eating — are perfectly normal. The other important advice is we shouldn’t worry so much about food that we cause a larger problem.

“I would consider picky eating in healthy children a “normal” phase of development, usually during transition from bottle to solids and especially from puree to textured foods,” says Dr. Manikam. “Children tend to ‘try’ new foods and spit them out if the food does not meet with their interest (smell, taste, texture, color, etc.). Continued presentation without pressure, in small amounts, and in a variety of preparations can eliminate the problem.”

Another good thing to remember, Dr. Manikam advises, is not to get hung up on your child “having” to like any one food.

“No one food ‘has to be eaten’ unless for medical reasons,” he explains.  “If a child is healthy and is taking a variety of other foods there is no reason to “force” the child to eat a certain food (sometimes it is a power struggle that the parent wants to win for no good reason).”

Food should not be a fight, Dr. Manikam, advises, which is perhaps the best message parents could hope to hear. For those of us who deal with the challenges of our kids’ food issues daily, however, Dr. Manikam offers some good strategies for how to solve the issues and avoid that conflict.

Food Jags and the Mac-and-Cheese Strike

So, what about particular issues, such as a food jags where a child refuses to eat anything besides the Evil Trinity of fat-sugar-salt, i.e. mac-and-cheese, fast food or chicken nuggets?

“Choose foods with similar characteristics such as color, texture, taste, etc. to reduce the child’s resistance,” Dr. Manikam advises. “Introduce new foods in small amounts, mix the two foods together where possible, make the new foods interesting like making them into interesting shapes, arrangements etc.; model eating the food with the child; find out what about the new foods the child dislikes: e.g., color, taste, smell, texture, etc and manipulate these food characteristics.”

Color Issues and the All-White Diet

Quite often, kids refuse to eat any food of a certain color, green for example, after one negative exposure to a green food. It doesn’t matter if the new food is juicy grapes or sweet kiwi fruit, all things green equal broccoli. Other children may refuse any food that is not white, beige or brown, otherwise known as the “white diet.”

Many of the same approaches for food jags, above, are also useful for a color aversion, says Dr. Manikam.

“It takes many tries to get a child to feel comfortable with new foods. Frequent introduction of new foods because the child refuses a food is not a good idea. Continue to introduce the same food for 16 to 20 times, experimenting with a variety of food preparations.  Strong resistance might have an underlying problem and not merely a ‘behavior’ problem and should be medically evaluated.”

Texture Issues

Texture issues, whether it is a preference for crunch or for soft textures, can be confusing since they show up across all different flavors and colors of foods. For kids with texture issues, Dr. Manikam advises parents to try and evaluate the source of the issue in case it is not just picky eating.

“Check to rule out oral-dental problems.  Rule out sensory issues.  Texture fading (gradually increasing the texture of the food presented moving from puree to thickened puree) is a strategy that works well most of the time in the absence of oral-dental and sensory problems,” he says.

Restless Eaters

Some of us have kids who can’t seem to stay still long enough to eat.  These kids are often slumping in their chairs, getting up and down, or won’t want to eat a full meal but then say they are hungry an hour later.

For these eaters, Dr. Manikam recommends a consistent schedule and being aware in case there are legitimate causes of a small appetite.

“Frequent meal-time changes can be difficult for the child,” he says. “Routine in other areas such as naps also helps mealtimes. Ensure that the child is ‘hungry’ before meals. Do not give snacks before meals. Feed developmentally appropriate portion sizes. Check to see if there is a medical reason for poor appetite. Children with poor appetite might need mini-meals (six to eight sessions a day) with gradual increase in portion size.  Children when ill or when recovering from illness cannot consume a full meal and could use mini meals until fully recovered.”

The Separate Meal Request

Feeding a family with all different tastes can be a struggle. It’s tempting to give into the request for separate foods — even just to get through one difficult evening. Once this becomes a habit, some children may insist on always being fixed a separate meal of foods they request. What started out as an understandable quick fix solution for a busy and stressed parent now adds to daily stress with the extra planning and preparation of this separate meal. How do you get the whole family eating the same meal again?

“If the child is healthy and well developed a ‘premack’ strategy can be used (i.e., to have the child consume a bite or two of the family food before presenting the preferred food and gradually increase the amount of the family food); or have the child leave the table and tell the child he/she can eat at the next meal (do not deprive the child of other food routines between mealtimes including liquids and snacks). If the child is not healthy or cannot afford to lose weight then food fading (gradual introduction of small amounts), food masking (mixing and hiding with other foods), and premack strategies can be used, ensuring that the child gets the required calories and nutrients,” says Dr. Manikam.

How Do We Tell if a Food is Disliked Because of Color, Texture, or Flavor?

Younger children cannot always verbalize their exact issue with a particular dish. It doesn’t help that one recipe for carrots can taste completely different than another recipe. How can parents of younger children “crack the code” on why their children won’t eat a particular food?

“One way to identify what the source of the particular food is to use the ‘elimination’ technique, similar to identifying a food that a child is allergic to,” says Dr. Manikam. “Change one characteristic of the food at a time for a few meals to see if it makes a difference.  Also, identify what the common elements are amongst the food the child is consuming and then use these elements to the refused foods.”

Stress Less. Enjoy More.

Overall, Dr. Manikam offers advises parents to remember, “Every eating ‘quirk’ is not a feeding disorder. If the child is healthy with normal growth trajectories the ‘feeding issues’ are overcome through ‘common-sense’ actions and time.“

He also advises us to simply enjoy our food as we introduce small bites of new foods to our children. Reintroducing a rejected food item is a good tactic. That small bite might get eaten after a few tries — just don’t force those bites, he says, or force your child to clean his or her plate.

If you find yourself still tempted to worry, focus on being sure your child’s menu is varied and provides adequate nutrition for his/her age and developmental needs.

Many thanks to Dr. Manikam, Director of the Center for Pediatric Feeding Disorders at St. Mary’s Healthcare System for Children, for his insights shared here. In the next post, he shares his experience and perspective for all parents, including how to deal with “picky” eating issues such as color, texture, food jags and other common food concerns.

Posted in By Beth, Healthier Eating, Uncategorized | 1 Comment

Feeding Disorders: When Should a Parent Worry?

By Beth

Have you ever wondered if your child’s picky eating is “normal?” If so, you’re not alone. The next couple posts for The Cleaner Plate Club will be a series from an interview with Dr. Ramasamy Manikam, PhD, a clinical psychologist and top expert on feeding disorders with over 20 years of practice. Dr. Manikam is the Director of the Center for Pediatric Feeding Disorders at St. Mary’s Healthcare System for Children.

Dr. Manikam has been kind enough to answer some questions for me. The first post will cover some background on what feeding therapy is and what conditions are most often related to a feeding disorder. The posts will also cover when a parent should — and shouldn’t — be concerned about a food issue.

The second post, for those of us who are blessed with kids who are just “picky eaters,” Dr. Manikam shares some of his perspective as a medical professional as well as a parent and grandparent on some of our “common” food concerns with our kids.

What is a Feeding Disorder and When Should a Parent Worry?

A genuine feeding disorder can be devastating. The symptoms, causes and actual behaviors of a food disorder vary. However, one constant is that dealing with a child’s food disorder can be especially hard for parents who blame themselves for the disorder.

Some parents I’ve talked with have children with eating habits that cause both the parents and children in these situations to dread daily mealtimes. Their children may gag when eating a disliked food or have another type of adverse reaction to some foods. Situations like this feel anything but “normal.” Where is the line between “picky” and when there may be an actual disorder? When should a parent seek medical help?

“The index I would use is the health, growth, and development of the child in relation to the food intake,” says Dr. Manikam. “Some children ‘pick’ during meals but then graze all day long and are healthy.  If the child is not receiving balanced nutrients with sufficient intake for proper growth and development then it becomes a disorder that requires medical evaluation and feeding therapy if warranted.”

Growth and development issues are gradual symptoms, but there may be short-term indications of a food issue as well.

“Weight loss, illness, allergy, crying during meals due to pain, etc. should be a call for medical evaluation to determine the nature of the problem,” says Dr. Manikam.

Other symptoms that can be indicators of an underlying medical problem include; difficulty with swallowing, vomiting during and after meals, choking and gagging during meals, poor appetite, and crying while holding the stomach.

“[These signs] can be indicators of an underlying medical problem that should be evaluated by trained and experienced medical professionals,” he continues.

What Causes Feeding Disorders?

The causes of a feeding disorder are most often a medical condition. Less commonly, a feeding disorder develops from inappropriate interactions with a parent. Feeding disorders affect approximately 25-40 percent of children from newborns to adolescents, a statistic that seems alarmingly high.

“These percentages are averages,” explains Dr. Malikam.  “The percentage varies depending on the definition of what a ‘feeding disorder’ is, the time of study, and the population and even the country where the study is conducted. The percentage can be as high as 80% for special needs children with developmental disabilities. I consider an individual to have a ‘feeding disorder’ when his or her health is adversely affected.”

Feeding disorders are more common for children who are born prematurely, or had a low birth weight as well. According to Dr. Manikam, other physical causes of a feeding disorder, eating aversion or failure to thrive, include:

• Celiac Disease

• Down Syndrome

• Prader-Willi Syndrome

• Heart defects

• Breathing difficulties

• Oral-facial malformations such as cleft palate

• Other Syndromes (e.g., Stickler, Cri du chat, Pierre Robin, Russell-Silver, Fetal Alcohol, Treacher-Collins, Smith-Lemli-Opitz)

• Food allergies, including milk allergy, and lactose intolerance.

Other physical causes may include gastroesophageal reflux (GERD) and Crohn’s disease. Sensory disorders, autism, and ADHD can sometimes be linked to food issues.

Only about one in ten food disorders are caused from behavior issues. These food disorders can be caused by negative interaction with a parent.

Examples Dr. Manikam provided include a parent that has low tolerance; has a poor understanding of developmental norms; or has been affected by the knowledge that other children were doing better or eating table foods earlier. Other negative interactions can include a parent who cannot read his or her child’s hunger cues, or who forces food on a child when the child is not hungry.

Parental aggression or anger during feeding times, a lack of nurturing, and parental apathy are other negative parental interactions that can lead to a feeding disorder in children.

How Are True Feeding Disorders Treated?

Treatment for a true feeding disorder can require an expert such as a feeding therapist. Dr. Manikam is a clinical psychologist, but feeding therapists may have different backgrounds. Feeding therapy, in some cases, requires a team of individuals with different specialties.

“Feeding therapists are professionals trained in the assessment and treatment of individuals with feeding problems. Generally, Speech Pathologists, Occupational Therapists, and Behavioral Psychologists provide feeding therapy services to individual with feeding problems,” says Dr. Manikam.

Feeding therapy team members may sometimes include a nutritionist, or a social worker or other medical professionals. The therapy process may focus on the patient only, or the parent, or both. This article on Dr. Manikam from the New York Times, has some specific examples of patient experiences.

“Depending on the patient’s age and developmental levels and the nature of feeding problems professionals might work with the patient and/or with the guardian. For example, therapists might work with an adolescent who develops ‘anxiety’ or ‘post-traumatic anxiety disorder’ due to a choking incident.  In the case of younger children, therapists might work with the child and train the guardians when an effective intervention is established. In some cases, the therapist might train the guardian to implement the intervention strategies.  The model of service delivery depends on the information obtained from the assessment,” says Dr. Manikam.

Many thanks to Dr. Manikam, Director of the Center for Pediatric Feeding Disorders at St. Mary’s Healthcare System for Children, for his insights shared here. In the next post, he shares his experience and perspective for all parents, including how to deal with “picky” eating issues such as color, texture, food jags and other common food concerns.

 

Posted in By Beth, Healthier Eating | 1 Comment

Veggie Love for Valentine’s Day: We Heart Kale

By Beth

Given the holiday today, we’ll profess our steadfast veggie love for kale. We met over a kale chip recipe, Ali and I. There are at least four kale recipes in our book, and I have several new recipes for kale that are being created all the time.

We love the stuff. And it loves us too. With over 45 flavenoids and phytonutrients, 1327 percent of your daily vitamin K in a serving, 354 percent of your daily vitamin A, and 88 percent of you daily vitamin C in a serving, kale is a rockstar for nutrition all packed into one under-appreciated leafy green that has only been familiar to us all previously as that leafy garnish around the salad bar bins.

So, today, as chocolate gets all the love, we heartily profess our abiding affection for kale!

Moroccan Stew with Kale

Sweet Potato, Kale and Farro Side

Kale Salad

Black-eyed Pea Soup with Kale

Beans and Greens and Grains Soup

Finally, here’s some great tips on how you can inspire your whole family’s affection for kale (and other greens!)

Posted in Uncategorized | 2 Comments

It’s Okay to Play With Food! Using Play Kitchens to Teach Good Food Habits

By Beth

Some years ago, I found myself in the aisle of a large toy store trying to find play food to go with a toy shopping basket and the play kitchen Santa was bringing for Christmas. I was struck by how hard it was to find “real” play food instead of cookies, ice cream, pizza, hot dogs, junk food, and worst, branded fast food play sets. Just like real world groceries, I had to pay more and had far fewer options to get fruits, vegetables, meats and breads.

Recently, I read research “Familiarizing with Toy Food” by Meghan Lynch from the University of Toronto. The research centered on how play in toy kitchens shapes children’s attitudes toward food. It was done by observing YouTube videos, posted by parents, that captured real life situations in toy kitchens. She was kind enough to answer some questions for The Cleaner Plate Club on how we, as parents, can use play to help our children develop a healthy relationship to food.

INTERVIEW with MEGHAN LYNCH, Nutrition Education and Behavior Researcher, questions in bold, and her answers are below.

Your research focuses on how a child’s social environment shapes his or her attitude toward food, meaning not just what foods are provided for children to eat, but shaping how they view food.

How important is social environment to our relationship with food?

The social environments plays a paramount role in shaping children’s lifelong attitudes towards food, as early experiences are pivotal in developing children’s food preferences. Children who are introduced to healthy foods early in life have the best chance of developing healthy relationships with food. After approximately age three, children model the nutritional behaviors of those in their environments, especially their parents’ food preferences and attitudes.

What does a healthy attitude toward food look like for kids?

A healthy attitude toward food for kids is in large part shaped by their social environments, and particularly with young children, changes and develops every day. It is important to understand that children’s initial rejections of new foods do not represent innate food preferences, but transient reactions that can be changed and developed through learning and experience. To foster children’s development of healthy attitudes toward food, parents should aim to allow children to eat when they are hungry and allow children to serve themselves. Parents should see their role as offering a variety of healthy foods, overseeing planning and assembly of meals, and setting schedule for meals and snacks, but they should not try to control the amount of food the child eats.

Can a parent give their child healthy foods to eat, but still role model an unhealthy social environment? How?

Yes, parents can feed their children healthy foods but still model unhealthy eating behaviours. Children learn primarily through observational learning, especially their parents’ attitudes and behaviours. Being a positive parental role model – that is, eating a variety of healthy foods and showing a willingness to try new foods –  is as important as providing children with healthy foods.

When you observed parents and children at play in the toy kitchens or with toy food, what types of behaviors would you say encouraged a healthy food attitude?

In the play settings, many parents could be seen encouraging their children to prepare and serve to the parent healthy foods such as green tea, soup, vegetables. Parents could also be seen encouraging healthy food preferences by pretending to consume the healthy foods and commenting on how delicious these foods looked or tasted.  These kinds of interactions are important, as they provide children with role models of people who enjoy healthy foods.

What types of behaviors would you advise against if parents want their kids to learn good food habits?

Whether in a play setting or real life, encouraging and modeling unhealthy food preferences and methods of food preparation are behaviours that are not helpful for developing healthy food habits in children. For example, voicing preferences for foods such as desserts or encouraging frying as a method of food preparation. Additionally, as described earlier, attempting to control over what, when, and how much children eat does not help children to learn to listen to their internal cues for hunger and satiety.

How important are the types of foods selected for a child to play with in shaping attitudes toward food? Can play scenarios help a child “rehearse” good food behaviors, or help counter picky eating behaviors?

Just why it is important to provide children with healthy toy foods to play with relates to the concept of “food familiarity.” Food familiarity refers to children’s preference for foods with which they are accustomed to seeing on a regular basis – the more familiar the food, the more likely the child will be to taste it. Importantly, children’s food preferences can be encouraged through their merely seeing these foods on a regular basis, and that repeated exposure to foods can overcome the initial refusal of them. It should follow, then, that one of the most important ways parents can encourage the development of healthy food preferences is by increasing children’s familiarity with new foods.

Thus, toy foods and play settings represent a way for parents to familiarize young children with healthy foods and act out healthy food behaviours. In the safety of play settings, parents can familiarize children with new foods and behaviours by teaching children how to chop vegetables, stir pots of food, and correctly use the oven or stovetop. In play settings, children in the higher age range (approximately five-to-six years of age) have been observed demonstrating behaviours that are the most representative of realistic food-preparation skills, such as setting the oven to a specific heat, covering foods before inserting them in the oven, and using pot-holders to remove dishes. Yet even with children in the younger age range (approximately three years of age), they can be seen acting out realistic food-preparation skills in their correct usage of utensils such as spatulas and whisks, in chopping and washing vegetables in the sink before cooking, and in stirring spoons in pots on stovetops.

How closely do children’s food play behaviors mirror their parents’ daily food behaviors?

Children have been found to treat their play with toy foods realistically, by acting out behaviours they have observed from others. Many children were realistically cautious in their pretend cooking, such as the young girl who washed and dried her hands before she began cooking. In my study, parents, too, were found to encourage use of the play-based setting as a venue for practicing realistic behaviours. In the majority of play settings, parents encouraged the washing of dishes and fruits and vegetables before cooking, as well as cautioned children about “hot” food and other dangers. In one instance, when a young girl’s father asked if she liked soda and the girl claimed she did, her father commented how her mother was the only family member who liked soda. The manner in which such play nutritional preferences were being influenced by the children’s real social influences could be seen most graphically in one play kitchen where a boy was making a pizza in a toy oven when his mother commented that it was “just like our pizza,” and the camera panned to the father preparing a pizza in the family’s kitchen.

Overall, how healthy were the majority of food behaviors presented in the videos? What types of trends did you see?

Unfortunately, many children were seen interacting with toy foods that more closely reflect typical Western diets of high-fat and energy-dense foods. The most common toy foods in the videos were nutrient-poor foods, such as cookies, fries, onion rings, and ice-cream. Children’s choices in food preparation in the play settings were dominated by behaviours reflective of family food-practices that are, unfortunately, detrimental to healthy nutritional development, such as reliance on easy-to-prepare foods. Interestingly, the microwave was the children’s most popular method for preparing food. Worth noting, too, was that in the majority of these cases, parents either did not respond (suggesting they were not surprised by their children’s knowledge and use of the microwave) or actually encouraged their children to use the appliance.

What types of foods were most often “consumed” in the play settings?

Foods consumed most often were what would be considered “extras” or “treats,” such as cookies, cakes, cupcakes, chocolates, brownies, and ice cream, coffee, sugar, salt, butter, and fast food (fries, onion rings, soft drinks, milkshakes). Cookies were a particularly popular choice for children to bake, eat, or serve to their parents. Parents, too, typically vocalized their preference for desserts and frequently encouraged their children to pretend to prepare, drink, or serve coffee. Additionally, nutrient-poor items from other food groups–hamburgers, hot dogs, macaroni and cheese, and pizza–were represented far more often than choices of greater nutritional value. Worth noting is that these interactions were limited of course by the toy foods present, yet very few replicas of grains and dairy could be seen. As stated, children were limited by the toy foods provided by parents, who themselves were limited by the toy foods available for purchase.

When I was shopping for my own child’s toy kitchen and toy food, I was overwhelmed by the amount of branded fast foods, fast food “play” environments and the difficulty of finding toy foods that represented fruits and vegetables and non-fast food and items not found on a typical “kids’ menu.”

How much influence, good and bad, do these branded items have on kids’ own food choices and preferences? What’s the impact of branded food items on a young child?

An interesting body of research has revealed just how much children’s preferences for foods can be affected by branding. Children’s preference for certain brands plays a large role in their preference for foods. Studies with young children have found they show a significant preference for foods if they believe the food to be from McDonalds, a finding which held even for food that is not even marketed, nor available, from McDonalds. For example, preschool children have been found to prefer carrots if they are packaged in McDonalds wrapping (when compared to the same food not packaged in McDonalds wrapping). Likewise, other research has found young children significantly preferred the taste of foods with popular characters on the packaging. What these studies show are just how young children are influenced by branding of foods and reveal the myriad of factors that are involved in children’s liking of food.

Based on your research, what advice would you offer parents on how they could use play food settings to positively impact their children’s relationship with food?

Play food settings can be used to improve children’s familiarity with healthy foods and thus, their willingness to try these foods in real life. Parents can use food-themed play settings to foster healthy nutritional behaviours by ensuring that children interact with a variety of healthy toy food replicas (such as fruits and vegetables, grains, and dairy). Through play in toy kitchens, supermarkets, and restaurants, children can also be encouraged to pretend to cook and eat healthy foods. Importantly, parents need to ensure that children are interacting with a variety of healthy toy foods, engaging in healthy mealtime behaviours, and experiencing adults who model healthy behaviours. However, it is essential to emphasize that this strategy is intended to complement and not replace offering new foods at meals on multiple occasions.

Meghan Lynch, thank you for taking so much time to share your insights. This is great information.

Additional Research by Meghan Lynch, and Related Research:

Lynch, M. Playing With Food: A Novel Approach To Understanding
Nutritional Behaviour Development
. Appetite. 54(3), 591-594.

Lynch, M. The Use of Toy Foods in Visual Familiarity Development:
Preliminary Research and Future Directions.
Journal of Nutrition
Education and Behavior.

Lynch, M. Play-based settings: An innovative method for the study and
development of nutritional behaviours in young children. Pediatric
Nursing.

Effects of Fast Food Branding on Young Children’s Taste Preferences Thomas N. Robinson, MD, MPH; Dina L. G. Borzekowski, EdD; Donna M. Matheson, PhD; Helena C. Kraemer, PhD

You can contact Meghan Lynch if you would like to cite her research or need more information:

Meghan Lynch
Mail: University of Toronto, Dalla Lana School of Public Health, 155
College Street, Health Science Building, ON, M5T 3M7, Canada
Email: meghan.lynch@utoronto.ca

Posted in By Beth, Healthier Eating | Leave a comment

Words I wish I’d written: chronos, kairos and carpe diem

Image pulled from momastery blog. Which you should read. Go.

If you haven’t read this piece on Chronos and Kairos and the old lady at the store — and you may have, for it’s a facebook favorite these days — read it now. It captures the experience of parenting so beautifully. It is something to hold on to when you’re in the middle of trying to get dinner on the table and you just burned the rice and one child is sobbing because her balloon popped and another is sobbing because you haven’t done her cousin’s Flat Stanley project yet and the dog just pooped on the floor again and the phone is ringing and you have 14 urgent emails you haven’t returned and I’m sorry, but couldn’t you have taken your muddy boots off before walking across the entire house?

Wishing you all kairos. Lots of Kairos.

Posted in By Ali, I Heart This | Leave a comment