Picky Eaters and Problem Feeders … Meal time challenges

Julie Albrecht Consultant Accredited Practising Dietitian

Meal times can often be challenging for families, with a large number of parents indicating that they often feel, “ stressed out” during their child’s feeding time, indicating that their child is a picky eater and difficult to feed (1).

The reasons why children don’t /won’t eat could be physical, including pain, malaise/discomfort or as a result of immature motor, sensory – motor, oral motor and or swallowing skills. The most common medical diagnosis associated with these problems is GORD, followed by neurological, cardiopulmonary and food allergy/intolerance, and constipation. Children also won’t eat as a result of behavioural, emotional and learning difficulties, encompassing child/parent/environmental factors (2).

Eating is the most difficult sensory task that children do and only the body’s third priority after breathing and postural stability. Eating is instinctive for the first month of life, where appetite drives intake for the first 4 – 6 weeks. From one to six months of age eating is reflexive and after this point it is a completely learned behaviour (2).

The sensory process associated with eating is complex and begins with sensory integration, which encompasses 6 major sensory components, including tolerance, interaction, smell, touch, taste and eating. Eating involves between 25 – 32 steps on the Steps to Eating Hierarchy, from tolerating a food to chewing and swallowing it (2).

As eating is a learned behaviour the development of this skill requires practice and experience. The developmental progression in learning to eat various textures requires both oral – motor functioning and sensory processing. A developmental food continuum should be as follows (2).

FOOD CONTINUUM

Breast / Bottle Thin Baby Food Cereals Slightly Thicker Baby Food Cereal – mixed with  a Thin Baby Food Puree – Stage 1 Thin Baby Food Purees – Stage 1 Thicker Baby Food Cereals and Thicker baby Food Smooth Purees – Stage 2 Soft Mashed Table Foods and Table Food Smooth Puree Hard Munchable		Birth – 13 months 5 months 5.5 months 6 months 7 months 8 months 8 months
Meltable Hard Solids Soft Cubes Soft Mechanical – single texture Mixed Texture – cube and puree Soft Table Foods Hard Mechanicals		9 months 10 months 11 months 12 months 12 – 14 months 16 – 18 months

One of the exciting steps in this development is the beginning of food exploration and the introduction of HARD MUNCHABLES. Chewing these hard stick shaped foods, moves the gag reflex to the posterior third of the oral cavity, providing practice for the child to move hard solid foods in their mouth, teaching lateral tongue movements. It provides jaw strengthening opportunities and works on kinesthetic awareness in the mouth. Hard munchable foods include raw carrots and baby rusks. The introduction of HARD METABLE FOODS, encompasses the next stage of the child’s development. These foods have a well defined texture to their exterior, though melt in the mouth. The next foods are the SOFT CUBES, like banana and soft cooked vegetables. SOFT MECHANCIAL -single item is the next step and includes food like bread, pasta and processed meat. This is followed by SOFT MECHANICAL – mixed, includes more than one texture – like macaroni cheese. The final two steps include SOFT TABLE foods and lastly HARD MECHANICALS – simple, including sausages, chicken, steak, toast and crackers (2).

Children need social modelling to support their development of eating skills. Ideally this should encompass family meals where the adult provides modelling for good feeding behaviours, where the food not the child is the focus and the food is fun. Research by Ventura and Birch revealed that the higher the level of parental pressure to eat is associated with lower levels of child intake and weight and higher levels of rating of child “pickiness”. Being rewarded for eating food, that is getting dessert leads to less liking for that food. They also identified that restrictive feeding practices can increase the intake of and preferences for, palatable foods and increased eating in the absence of hunger (3).

When feeding times get difficult, often distraction is used by parents to assist in getting their child to eat. Unfortunately, this method is counter- productive, as the child lays down brain pathways for the distractor – toy, television and shifts into reflexive eating mode. The child does not lay down pathways to eating, in essence they are not learning how to eat when not distracted (2).

Children also benefit from structured meal and snack times. This encompasses a designated place to eat, a routine to meal and snacks - notification of meal time; transition activity; sitting at a table; serving; eat; clean up; presenting foods in manageable bites and a base structure of 1 protein food, one starch and one fruit or vegetable. Length of meal time is also important and should be between 15 – 30 minutes. Allowing the child to graze at food, eating sooner than every 2 – 2.5 hours results in the chid consuming just enough food to take the edge off the hunger and then move off to do another task. The child then has little motivation to explore more difficult foods and may consume up to 50 % fewer calories in a day, in comparison to eating to a schedule (2).

Offering children a variety of food at a young age is important and a high percentage of food preferences are formed as early as 2 – 3 years of age. Food jags, is a term given to the eating pattern, when the child consumes the same food prepared the same way every day or at every meal. Children eventually burn out of on these foods and these foods may be lost permanently from their food range. The goal is not to offer the same foods the next day, or the same food prepared the same way (2).

All of the above raises the question of what can families do to develop their child’s eating skills and food variety and overcome picky or problem feeding. In August 2009 I attended Picky Eaters vs Problem Feeder: The SOS Approach to Feeding Workshop conducted by Dr Kay Toomey and Dr Erin Ross in conjunction with the Children’s Nutrition Research Centre. The SOS Approach to Feeding encompasses a Sequential Oral Sensory Approach to assessing and developing children’s eating skills. I am now trained and authorised to conduct this program and have been implementing components of the program with children and their families. The practice is also considering developing a multidisciplinary clinic – focusing on children with picky eating or problem feeding. The SOS Approach provides a structured program which results in positive outcomes. If you would like more information, please contact the writer.

References:

1. Lewinsohn, P., Denoma, J.Gau.,Joiner, T., Striegal-Moore, R., Bear P.,Lamoureux, B., (2005). Problem Eating and Feeding Behaviours of 36 moth old Children. International Journal of Eating Disorder,38(3), 208 - 219
2. Twoomey.K., and Erin Ross., Picky Easter and Problem Feeders., Workshop., Brisbane 2009.
3. Motion, S., North K., Emond. A, and the ALSPAC study team. Persistent Early Feeding difficulties and development Outcome. Ambulatory Child Health. 7, 231 - 237(2001).