Whether a child’s intake is normal or cause for concern, pediatricians who offer parents simple guidelines can help them create stress-free mealtimes and kids who (sometimes) enjoy trying new foods. In this video, pediatric nutrition specialist Nancy Matthiessen, RD, MAS, provides keys to identifying an issue, red flags for problematic feeding dynamics, and suggestions as well as resources to give worried parents. She also clarifies when referral may be helpful or necessary.
So let me introduce our speaker. We are so happy to be joined by nancy Matheson and she is one of our pediatric nutritionist. She's going to be talking. She's a registered dietitian and a certified specialist in pediatric nutrition. Um She provides medical nutrition therapy for Children with a wide variety of conditions. She's particularly has interest in caring for Children with cystic fibrosis and Children with gastrointestinal neurological diseases or disorders. Um She was just mentioning she was working with the G. I. Team today. So um she's gonna be talking about picky picky eating in the pediatric patient. And also just a reminder that you will receive your evaluations in the email in an email after the lecture. So please make sure you fill those out. That will be that's the only way that you can get credit for attending. This is if you fill out your evaluation and if you don't get those to come from a similar zoom link that you got for this lecture. If you don't receive that, please let us know we will make sure we get that to you. So I'm going to stop sharing my screen and I'm going to let nancy share her screen and you're still muted nancy's. And just so you know, oh and please if you have any questions during the lecture, put it in the Q. And A. And we will answer those questions at the end of the lecture. Alright, thank you Tabatha for that kind introduction and I'll just get my presentation pulled up here. Okay. All right are we all set. Okay. Okay great so welcome everyone. I appreciate everyone being here today. I'm going to be discussing picky eating providing guidance for families of selective eaters. Um In addition to working in the gastroenterology clinics for cystic fibrosis clinics as haven't mentioned, I do general nutrition clinic where picky eating is one of the most common reasons for referral. So this is something that I work on in families a lot. So our learning objectives today we're going to talk about causes of picky eating with specific interventions for picky eating. With a special focus on effective parent child feeding dynamics and identified Children who would benefit from referral to a specialist. And um to make note no one involved in the planning or presentation of this activity has any relevant financial relationships the commercial interest to disclose. Alright, so starting by defining the problem. So picky eating is a rather big term also sometimes called avoiding eating selective eating. And there's no consistent definition. Um You know but looking at various sources, it generally implies selectivity with food choices and or poor appetite. So amount of food. Now feeding disorder moving um to you know an increased level of severity. Um one definition given is a term contemplating a severe problem that results in substantial organic nutritional or emotional consequences equates with the avoidant restrictive food intake disorder or are fit in the d. s. m. five and it's it's understood that um feeding issues exist on a spectrum, right? With more mild picky eating issues on one end progressing towards more significant feeding disorders with more significant consequences on the other. So why is this a problem? It can have a big impact. Picky eating can impact growth with either inadequate weight gain or rapid weight gain nutrition status such as micro nutrient deficiencies. Social anxiety is actually a really significant one. Um picky eating can make it difficult for Children to eat at friends houses to eat at school, to go to sleepaway camp, to eat out at restaurants also causes a lot of parental stress, worry about their child's health and navigating their their Children's challenges with food and in turn the parent child relationship, right, this feeding is parenting and this is something families are going through multiple times a day and it can bring up a lot of conflict between parent and child. So this graphic is just giving us a sense of the scope of the problem. So over here on the right we have 25% of parents affirming some kind of feeding problem in their Children. The authors of this paper further broke that down into three different groups. There's our misperceived feeding problems where the parent um is thinking that there's a feeding issue when really maybe it's just a sort of developmental phase not actually um causing a problem. We have our milder feeding difficulties and then our feeding disorders But the point I wanted to make here 25% of Children. So this is something that we're seeing a lot. So just a few presenting features that might come up with feeding difficulties. Um Probably the most common is parent report, you know, coming into the office um with concerns about what or how much their child is eating. Others include stressful or prolonged mealtimes, lack of independent eating, not advancing as expected, with textures, reliance on distraction to get the child to eat. So, you know, parking them in front of the ipad while you spoon feed them would be an example, growth concerns or missing food groups in the child's diet. So let's explore a little bit more. Where does this picky eating come from coming from? I think it's really helpful to think about that because it helps us better understand how to respond and how to guide families. So this isn't necessarily meant to be an exhaustive list, but just some of the more common reasons. So first we have a misunderstanding of normal developmental stages. Alright, so this could be um actual or perceived low appetite, actual perceived selectivity selectivity. That means um being particular about types of foods that a child will or won't eat, perceived or actual growth issues, fear of feeding the parent child feeding dynamic and developmental differences. And we're gonna go into each of these in a little more detail. So Normal childhood development can be misunderstood as picky eating. So we're focusing in here on the early years, starting at about 12-24 months and into the third year. We see that there's this slowing of weight gain right right about here. I'm looking over here on the growth chart, we see that we go from this really steep curve to a flattening out. Okay, so appetite decreases during this time. So a child that maybe up until one years old was really enthusiastic about eating might suddenly have some meals where they're really just not that interested. Children at this time also start to develop me a phobia, resistance to new foods or even foods they previously accepted developmentally normal that can be misperceived as picky eating and appetite and food choices can during this phase can become highly variable from one meal to the next, from one day to the next. These normal developmental changes can trigger worry and parents and internally to counter productive feeding practices. This can set the foundation for ongoing feeding difficulties, right? Something that was developmentally normal. We overreact and then we actually set ourselves up for a problem. So, just looking a little bit closer at appetite. What's really interesting when this is studied is Children that are allowed to self right, regulate their energy intake. Um Well, typically have a pretty variable intake in calories from one meal to the next. You can see this graphic over here on the right um calorie intake, um going up and down. However, when averaged out over time, Children are generally really good at meeting their energy needs. Again, assuming healthy child and assuming that they're allowed to follow their own hunger and satiety cues without interference, Children who are allowed to self regulate are also more likely to grow well, you know, not growing too little or too quickly. Um, other things that can have a negative impact on appetite and actual, you know, impact on appetite are factors like grazing. So think of the kid who's, you know, nibbling on dry cereal crackers all throughout the day, excessive intake of drinks like milk, juice or other sweet drinks, constipation distractions at mealtimes were being distracted by screen, for example, or Children that would really just rather go play, they don't really want to be at the table selectivity. So again, selectivity to a certain extent is a normal part, especially of early childhood development. Um, but what does this look like? A child may eat a lot of a certain food one day and rejected the next. Anyone Neil or anyone day might not appear very balanced. But the interesting thing again, is when we average a child and take over time, healthy Children that are exposed to a variety of foods from all the food groups generally do meet their nutrition needs. There are some really interesting foundational research on this all the way back in the 1920s actually where they took healthy one year olds. Um, and they put out a variety of foods of all food groups at each meal and they really let them decide what and how much to eat out of what was provided, no interference from the caregiver. And they did these detailed nutrient analysis and it was fascinating because these Children intuitively um ate what they needed to meet all their vitamin and mineral needs, even though one day might not be very balanced now, averaged out over a week or two, They did a really good job. So what I'm trying to get out here is um parents may look at this and think that their child is picky that they're not eating a variety of foods if they're just looking at one meal or one day. Um but there might not actually be a problem. So growth can also um growth concerns can also lay the foundation for picky eating issues. So parents concerned about the child's growth that can lead to them doing counterproductive feeding practices. So for example, they might become controlling. You must eat this food right, you have to eat you know, your meat, whatever it is, you have to eat this much of that. You have to have so many bites that can even go to the point of force feeding right? And coming from a place of, you know, the parents trying to do their best for their child or it could take more of the indulgent route, right, You can have whatever whatever you want whenever you want. I just want you to eat. Understanding normal growth can prevent unnecessary worry about a child's child's eating. So we really want to help frame um growth for parents. Um And you know dispel any unnecessary worry about growth for a child. That has true growth concerns. We want to help parents understand that how we feed is just as important as what or how much the child eats. We're gonna talk a lot more about that fear of feeding can also be at the root of picky eating. So this can happen after a single event. Maybe a child chokes and after that they only want to have liquid or pureed foods for example or due to history of unpleasant stimulus from oil procedures. Think about intubation or um uh N. G. Tube placement or something like that. Um Or an O. G. P. Replacement or due to missing developmental milestones of feeding or lack of skill or experience of eating right? So think about a baby who was born with a congenital heart defect and um you know just couldn't meet their energy needs by mouth. And so they had to have tube feedings for the first year so of life. And maybe missed out a lot of those developmental windows for introducing foods and textures and advancing along with textures. Parent child feeding dynamics are a big part uh that can play into picky eating. So some red flags to watch out for high stress mealtimes um Families where there's a lot of pressure to eat, or even force feeding lack of structure with meals and snacks, just sort of eating whatever whenever um, parents making a separate meal for the child, often called short order cooking, right? I even have this picture over here that I that I found I have two titles mom in short order cook, right? So that's a red flag. You know, we want to be be paying attention to that. So this graphic is really getting into the concept of, you know, how child's feeding difficulties. Um, and a parent's response can sometimes turn into this counterproductive cycle. Alright, so we have a child that has some kind of feeding challenge um or maybe a growth challenge and we have a concerned parent, right? And from a well meaning place, you know, they're trying to find a way to help their child. Um, but they might not have information they need or the support they need to go about that in the best way. Right? Oftentimes, what we see is that worry from parent leads to more of those controlling or indulgent feeding practices. Um, pressure in particular, um, tends to lead to more resistance to eating from the child and then we can go around and round in the circle where the parent pushes the child resists and eats even less. The parent pushes more the child eats even less. Um, and that can really get us down a difficult road. Finally, developmental differences. So autism spectrum disorder, estimated prevalence of feeding difficulties in this group. Um You know, wide ranging 50 about 50% to about 90%. And most of these are selective eating issues. So particularity about what foods they eat. Some may be highly selective eaters limited to 10 to 15 foods or less. Um and have sense refuted food aversions, refusal to heat eat whole categories of food related to their taste, texture, smell, temperature or appearance. Okay, so that was just our our trip through where where are all these these problems starting? And again, not an exhaustive list, but it sort of helps us understand there's a lot of different ways um that we end up in this situation of picky eating and knowing where we came from can help us figure out. Okay, how do we help? So how do we help some of the things that we're going to talk about in supporting the selected leader, we're going to really talk about the feeding relationship. That's a big priority when we're addressing picky eating and setting that foundation of a healthy feeding relationship. And we're going to build on that with creating routine that supports appetite, creating a supportive feeding environment, um providing repeat exposures to new foods about pressure, addressing growth concerns are getting help with those oral motor difficulties. So, we'll go through those one by one. The beating relationship feeding difficulties must be conceptualized as a relational disorder between the feeder and the child and the caregivers feeding styles must therefore be incorporated into the management of these problems. Okay, so we see that how we feed is this really key part of how we manage feeding difficulties. So what are some different feeding styles? This table here is breaking it down for us, where we see um you know, we have structure versus minimal structure and responsiveness versus less responsiveness. So up here on the top left, when we have parents that are providing structure around eating and responsiveness to the child, um what we have is, you know, a parent setting a schedule for meals and snacks deciding what's offered, but then giving that child autonomy within the meal as far as what and how much they want to eat. This is the type of feeding style where Children tend to do their best with eating. Um then moving over to the right here, we have our more indulgent feeding style, so we don't have much structure here, were very responsive to the child, we give them whatever they want whenever they want without that structure. Okay, but this doesn't really allow Children to do their best with eating. Then down here we can have more, we can have structure but less responsiveness. So this is when a parent is really taking over all the jobs of what food is offered and when and what and how much that child's going to eat at each meal. So we see coercion, um you know trying to get Children to eat certain amounts or types of food and then if we have a little structure and little responsiveness, that would be a neglectful style, right? So there's no structure predictability, food may not be consistently available. So you know, sometimes we we are moving between these different categories, that's not to say that we're just in one, you know, family is just using one feeding style. Um but we can sort of recognize what those different approaches look like and it helps us um you know, to have an idea of what is going to be the most effective approach for feeding Children. So if we want to be responsive um feeders, what does that actually look like when we're feeding kids on the practical level. So this idea of the division of responsibility helps give us that practical day in day out at the dinner table guidance of how we go about feeding. So it really breaks it down into parent responsibilities and child responsibilities. Parents are responsible for when, when, when foods are offered, having a consistent meal of sorry, consistent schedule of meals and snacks and what foods are offered at the meal and then the child gets to decide what they're going to eat from what the parents have offered and how much they're going to eat or whether they're going to eat at all and what this allows us to do is it allows us to be really clear about where what what our job is as a parent and what is in our job and this can actually really decrease stress, you know once you know the parent has put the food on the table, you know they're providing these consistent meals and snacks, you know now it's their their child's turn to decide what and how much to eat, it's not it's getting away from that I have to get my child to eat and for the child it can also reduce stress right? Um Getting out of that feeling of someone pressuring them to eat instead they've got options in front of them and they can decide what and how much reducing stress is one of the really important pieces of this, especially reducing the stress for the child because we know that stress anxiety at the dinner table, those things can actually decrease appetite and make it even harder for these kids to eat. So we talked about how one of the parents responsibilities was when food is offered, right? So that's schedule. Um and this is one of the things that um in addition to being one of the parents responsibilities, we also really focus focus on because it can really help with supporting good appetite. So we're talking about semi scheduled meals and snacks that doesn't have to be a really strict meal and snack routine, you know that it has to be right at, you know breakfast is right at seven etc. Um but what we're really going for is that we're offering food about every 2-3 hours, but with nothing but water in between. This gives us time for the appetite to build so that we're ready. Um and comfortably hungry for that next meal or snack, which is gonna allow Children to do their best with eating with what and how much they eat. Interest in new foods. It also provides routine and predictability, right? So the child doesn't eat very much at one meal. They know that there's going to be another meal or snack in 2 to 3 hours. So it's, well, maybe I didn't like so much what mom and dad had for her lunch today. But you know, I know that there's that predictability of that next not coming in a couple of hours. That's also really reassuring to parents, right? And they're like, well this this meal wasn't such a big one, but we're gonna have another chance to Other things that we can do to help support appetite. You really want to limit those grazing behaviors, right? We don't want to be snacking all throughout the day. That's going to blunt appetite for meals. We want to address excessive beverage consumption as well. Right? So, so this is all familiar to you, but limiting milk 16-24 oz per day. And limiting juice and put that the ap recommendations for juice limits based on age and for a child that's really having difficulty with appetite. I would go a step further and encourage families to try and hold off on those beverages until the child's most of the way through their meal or even at the end of their meals. So not filling up on those liquids. Of course, we want to minimize soda and other sweetened drinks. And finally, one other thing that can be really helpful with appetite is treating constipation right? Because being backed up, it can just contribute to that feeling of fullness and lack of interest in eating. Alright, so, um getting into a little bit more of what our feeding environment is like in the home. Okay, so supportive feeding environment, some of the things that we want to see our family meals trying to sit down and eat together at the table as often as we can now. I know that's uh busy modern life doesn't always allow that to happen, but trying just striving to have it be something that we do when we can as often as we can. This allows an opportunity for parental modeling, right? Where parents see, sorry, Children see their parents eating a variety of foods. Research shows that Children tend to grow up to eat the food that they see their parents eating, right? So parents have an opportunity here um to lead by example and it's actually much more effective um to lead by example than it is to verbally try to push kids to eat certain foods. We want the atmosphere at meals to be pleasant and neutral, right? We want to take the focus off of the eating. Actually talk about other things, Talk about each other's day um and be neutral about what your child is or isn't eating or how much they're eating. We really want to take the emphasis off of that. There's actually a great website, I'll put a link to at the end of the talk called the Family meal Project, which gives families some ideas of how to get started with family meals. What do we talk about? What are some easy recipes that, you know, are family friendly and all that kind of thing? I want to minimize distractions, so screens, tv um tablet, etcetera um for the younger child, especially providing supportive seating. Oh, I think I actually actually advanced too soon. Sorry about that. Um my last point on this one was getting caregivers on the same page on feeding practices. So really important, right? Like if um, you know, one parent learns about these feeding approaches and and want to take a new tactic, it's really important that we get all caregivers on the same page that we're being consistent with the child and if these types of ways of feeding are going to be really different, maybe even talking to the child about it too. So they're they're prepared for some of the changes. So supportive feeding, more aspects of the supported feeding environment um is when we're actually thinking about um the food providing age appropriate foods, right? Making sure things are of a texture, um or size that it's easy for the child to handle. We really want to encourage self feeding. Okay. Um one thing that I see often with picky eaters is parents are feeding the child instead of allowing them to self feed, because they feel like this is the way they can get more food into the child. Um But in the long run it doesn't tend to pan out very well. You know, one of the developmental um tasks in early childhood as you know, is that developing autonomy, right? Um So allowing them to self feed allows them that autonomy allows them to develop those. Um Those skills of self feeding can prevent some of those power struggles between parent and child. It also gives the child the chance to really follow their internal cues and self regulate, right? We're all born with this ability to regulate our calorie intake. And as those studies I mentioned earlier showed even our our nutrient intake and as long as that doesn't get too tinkered with, we can really help Children um preserve that more intuitive sense that they're eating, we want to allow Children explore food with their census, right? So the first few times they see a food, they might not be ready to eat it yet, but they might want to explore it, right? If they got that piece of broccoli, they might want to see what it feels like when they squish it, they might want to um pull pull it apart into little pieces. They might want to smell it, they might want to put it in their mouth and spit it out again. Right? And these are all things that we want to allow them to do, because this is a part of their process of getting familiar with the new food. All these things are new to them, right? Imagine us going to a place where um there's all these foods we've never seen before, we might not want to eat a big serving of it right away. We might want to warm up to it. Um supportive seating can also actually be really helpful in helping Children do their best with eating so good, 90 degree angle for the hips and the knees and foot support, along with exploring the senses we want to tolerate, mess, right? So Children learning to eat is messy. Put down a drop off on the floor upon a bib or a smock. And and you know, really let them have that sensory exploration. Um Now, I'm gonna be talking about exposure without pressure. So, we know, repeat exposure to new foods is one of the critical things for helping with picky eating. But how we do those exposures is so important because there's so much research out there, showing that an association between pressure to eat and avoidance of eating from the child. Right? So again, we have this graphic here. So we want to routinely provide new or non preferred foods without pressure to eat them. At the same time. We want to plan our meals to include at least one of the child's preferred foods. This is important because when the child comes to the table, we want them to see at least one thing that feels safe to them. Something that's familiar, they come to the table and everything is new that can actually generate that stress response in them, right? And that blunts appetite that can make them even not want to come to the table. So we want to have that preferred food there. Um and that can reduce the parents stress too because the parent knows well I know that will at least leave the bread. Okay? So I don't have to be worried about the meeting. Nothing. And again, we want to avoid that temptation to short order cook, what will you eat? I'll go get up and make it. Um So allowing that preferred food there helps prevent that. Um, ideally we want to serve the food buffet style allow everyone to decide what and how much they want to eat from what's provided. Okay? And when we're talking about repeat exposures, we're talking about actually having the food at the table, right? Not just asking your child. Like do you want cucumbers with lunch? Do you want carrots with lunch? And they just say no, no, no. We actually want that food to be on the table. So what are some examples of pressure? Right. We really wanna recognize pressure when we see it. So here's a list of examples. So it might be saying telling the child how much is something they have to eat. You have to have three bites bribing, you know, eat your broccoli, you get dessert negotiations scolding even praise sometimes, you know, too much praise can make the child feel like they have to eat certain foods to get that praise. Um talking too much about nutrition, comparing to how other Children eat, playing games over exaggerating your own enjoyment of the food in a way that's not authentic or or force feeding all these things can be felt as pressure for Children. It can be subtle though what what is what is or isn't pressure. So this example um here um courtesy of your feeding team, which is a really helpful website. They give this example. So I made green beans with butter for lunch today, serve yourself some if you want very neutral statement, you're just letting the child know that they are available and how they're prepared and they can decide whether to eat them. The red X. Over here we have our more pressure for example, try this green bean. It's delicious and good for you. Right? So I'm telling you to eat it and then in the middle here we have this in between. My green beans are crunchy. Are yours crunchy. So you're inviting the child to explore the food to try it. Now for some kids that's gonna be a helpful comment that's going to encourage them to give it a try and maybe you know, they'll they'll like it but you're not telling them that they have to, you know, it's sort of open ended some Children however, going to experience that as pressure, right? Especially if their child has had a lot of history of getting a lot of pressure to eat. So we really want to be responsive to this child. How are they responding to it? If they look like they're responding negatively, it's causing more resistance. If it feels like pressure when you say it then that's a good Q. Two to back off. Another example of this can be the no thank you bite. Uh this is, oops, sorry I did that again. Um This is something that comes up often. You know, it's a no thank you bye to good idea or not a good idea. And again, I think it really depends on the child, right? And how they respond to it. If you're saying you know you have to take at least one bite and it's creating this huge power struggle. Tantrums, tears all this kind of thing. I don't think you guys probably not working right? Um that it's feeling like too much pressure for this child. So we want to back off. So there's lots of ways to, oh sorry. Um So repeat exposures to new foods. It may take 8 to 15 times or many more for the child to learn to like a new food. So we're really playing the long game here, exposing over and over again. And there may be foods that they never like, right? Just like for many adults or certain foods we don't like when we're doing these repeat exposures, we want to try preparing the food in a variety of ways. We can serve really small portions, right? Children might feel overwhelmed. We have a huge portion of a new food on their plate. Um And for selective eaters, we want to expect this process to be slow, right? These aren't things that generally change quickly. We really want to be playing the long game. So there's ways that we can expose beyond the table, right? Doesn't all have to be, you know, um at mealtime can be getting kids involved with cooking, with gardening, grocery shopping, going to the farmer's market, um food place. So having little um, broccoli, broccoli trees among the legos. Um But while we're doing these things, we want to keep it fun, mutual pressure free, right? So it's not like you helped me cook these green beans. Don't you want to eat them? You know, we want to we want to keep it more neutral. Um So just some examples of um you taking carrots and looking at many different ways of preparing them. So raw with dip graded into a salad cooked in soup or stir fire casserole roasted in the oven graded and added two methods pureed and added to other foods. But not secretly. We don't, we don't want to do any trickery here. So something that um I hear sometimes people say, yeah, but I feel like I hear you say that we shouldn't ride, but I feel like it works. I tell my kids, you know, eat this broccoli and you get dessert and they eat the broccoli. Um And the thing is, is it does tend to work that night or maybe a few times. But what the research is showing us is the more that we do that kind of bribing. Um the less likely Children are to accept those foods in the long term. Okay. We have, we're sending this implicit message that there must be something undesirable about this food. Um If you're having too bright, need to eat it. They actually did an interesting study with toddlers. Um, toddlers were either given broccoli and told if you eat it, you get a cookie or they were just put in the room with broccoli and allowed to eat it if they want it or not, if they didn't want to without really any kind of pressure and the Children with no pressure were much more likely to eat that broccoli on a second exposure than the kids had been bribed with the cookie. Um, you know, pressure often comes up because parents are feeling anxious about nutrition and this is true more so than ever. You know, nutrition is one of those things that's a big concern for a lot of people. And a lot of parents and vegetables are one of the most common things that they're worried about. So when I'm working with the family on this, I like to think about it as short term and long term goals. Short term. We want to assess the child's intake and ensure they're meeting their nutrient means long term though, we want to raise a child who chooses to eat vegetables of their own accord. So we want to feed in a way that supports their exploration of new foods and resist the temptation of pressure tactics. So, you know, how are we assessing for nutrient intake? So, if a child won't eat vegetables, something to keep in mind, there's other sources of some of those key nutrients that we get from vegetables, vitamin A. We can get from a variety of fruits that you see listed here, right. Apricots and and and mango. Just to name a few vitamin C. We can get from a variety of different fruits as well. Um, and if the child doesn't eat a variety of fruits or vegetables daily. They're missing both of those, those groups, then we can put in a pediatric multivitamin to cover those gaps while we work on these, while we work on building up acceptance of those foods. Um Other ones that I would screen for iron rich foods, so beans, lentils, meat, etcetera. If that's also a concern, then we can choose a multivitamin with iron. Right? So Flintstone complete centrum kids are good examples of some chewable ones. Um liquids, nova fair. Um Young multivitamin, iron is actually a decent tasting multivitamin with iron, which is a good one to know about. One thing to note is pretty much no gummies have iron in them. Okay, so there is something you're concerned about, you know, asking what type of multivitamin that child's taking is important because lots of kids do take gummies these days. Um Other things I would screen for, it would be calcium intake. So aiming for about three servings per day of calcium rich foods may be more like two for the two and three year olds. Um and you know, we have examples here what a serving of calcium rich foods would be um And again, you know, if we're not meeting those goals and it's and it's gonna be um we don't see the child making a lot of progress with increasing those foods yet, we can take the stress off by by adding in a supplement if needed. Now I realize that doing this kind of assessment of nutrient intake may be beyond what you have time for in the primary care setting. So you can always consider referral to a dietician for detailed nutritional analysis, particularly helpful if the child's diet is very limited. Um There's whole food groups that they don't eat and sometimes you can just provide a lot of helpful reassurance to the parents um to have take off some of that anxiety that they know their child's getting the nutrients that they need. So addressing growth concerns in the picky in the picky eater. So we want to set the tone for parents regarding growth um So that um you know we're not triggering them to do counterproductive feeding practices out of anxiety about growth. So we want to provide reassurance for the child whose growth is normal, especially for those whose growth is tracking at the extremes. So on the very low end of the curve, on the very high end of the curve right? We have a child who's consistently tracking um and their VMS within normal limits. You know, even if they're at one of these extremes, you know we're not as concerned for the child that does have growth concerns. We really want to help parents have a balanced view. We want them to have the long view that how we feed is as important as how what or how much that child eats, right? So um I know this is sort of a dense slide. Um The point that I wanted to make here is when there is a growth concern we are concerned about waking. Um What do we do? So the first part of this I've summarized all the things that I've just talked about so far about parent child feeding dynamics and supporting appetite and how to expose to new foods. And then in bold I've added what are some of the extra things we've added on to help with weight gain. So providing a high fat food option with each meal and snack um Using whole fat milk, keeping the milk or juice for the end of the meal or snacks they don't fill up and considering a high calorie smoothie or nutrition shake to have at the end of the day. Okay. And then for the child who is having faster than expected weight gain crossing percentiles upward again, most of the recommendations are the same, right? All the same things up here in the top. And then the special things I call out for this population is one about treat foods. So I actually encourage we incorporate those treat foods into planned meals and snacks. We don't want to make those things forbidden, which tends to make them even more desirable. Instead including them as part of an overall balanced meal or snacks puts them in their place. It takes away that forbidden fruit feeling um and having them as part of a balanced meal helps Children better regulate their intake of those. And we really want to avoid talking about weight and dieting um in these cases um there's actually um some evidence that the more we talk about weight and diet um it actually increases the risk for excessive weight gain eating disorders. We really want to support a positive body image. One thing I want to call out between these two slides is just noticing that most of the advice for patients growing too slow or too fast is the same, right? A lot of it comes back to those feeding dynamics, having having some structure with how we're feeding as well. Finally getting help for oral motor difficulties, right? So if you're noticing trouble chewing, swallowing, um gagging or any of that kind of thing. Really significant sensory issues. Like there's a whole category of textures that the child can't eat and it's really limiting the variety of foods that they can accept. A fear of eating at all. Um You know, this could be a time to refer for feeding assessment with an occupational therapist, speech, language pathologist that specializes in feeding, but even for these kids where it seems like a lot of issues sensory these feeding dynamics. We're talking about still play a really important foundational role in helping with their eating. So now a quick case study. So this is patient M. N. He was referred to nutrition clinic and otherwise healthy, three year old male picky eating. The parents concerns were his limited variety and quantity of food and they were very worried about his growth. So um information uncovered and visit parents are spoon feeding him not allowing him to self feed. Um They feel they have to force feed him to get him to eat a certain amount. Feeling like if they let him decide how much to eat, he'll only take a few bites, he won't get enough. They were having some meals that were lasting up to three hours to get him to finish his bowl of rice and meat. Um and they're really only offering him foods that they think he'll eat, foods that are familiar that he's eaten before and they described mealtimes is very stressful. His diary Calitri reveals he does eat foods from all food groups. That's great. He is drinking 8-16 oz of juice per day. Some notable feeding skills. He's been pocketing food in his cheek. He can be very slow to chew. He sometimes even vomits when dad brings a spoon to his mouth. But interesting thing was his dad says these things don't happen when it's a food that he really prefers like a cookie or something like that. It only happens when he's being fed by his parents. So looking at his growth, What we see over here is that um his weight had been tracking in the 25th of 50th. He did have this, you know, significant drop down to the 5 to 10% out and then he recovered his height is pretty consistently tracking at the 5 to 10. This one outlier. His B. M. I. Has always been normal even when he had that little drop. Remember this family was very concerned about his growth. So what did we what do we do for? Mn. So in our first visit we had to figure out where do we start? Right? We're far away from that healthy kind of feeding dynamic that I described. And so in the first visit we're trying to figure out what what's one change the family is willing to make to go in that direction. So this family was willing to focus start trying out just shortening the meal time, trying to work towards a better schedule where he's not spending hours and hours and hours a day sitting at the table. They're also willing to limit his juice and take. So both of these things were things that we're doing to help support his appetite. I visit two and three. These are the things we focused on. We did a lot of reassurance about his growth pattern because they were so worried about him not growing well in particular um height wise. That was feeling a lot of these um counterproductive feeding practices. So just really talking about how he was tracking really consistently along his curve. He was very proportional. Um And we really worked more on that meal snack schedule trying to do a meal or snack every 2 to 3 hours to reassure family that if he doesn't eat well this meal, he's gonna have another one in 2 to 3 hours um allowing him to feed himself and letting him choose what and how much to eat was was probably the hardest change for the family to make. Um They told me they would try it for two weeks. Um They were willing to do it for that long. Um We I encourage them to keep offering new foods and not just his familiar foods and I really encourage them to talk with each other the parents because not both of them were coming to the visit. We really wanted to make sure that they're talking. Um and on the same page, so he came back to visit four. He's now feeding himself. Um Family is, feels like he's making really good progress. Um They still don't think his portions are are big enough, they have this idea that he should be eating these really large portions, but his appetite is variable and we talk about how that's really normal for child, his age is sometimes he's gonna eat a lot and sometimes he's going to eat a little, so just really normalizing that and so some of those feeding difficulties he was having the vomiting etcetera have gone away. Okay. Um so finally managing the selective eater in primary care versus when to refer. So um primary care, there's minor or no growth issues. The diet includes all food groups. Maybe not veggies but at least a variety of groups. Um family is receptive to counseling on feeding dynamics and no major oral motor difficulties, you know very well may be able to manage that in primary care. Some things to consider referring out for. There are growth concerns or missing food groups, really high stress meals or feeding dynamic issues that need more counseling time than what you have available in primary care or motor difficulties, significant gi issues, complete food referral or suspicion. For some other reason the child's not eating like disordered eating. So um what I've done here on these last few sides is just summarize some of the things that were in my private slides about what are some of those key interventions to focus on in primary care. One of those being setting the tone for parents regarding growth. And I've already run through this so I won't do that again. Um And then um summarizing how, how to feed, you know, how to feed to have those positive feeding dynamics, um What to do when we're having trouble gaining weight and what to do if we're gaining too quickly. Finally, I've created a resource list of resources that you can point families to to do more reading on these topics to get more more help with specific items listed here. Um And my citations and that brings us to the end. Um Here's me and my colleague and there's also several more of us that do nutrition clinic um and information on how to refer for nutrition clinic. So with that I know I'm a little over so I will stop here and take questions. That's perfect. Thanks nancy. Um If anybody has any questions please go ahead and start putting them in the Q. And A. And we'll go over them and dr Hadley has a few already so I'll read them off to you. Um Do you have any recommendations for infant toddlers with severe with several food allergies like dairy nuts, eggs soy and calcium supplementation? Mm hmm. Yeah. Um So my first thought would be to try to find a food based um source of calcium. So with multiple food allergies something like like ripple milk. A pea protein based milk might be one to consider um for a low low likelihood for um um allergy having an allergen. Um Some kind of fortified milk that has a decent amount of protein. If soy isn't an allergy, that would be another option. Soy milk. Um Yeah yeah I mean other than that we could always go for like a liquid calcium carbonate um supplement. If if there isn't a a formula option or sorry a plant based milk option. You could also consider formula especially if growth is an issue. Um Plant one of the plant based formulas keep farms for example. Perfect. Okay the next question is also from dr Hadley. Do you have a favorite brand of multivitamin for toddlers? She gets asked this all the time. Okay. Yeah so um Flintstone complete is one of my go to ones the chewable um if the liquid is a, if there's a preference for a liquid then that nova Farum products that I mentioned is a really great one, especially if they need iron. Also child life liquid multivitamin is a good one as well as animal parade liquid gold. Those are some of the most common ones that I recommend. Thank you. Dr jen wants to know what's your week time for consultation? Oh goodness. Um I don't have the answer to that off the top of my head I can ask my managers or maybe if you could put your email address in the chat and I can circle back, it's a little in flex right now because someone come back from maternity leave so it's all sort of change actually if you let it let me know and then we can send that information out when we send a copy of your slides and the information so we send a information you can send that out to everybody so that they can everyone can get that information. Somebody was also asking if you could briefly put up the resources because they were looking for the meal family meal project so once again we'll also send out the slides so that you can have that but if you want to write them down right now um go ahead and do that. Sorry, I was trying to highlight it, but I can't do that when I'm in presenting just, I'm sure they'll be fine. You have any pearls for preteens or teens who still are picky? Yeah. So I would really get back to the feeding dynamics still, even for these older Children. So still trying to have those family meals, that's something that tends to happen less and less as as um kids get older. So still trying to have those opportunities, um trying to, you know, present again the preferred foods and non preferred foods getting them involved with cooking. Um, these would be some of the things that I would suggest really trying to avoid pressure because just like toddlers who are really trying to assert their autonomy. So are, you know, the teams as well? Next one is how do you feel about baby led weaning? And it's better to recommend no juice. Any point of allowing a few ounces. So the first question was about baby led weaning. Yeah. So I think the really um important part about baby led weaning is the fact that caregivers are encouraged to let the child decide to leave the process of what and how much they're eating, right? Um you know, whether or not you're doing, you know, the solid foods like they recommended with baby led weaning versus the pure A's. You know, like I don't know that that part matters as much with the picky eating piece of things. Um But that whole concept that the child's getting to decide what and how much they're eating is is really important. Um You can do a similar thing with puree is by putting the puree on the spoon and then putting it down and letting the child decide to pick it up and eat it. One other thing that I would add there is um you know, it can help prevent that delay progression of textures because sometimes when we wait too long to progress past Pure A's and too lumpy foods and soft table foods, we can miss that developmental window where Children learn how to handle those more complex textures. So, you know, families doing that more traditional feeding approach, we do really want to be counseling them. Once they've mastered this consistency, you want to move on to the next more complex texture. We don't want to get stay on Pure A's for a prolonged period of time. Great. Thanks. So the other question is, isn't it better to recommend no juice. Any point of allowing a few ounces. Yeah. You know, certainly, you know, juices is not necessary, right? Um We can always counsel and eating eating fruit instead. I that that's something I individualize based on the family I'm working with, you know, depending on, you know where our priorities are for making changes. Um But yeah, certainly juice is not necessary. Okay dr keith says um I find family dinner can be counterproductive for kids under five as the meal is served too late. Kids have been given snacks to hold them off and then they aren't hungry. How would you advise? Uh Yeah, that's a great question. So um trying to have like a well timed snack, right? So this is going to depend on every family's schedule, but trying to have a well timed snack about two hours before whenever dinner is going to be, um and then having a good break to allow them to get hungry again. Great. Um what do you think about toddler formulas? Like Neto vs regular milk after 12 months? Um I would encourage doing regular milk if at all possible. Um I think that what tends to happen sometimes with the toddler formulas is um I tend to see a lot of that grazing behavior. They're continuing to drink them from a baby bottle there, sipping on them all throughout the day and it can interfere with appetite. Okay, thank you. The next one is if you have the dessert that you said your child will get as part of the meal, but then they refuse to eat the meal. How would you approach this? I wouldn't make the dessert contingent upon eating the meal, right. Um I would have the dessert be an option whether or not they ate their food, right. You don't want those two things to be connected, but they have to eat the food to get to the dessert because then again you're sending that implicit message that the dessert is the more desirable thing and the meal is the less desirable thing. Great thank you. Um I think we already answered this question. What do you think? Oh that's the one uh for a child who does not drink any milk, calcium supplement recommendations, what brand and does do you recommend? Okay. Yeah. So depending on the age um there's there are liquid options. Child life I mentioned earlier also has a liquid calcium supplement. Um Or you know you can order a calcium carbonate suspension. Um Or for older Children there are calcium chews by active. This one um That tends to be pretty popular too common caramel or chocolate flavors. Um Or you know if the child's fine um swallowing a tablet there's a variety of you know over the counter calcium carbonate or calcium situates. Supple supplements. That would be fine. Okay thanks nancy. Okay the next question is does car box iron absorbed well enough in vitamins? Car box cell iron. Um I don't know enough about that one to answer. I apologize. What do you think of PD azur for kids not eating a lot on less than 5%.50% of weight. 5th%ile of weight. Sorry? Yeah I mean I think Pd Ascher can be a tool. I think we have to be really careful about how we use it. Right? So for introducing Pd Azur I counsel parents on you know um you know try giving it at the very end of the day after they had all day to eat food. And um so that the Pd Azur isn't interfering with their appetite or if they are using it during the day serving it towards the end of meals. Like like maybe having um four ounces of Pd Azur at the at the end of breakfast at the end of lunch or something like that so that they still have a couple hours to digest before their next meal because we always wanted to be an addition to what they're eating and not replacing the food that they're eating great. Thank you. And last question, what is the main difference of toddler formula and infant formula in terms of nutrients, how long can a child have infant formula for past one year if needed for growth or dietary constraints. Yeah. So um tell their formulas generally don't have um This is quite the same. Micronutrient profile is one of the main differences there more meant as like a supplement to um the toddler's diet and not a sole source nutrition. They're not designed for sole source nutrition. Um So that would be the big difference between the two and they also tend to be sweeter, right? Um Whereas formulas are unflavored. Some of the toddler formulas are more or more sweet. Um And how far past a year within formula. I mean there's not really like a hard, hard cut off their um You know, going going a few months, even up to 18 months, you know, on infant formula would be fine. We had one more question come in. How much time do you give to finish a meal? I I generally recommend that we're working towards the 20 or 30 minute long meal clinic and that's it. Okay? So I just wanted to say thank you to everybody for joining us today. Um Please don't forget to fill out your valuation forums. They will come in an email from you from us. So look out for those. If you don't get them, please contact your physician liaison and thank you so much nancy for joining us, we'll make sure everybody gets your slides. So if you have, if you wanted to get those, they will come to you with your credits. So thank you so much. Have a great afternoon, everybody. Thanks nancy.