When kids eat very little or only a few foods, they risk developing nutrient deficiencies – or behavioral issues because of how their parents respond. In this guide, pediatric dietitian Megan Murphy, RD, offers simple steps to evaluating a child’s nutritional status (including how to distinguish picky eating from a more serious disorder) and ways to help parents turn meals into pleasant, not pressured, experiences for the whole family.
awesome. So yes like Maria just said I'm Megan Murphy. I work on a pediatric dietician at the Children's Hospital in Oakland and I actually um exclusively work in our gi clinics but uh I know that we get a lot of um picky eaters come through G. I. Maybe they're getting a medical work up and I know we have a lot in our nutrition clinics. So um my colleagues and I see a lot of this and we are not necessarily always the one stop shop for it. But it is really good too. I think when you have a limited peter get a nutrition evaluation and then um I'll highlight the other specialties that I like to make sure we lupin. But basically um. Ot and feeding therapy is a huge huge help for us too. So we work closely with our occupational therapists. Um So just to quickly show you wanted to talk about, just want to define what picky eating is versus um are fed which I think requires much more support. And then I'll walk you through what a typical like nutrition assessment and eval will look like from my end. Um If during that you guys wanna ask any questions. I'm happy to pause in the middle of that. Um And then just resources for families as well. All right so um what is picky eating? So I went through looking because I know in my head it's a sort of a subjective thing that a lot of parents will say like oh they're picky eater, what does it mean? And it's different to everyone and so it's a little bit happy to see that there's not really a real medical definition for actual picky eating. I know there's an I. C. D. 10 code. Um So it's kind of hopeful there would be but it seems like it's just like this term for strong food preferences not eating enough food or restricting some food groups um eating a small amount of food or not willing to try new food. So I think that kind of fits the definition that we would all think of in our head of like this kid is a picky eater. Um And a lot of the studies they did on picky eating that I was kind of just like browsing through our subjective questionnaires asking parents like is your child a picky eater? What makes them a picky eater? It's and it's so interesting to read because it sounds exactly like what we get in clinic. I'm sure you guys do like the only mac and cheese or they only eat foods in a certain brand or um they won't eat any but you do a diet recall and they do eat a lot of foods. They maybe just don't eat like chicken and they prefer beef or something. So kind of stressing out what is what is the actual pickiness of that patient is. Seems to be really subjective and it's kind of what the medical literature is saying too. So what could cause it um I think some kids and adults, humans in general were naturally more sensitive to taste or smell er textures. Um They can also develop it from modeling their parents or their friends, um you know, teachers, things like that, and then it could also develop from like punishing or bribing, even rewarding, like positive reinforcement or negative at the table can really shape their entire view of what they want to eat. So a lot of it I think is behavior, there are some where it's gonna be um more into the textures and tastes and things like that, so sensory stuff. Um So I just want to touch on our first um because I do not work in our eating disorder clinic and it is considered an eating disorder. Um but I do see these kids sometimes, and I'm sure you guys see them in your clinics um in primary care, getting them to the right team is helpful, but figuring out when it started versus picky eating is really tricky. So I think like the key for what I look for is like this severe restriction or they won't touch things of a certain texture color, they're really specific to brand. So, I'm thinking about my kids that I see on the autism spectrum disorder, who will only eat yogurt out of the Yoplait container and when you play changes, that's branding and packaging, parents will go and buy as much as they can, so they can wash it out, reuse it with the new one. Um So that's that's a really severe restriction. Um They're red flags are like low interest in food, The sphere of choking or vomiting. We've seen patients like this where they have a traumatic event where they choke on something and then they really don't want to eat solids again. Or they could have E. O. E. And they just have trouble with meat. So they avoid them um feeling full around meal times or you know, maybe they just don't have a good appetite. So looking into why um kind of avoiding social settings with eating because of their food restrictions, feeling like they may have food allergies or intolerances. Um and that could lead to like a vicious cycle of like I can't eat this when I eat it, I have a symptom when I don't eat it and then they just get stuck in this big cycle. So it's different from, you know, anorexia and bulimia, which is more on the weight based image body image side of things. This is just avoiding these unpleasant consequences with eating um really sensitive. So that's where like. Ot and working on sensory stuff would come into really big play And then just a general lack of interest in eating. And so once you've figured out it's not anything else medical um it might be a good idea to send them to the eating disorder specialists in your area. They see kids with our Fed, sometimes they have aged limit cutoffs. Like I know we do, I think eight or 10 enough, so it can be a little tricky for the younger kids, but um okay, so uh in terms of what I do and what my colleagues and dietitians do, we usually do a thorough nutrition assessment. So if you guys in primary care had time to do a few of these questions, it could help you decide like if a feeding therapist, nutrition visit or g guy referral, something like that would be more appropriate. Um but I know that primary care visits can be really fast. You just have to cover a lot of stuff, so we're happy to help. Um So basically when I'm going through, like what they normally eat, I want to know what their meals, their snacks and the drinks are, um what's being served? And then my follow up question to, you know, oh, we have chicken broccoli and rice for dinner. Is is that also what this patient is eating? Because sometimes it's, oh well no, they won't touch it. So I make them chicken nuggets or I make them pasta because I know they'll eat it. So is what's being served? What the patients also eating? That's a really big key question. How much are they eating? And I do have a good appetite. So sometimes comparing them to siblings or if they have cousins, friends, maybe they go to school and you can ask if like the teachers feel like they eat about the same amount. Um Sometimes parents will report their kids are never hungry, they have to remind them to eat. So I like to know like how's your appetite and kind of not like a 1 to 10 scale because it's also so subjective, just kind of writing it down so that on a follow up evil, if I need to ask again and it's improved, that's helpful for me to know um If it's the same, that's also still helpful amount of time it takes to eat a meal is something that I like to ask too, because this could like red flag it for you have some chewing and swallowing issues? Um Are they really distracted? Is there something else going on? Do they just not want to be there? Is it making a two hour meal miserable for parents and Children involved? There's all this like tension at the dinner table too. Um And that kind of segues into like who's helping with mealtime. So some kids have had a wonderfully at school and daycare and then some kids don't eat it all at school and daycare um when they're eating at home, is there an improvement in their eating habits or is it worse had kids that refused to feed themselves at home and at school they're fine, they can eat on their own, but at home they know they can get spoon fed, so there are four or five year olds not feeding themselves, so that's important. Um parents versus other caregivers, uh you know, nannies, grandparents are a big one, grandparents can either be super soft and let them get away with anything and make them stop meals and snacks and graze throughout the day, or they can have them, you know, sit there until they're done with their meals and put a lot of pressure on finishing the plate. So who's in charge of most meals and how does that affect how the child is eating in terms of their picky behaviors? Um And then this mealtime habits is another environmental behavioral thing I like to check in on, So are they eating at a table if they're supposed to be in a high chair, age wise, are they in the high chair, are they sitting for all their meals and snacks? Are they having any family meals? Um Do they sit alone while everyone else is, you know, out and about family meals are tough because I know everybody has a lot going on, but if we can aim for just one a day, it's super helpful for the kids. Um Also like helps them, you know, learn good habits at the dinner table and all that. I have a slide on family meals in a second, um grazing throughout the day can be really tricky. Our kiddos who are underweight, have a lot of access to snacks whenever, wherever, whatever they want and I think sometimes we end up making them a little bit more picky by kind of just focusing on trying to gain that weight no matter what it takes. Um So we actually find that kids eat better when they have just meals set times for meals and snacks um so that they're not always just a little bit full and never have an actual hunger for a meal and last the screens and distractions at the table is big. A lot of kids that are picky or again, like underweight parents are concerned, they'll start doing screens at the table because they won't pay attention, they can feed them or they can, you know have them just take bites while they're not even paying attention. So that's something really hard. It's a hard habit to break. Um But it's important to break it because being aware of what you're eating, you know, being in tune with your body for like hunger and full cues is really important. Um But it's working with the families on which of these habits and behaviors and environments can we work on slowly changing? So I usually get like two goals at a time, otherwise it's very overwhelming. Um And picky eating takes a while to reverse if they're, you know 678 years old, it's been going on for that many years that I have to slowly undo these habits. Um And lastly I do check in on if they're drinking any supplements like Pd assures or boost. Um and if they're taking any vitamins and minerals because I want to know what the nutrient gaps are. Um So I kind of touched on this already but like waking and growth assessment I like always dietitians will always look at this of course. Um But their pressure on both ends of the underweight and overweight child so feed them as much as they want whatever they want whenever just to get them to gain weight. And then the overweight child is restrict and that can also lead to you know picky eating habits. Bad mealtime habits. Speaking of food so it's a balance. Um And then I've had patients who are able to seriously maintain their weight and growth curve on literally three types of food. Um But what are they missing? You know if it's yogurt and chicken nuggets and I don't know milk then you know I'm okay with their calcium and they probably are getting enough protein. But are they getting any vitamin C. Because I know at Oakland we've had in my few years here we've had a couple of patients with scurvy. So you know checking in on these micronutrients that we don't even think about being a possibility vitamin C deficiency but some of these kids are really severely restricted. May maybe missing something really basic like that and they won't take a vitamin they won't take a nutrition shake um So also just asking for some labs. So usually a Cbc A. Cmp and a vitamin D. Um If I'm also concerned I might ask for iron studies if they really don't have a lot of iron in their diet. And then I like sleep habits because some kids go to bed so late or they snack really late in the middle of the night and parents are confused by they won't eat breakfast or they don't take naps. And so they're really like kind of disoriented and you know they can't feel hungry and full if their whole like nap schedule sleep schedule is off. Um And physical activity if they're really active they're probably going to be more hungry if they're really sedentary they're probably not gonna be as hungry. So can we make any adjustments in that realm? And then because I'm in G. I. I have a little thing about the G. I. Work up. Um So some of these things that we see these patients come in for us obviously E. Oe like toddlers with an E. O. E. That's undiagnosed may have really soft foods in their diet and be really picky. Um Because things don't feel good when they swallow and they can't really express that to anyone pooping is a huge one. So if they're really constipated um They're not gonna have a good appetite. They're not gonna want to eat. So getting those bowel habits nice and regular can help. Um Just that alone can sometimes fix this picky eating picture because they have room to eat more things and they feel better. Um Other things we see as kids with dysplasia guard. Um Some medications or treatments for that can help vomiting can really throw kids off like if they vomited from a certain food, they may never want to touch it again because it was like very traumatic. Um Sometimes kids are unfazed by vomiting so it's kind of a wild card and then you know celiac I. B. D. G. I. Allergic disorders, anything that causes inflammation um They just might not be feeling well and they may have trouble gaining weight and there might be this push to add calories but it's not working. So just working them up for that obviously can help. And then I highlighted um I love my feeding therapist so an ot evil for feeding issues beyond you know when you've looked at the behavior and the environment there um Just asking for help with sensory stuff for mealtime habits, things like that. They're really good at working with kids on food. Chaining to get them from. You know they only goldfish, how can I get them to eat a carrot so they can work on, you know the textures and the colors and getting to that point. Um I see two questions that I'm just gonna answer before I move on. So do I encourage supplements? Like pd assuring Children who are not underweight. Um So it's tricky I think if they have super limited amounts of foods that they actually eat um I would like them to be on a supplement so that they're getting all their vitamins and minerals, they're getting enough protein, they're getting good fats. Um We think about essential fatty acid deficiency and um essential amino acid deficiency if they're really not eating a lot of foods like only two or three. Um But I have also yes, had kids do these supplements reinforced problematic eating habits. Yeah. So sometimes they may be drinking their P D'Azur all day which is essentially grazing and they're not hungry. Um So a kid on three or four piasters today could probably have a beautiful weight curve. Um And they're very well nourished and they have good nutrition status, but that's where I would turn to ot to help us work on eating these real foods because they can't be on supplements for life. I mean they could but it's not really like socially helpful and they probably are gonna get annoyed at some point and drop the pd Azur. Um So yeah, that's a really good question And then there's the question, what's the normal time depending on the age of what it should take to eat a meal and I say we typically go with what are feeding therapists say, which is about 30 minutes. Um anything longer than that and it's gonna be a battle in some way if it's parents getting frustrated, kids getting frustrated that they still have to be there um if they're not distracted and they're able to eat normally. There's no like chewing and swallowing issues. They should be okay in about a half hour. You know if you guys are having a long lovely family meal it can go longer but probably a half hour is about where we kind of cut it off. Um Good questions. So I kind of already talked about some of this with the examples I've given but you know we always look at the food groups to see if there's a protein, a whole grain fruit veggie, the healthy fats, dairy or calcium fortified dairy alternatives. Um Things we're looking for specifically it might be calcium. Iron, zinc is a big one, vitamin D. Vitamin C. For the scurvy kids and then B. Vitamins if they're not eating any animal foods at all. Um B. 12 is important. So a multivitamin is gonna cover most of those or a nutrition supplement but it just may not be doable if they won't accept the vitamin or the supplement. Um We also just check in on their hydration status. So if they're not drinking much like maybe they're only taking in eight ounces a day that could be contributing to a lot of things but like I think about constipation then you know are they not hydrated so they're not pooping well is that affecting appetite they just feel kind of crummy all the time because their stomach hurts. So checking in on that is important and I already kind of mentioned the essential amino acids or fatty acids. We've seen kids um at risk for this. We had a patient who is exclusively eating sweet potatoes and nothing else for over six months, maybe a year um for not picky eating his, it was a his mother's dietary choice of treatment. Um Anyways he was essential fatty acid deficient and we were really concerned about his demeanor acids. Um So not a picky eating scenario but it could happen right if somebody didn't have more than one food. Um And any supplementation so just just a little heads up. Um So yeah let's require a vitamin or mineral of some sort. Maybe it's just calcium, vitamin D. Maybe it's iron labs can help us decide to if there's extra needed. And I think that anecdotally most extreme picky eaters that have only a couple of foods that are willing to eat will probably require oral nutrition supplements. Hopefully they can drink it. We've had kids that needed energy or even getting a g tube to kind of supplement that. So I still this slide from iii ou talk but it does kind of give you a nice idea of like if they're not eating anything in a dairy group, what foods you know, what nutrients are they missing and what are the alternative food sources. So for a picky eater that isn't eating any dairy, you know we have all these nutrition concerns but are they eating maybe some beans or whole grains or fortified alternatives, like fortified soy milks, things like that. And if not that's when you really want to think about just referring to a nutrition appointment or you know G. I. Or someone to kind of make sure that they're not missing massive amounts of food groups and vitamins and minerals. Um So these are the resources I think most of my team and I use the same ones. So I have three. I like Ellyn Satter and solid starts and kids eating color and I'll show you guys their websites in just a second but they're really um user friendly, a lot of the materials are also available for free and then they have like purchased things as well as families really want to tackle this on their own. Um So Ellyn Satter came up with the whole idea behind the division of responsibility. So this is something that I counsel patients on all the time. So the parents are in charge of the menu. So what it is when it's being served and where so if you guys aren't eating at the table because they're having a picnic outside like that could be fun but parent decides those things, the child decides how much to eat and if they're gonna eat. So in a really picky eater, you always want to give them a couple of safety foods, So for example, like maybe they'll drink milk and you know, they'll eat noodles but you're not sure about the vegetable or the other greens that you're offering, that's okay. You know they have to safety foods 1-2, depends on how lucky you feeling they are. Um and then there's no pressure, it's there, they can eat it. You don't have to ask them if they want to bite you have to encourage it and that kind of lets them feel their hunger and full cues. But this is this is a hard thing for parents to pick eaters to get. And I totally understand because if you're worried about your kid being underweight or going to bed hungry and waking up, it's hard to say this is what's for dinner, this is on the menu. So it's tricky but it does help and then she has even more information on like going more in depth. So we kind of just talked about it, but like keeping the environment nice and pleasant, you decide what's being served, Keeping boundaries and not pressuring any sort of extra bite one more bite sort of thing. No bribing um And the child is allowed to eat eat as much as they want, enjoy. Learning to enjoy eating is a big thing for picky eaters too because if they've had a lot of pressure for negative experiences at the table, it can be an unpleasant experience for them to be even like thinking about dinner. Um And we have to trust that they'll grow in the right way for themselves and learn to behave while at mealtimes. And she has this whole thing on family meals which I think is pretty interesting, but basically there's lots of benefits to family meals beyond just you know eating and having a good variety of food and social aspects. But um you know they have more to do with raising half happy and healthy Children and income number of parents after school activities, tutors, church. I thought that was really interesting. Um As teenagers get older they have less family meals but it's a good thing to set up in childhood, so it's like a mealtime habit essentially. Um So that's just her little tidbit on family meals. Um So solid starts is another great website for families. They have a really nice app, they have a good instagram account too. Um And they're big on Baby led weaning which they have a lot of um blog posts about it and they've done some research but I think it was interesting to read that it allows the baby to control what and how much they eat, which is the same thing that Ellyn Satter pushes the division of responsibility. So instead of spoon feeding the baby that pure a's they're having more access to choosing what they pick up and they're eating and practicing. Um it's helpful for like oral motor skills and um other like um fine motor skills too. So like tongue movement, drawstring swallowing picking up things. Um And they also encourage family bills and then they also have a little post on preventing or reversing picky eating. Which obviously preventing is easier, but reversing is probably what we see more of. Um So independent eating again. Giving the child more autonomy to choose what they're eating by giving them a few safety foods. And some new foods getting messy is huge. I know this is something that parents don't love when they're starting solids but that helps with texture and sensory stuff. Um setting an eating schedule even when they're very young. Kind of sticking to it is really helpful. It helps predictability and toddlers specifically thrive on that. Um giving them a choice. I like this one because sometimes you know what you're going to serve first snack. You want a fruit and a string cheese but you're like you want an apple or a pear. And so you're still giving them the choice which helps but you're also giving them to safe foods that you want them to eat. So I like that. Um checking your emotions at the table. We talked about this in the very beginning. So bribing celebrating or you know, scolding for eating. Just try not to do it. Try to just pretend that it's just a great normal day. They're eating broccoli for the first time ever. Like internally celebrate, but don't worry about shouting it from the rooftops. Um, and then constantly introducing new foods, new textures, keeping things, you know, colorful eating with your child and then making them fun by keeping it about food. So you can do things like have them Sprinkle their own cheese or cut their sandwich into squares one day and triangles the next day. It's kind of just little fun things. And then the third website that I love is kids eating color and you can see there's like a theme throughout all three of these. It's basically boundaries family meals and you know, keeping the decisions to two things, but still offering choice, no pressure meals. Eat it when you're ready. Um, the open and closed hours for the kitchen is really nice. Some parents have to go back three or four times make different meals, snacks for this kiddo. Just trying to just stop that and you can do it cold turkey. Um, you have a couple of rough days, but it's okay. Um, sitting down to eat. It's really important. Again, parents set the menu, some food activities. Sprinkling shapes keep serving the food. So, um, families that are like, oh, they don't like carrots. They tried it once you got to try it again, it's like 10 to 20 exposures before they like, like or dislike a food. So just keep trying. Um, and then I like they have a really nice page that tells you what the food does in their body. So, you know, vitamin A. Is and carrots, it helps us see well at night, so not labeling a food is like a good for you food or a bad for your food, but like this is what this food can do for your body and kids really enjoy that. Um I like this and it's kind of a crazy concept that dessert should be served with the meal. It doesn't have to be every day, You don't have to have dessert every day, but when you do have dessert, if you serve it at the same time as a meal, kind of takes it off a pedestal of being like this really cool thing or like the pressure to finish your dinner before you can have dessert. And it works. It's weird, but it does work most of the time. Um If the kid is only eating ice cream for dinner six days a week and like it's not working, we need to adjust, but sometimes it can be really helpful. Um and then modeling the behavior. So I linked all those websites that I just talked about and then um a few of the places where I got some picky eating uh details for you guys. But yeah, that's pretty much it