Food Chaining

Introduction

AS PARENTS, WE face many difficult challenges as we try to raise happy, healthy children. One of the biggest challenges is helping our kids learn to be good eaters. We all want our kids to eat nutritious foods from a wide variety of sources in the proper portion sizes. We do our best to prepare appealing and well-balanced meals for our kids and show them how to make smart food choices. But eating the right foods, or even eating at all, is not so easy for some children. Between 25 and 35 percent of children in the United States are considered picky or problem eaters. This statistic becomes even higher—between 40 and 70 percent—for children with chronic medical problems. Parents are often told, “It’s just a stage, he’ll grow out of it,” or, “He’ll eat if he gets hungry enough,” but picky eating and problem eating, also known as feeding disorders, are serious concerns. They can cause medical problems such as malnutrition, frequent illness, and congestion. They can affect your child’s development in areas such as growth and weight gain. They can negatively impact your child’s behavior. Feeding disorders can also interfere with his social skills and his ability to concentrate and learn at school.

Your child isn’t the only one affected. Living with a picky or problem eater is stressful for the entire family. “Every meal is like a battle. I constantly try, but my son won’t try anything new or eat any food that isn’t on his list of favorites. It drives me and my husband crazy, and we often wind up taking out our frustrations on the kids. The whole family is usually miserable by the end of each meal,” says Jill. Many parents report extreme stress at mealtimes. Problems with eating often start in infancy, and these problems must be faced multiple times every day, with every meal. So it’s no surprise that mealtimes can become anxiety-driven experiences or constant battles that involve everyone at the table. You may be feeling anxious about your child’s nutrition and growth. You may feel angry and frustrated by the way he’s behaving. You may be having doubts about yourself or your parenting abilities. You may even be feeling depressed about your child’s situation and your apparent inability to fix it. These negative feelings can easily spill over into other areas of your life, such as the workplace or your relationships with others. Your relationship with your child may also be suffering. Feeding problems can cause children to withdraw or act out. You may find that you’re constantly arguing with your child over eating and the way he’s behaving. One mother told us that her child’s feeding problems made her life feel like “a train that has derailed.”

Siblings are also affected by the stress of living with a picky or problem eater. Some parents (understandably so) spend so much of their time and energy focusing on getting their child to eat or managing his behavior that the needs of their other children get overlooked. It’s so easy to become angry and frustrated by their picky or problem eater and unconsciously take that stress out on the rest of the family. Meals and family time in general become unhappy and toxic for everyone.

You may find that your relationship with your partner is suffering, as well. The constant stress caused by your child’s feeding problems can create tension between you. You may not agree on the right way to handle mealtimes with your child or the best way to manage his behavior, which can lead to arguments and bad feelings.

Clearly, picky and problem eating are major issues that affect a huge number of children, yet they are still widely overlooked problems in the medical field. A child can be at an appropriate weight, but poorly nourished. Many picky and problem eaters appear well nourished and thrive despite their feeding problems (some are even overweight), which can make health-care practitioners reluctant to address the issue. It’s not unusual for health-care practitioners to tell concerned parents that their children will “grow out” of their feeding difficulties. Many times this is simply not the case. Based on our experience as a feeding team and as medical professionals who work with children, we can tell you that your child’s eating issues will probably not resolve themselves on their own, and it’s unlikely that can you solve this problem without help. Feeding issues are very complex—they can have health-related, physical, sensory, or psychological causes, or a combination thereof—and it takes the expertise of several different types of medical professionals to determine the nature of your child’s problem and design a treatment program for him. Food Chaining will help you navigate this process so your entire family can live happier, healthier lives.

IS YOUR CHILD A PICKY EATER OR A PROBLEM EATER?

Sometimes it can be difficult to tell if a child is a picky eater, has a more serious feeding problem, or is just behaving as normal children do when it comes to food. Most parents expect a certain amount of resistance and fussiness from their kids over food and mealtimes. For your convenience, we’ve listed below the criteria for normal, picky, and problem eaters. This will help you differentiate among the terms and determine into which category your child falls.

NORMAL EATERS

Following is an at-a-glance guide to normal eating behaviors and skills for newborns through age two.

Newborn Baby to Three Months A typical newborn baby consumes 2 ounces (or 60 milliliters) of formula in as little as about 5 minutes up to 20 minutes. At this age, your baby may not completely coordinate sucking and breathing at first.

Three Months At this age, your baby should sequence 20 or more sucks from the breast or bottle, and breathing should follow sucking with no pauses when he is hungry. Your baby should be able to coordinate pauses for breathing. You may observe an occasional cough if his coordination of the suck/swallow/breathe sequence becomes irregular. He still does not have the skills to start baby food.

Four to Six Months Now your baby should use long sequences of sucking, swallowing, and breathing when breast- or bottle-feeding. His tongue should show an extension-retraction pattern of tongue movement, or a forward and then backward movement. If you start your baby on a spoon now, he is likely to push it out due to the continued presence of the tongue protrusion reflex. It is best to wait until closer to six months to introduce a spoon.

Cup Skills Many parents are instructed to introduce a sippy cup to their child at age six months. However, this does not mean that your child should be expected to take all liquids by cup. Some children do not demonstrate good cup skills until 9 or 10 months of age, and still others don’t become adept at cup drinking until 12 to 15 months. Your baby may continuously suck liquid from the cup and then have periods of uncoordinated swallowing. He may lose much of the liquid while drinking. Larger mouthfuls may result in choking or coughing.

Six Months At six months your baby should develop a more mature sucking pattern. His jaw movement should decrease and his lips should more firmly surround the nipple or spoon. Your baby is now ready to accept thicker consistencies of food. His tongue protrusion reflex should be integrated, and he should no longer push food out of his mouth with his tongue. When eating meals, your baby may need more support for his body, such as rolled towels wedged on either side of him when he’s seated in his high chair.

Nine Months At this age, your baby should exhibit long sequences of continuous sucks when cup drinking, though he may still have coordination issues with the cup. Usually at this age babies can take three sucks or so before pulling away to breathe. When spoon-feeding, you may see a munching style (up-and-down sucking pattern) on the spoon, but a more mature pattern of chewing should be emerging. You may also see his tongue protrude between his teeth or gums. He should be stable while sitting by this point and no longer need additional support for his body.

Nine to Twelve Months You may still see occasional mild coughing when your baby drinks from his cup. He should be able to lateralize his tongue more efficiently now (move it to the side of the mouth). He should be able to take a controlled bite of a soft cookie. He may suckle on a harder cookie or food to soften it prior to taking a bite.

Twelve to Fifteen Months At this age, your baby should have a well-coordinated suck/swallow/ breathe sequence, and only rare coughing or choking spells should occur. Your baby should be able to suck food off a spoon. Your baby should be developing a pincer grasp and beginning to master self-feeding. He should be able to hold his own cup. Your baby should be able to handle a variety of textures of food by age 15 months.

Eighteen Months You should no longer see an extension-retraction pattern (a forward and then backward movement) of your child’s tongue with a spoon. He should have a more mature pattern of chewing where food is pushed from the tongue to the biting surfaces and moved back to the tongue to prepare for swallowing. Your child should have good lip closure while chewing and not lose food when eating. He should be able to take a controlled bite of a hard cookie. You may notice that your child moves his arms or legs while biting or tips his head back slightly to assist with the bite. At this point your child should have excellent hand-to-mouth skills and may be able to drink from a straw.

Twenty-Four Months Your child should be able to drink well from a cup or straw. He should be able to skillfully swallow a combination of food textures. He should exhibit controlled biting patterns and be able to keep his head in a midline position while biting into food.

Children Over Age Two Your child should continue to improve and refine his eating skills during the years of early childhood. He should master the ability to manipulate all types of food easily in his mouth and develop very sophisticated chewing skills by age six. By this point, your child should be able to eat even the hardest-to-eat foods, such as taffy and all types of meat.

Picky Eaters

• A picky eater is very selective about what foods he will eat.
• A picky eater accepts 30 or more foods.
• A picky eater will want to eat certain foods for many days at a time.
• If a picky eater tires of a food and stops eating it, he will usually accept the food again after a break from eating it.

Picky eaters generally don’t have a medical condition but they may have had reflux as an infant or a milder underlying sensory issue that prevents them from eating certain foods. They often become picky because they’ve been exposed to only a few foods and have developed food preferences based on a cycle of limited exposure. However, picky eaters can experience true distress at meals as well.

Three-year-old Emma is a good example of a picky eater. Her mother, Cara, says that Emma ate very well during her first year of life. She ate all her fruits, vegetables, and meat baby foods until she was well past her first birthday. When she was 15 months old, her mother tried to transition her from stage III baby foods to table foods. (Babies foods come in stages based on a baby’s age and eating abilities. All babies begin at age four to six months with stage 1 foods, which are single ingredient foods like rice cereal and pureed fruits and vegetables. At seven to eight months of age, babies begin eating stage 11 foods, which consist of single ingredient and combination foods that are strained instead of pureed. At nine to twelve month of age, babies are ready for stage 111 foods, which have more texture and contain chunks to help encourage chewing.) Emma slowly made the transition, but she was very selective with table foods and would only eat particular brands or food from particular restaurants. One day Cara offered Emma macaroni and cheese, which she ate very well, and Cara was thrilled. For a long time after that it seemed that macaroni and cheese was the only food Emma ever wanted. Then one day she stopped accepting it and refused it each time it was offered. Cara says that this became a pattern with Emma. She would eat one “favorite” food for a long time and then reject it. Emma eventually tried the food again, but it never again became the favorite food it was when she first accepted it.

Problem Eaters

• A problem eater accepts only a few foods, usually fewer than 20.
• A problem eater may have a strong phobic reaction to new foods. He may cry, throw a tantrum, gag, or vomit when a new food is offered.
• A problem eater may not even be able to touch new foods.
• If a food is rejected after eating it for an extended time, a problem eater has a hard time accepting the food again.
• A problem eater may reject entire groups of food (i.e., he won’t eat any vegetables or any fruits at all).

Problem eaters usually have some type of medical condition, such as GERD (a condition where a child experiences recurrent vomiting or spitting up as well as other possible symptoms, which are discussed in chapter 1) or oral motor skill problems, that prevents them from eating certain foods. A problem eater may also have a sensory processing disorder or food aversion, meaning they may gag or vomit at the sight or touch of food.

Two-year-old Jack is a good example of a problem eater. His mother, Amy, says eating has always been difficult for Jack. As a baby, he had to work hard to finish his bottles. He struggled with the transitions to spoon and cup. He never seems hungry. He doesn’t appear to have a choking problem, but he never seems to enjoy eating. Meals are always a struggle. Every new food Amy offers seems to cause Jack distress. He appears to be almost afraid of food. After Jack moved to table foods, he became more and more selective, and now his diet consists of only five “junk” foods. Amy is very worried about nutrition because Jack will not eat fruits, vegetables, or meats. Each time she offers these foods, Jack gags, cries, and refuses to eat.

Regardless of where your child falls in the categories listed above, if you find yourself short-order cooking for your child, if food items are dropping out of his diet, or if mealtime battles are a regular occurrence, it’s time to discuss these concerns with his pediatrician and have him evaluated.

HOW TO USE THIS BOOK

We wrote Food Chaining as a tool to help as many children with eating problems as possible. In order to do this most effectively, we have detailed how the food-chaining program works in its entirety. Not every child will need to see every health professional or go through every step that we describe in this book, but some will. For instance, kids who have a milder picky-eating issue may not need to see a nutritionist. Kids who suffer from a feeding disorder caused by a medical condition may not need to see a behavioral psychologist. On the other hand, a child with a serious feeding disorder will almost certainly need to follow every step in the food-chaining program. It will be up to you and your child’s pediatrician to determine the extent of your child’s program based on his needs. Regardless of where your child falls on the spectrum of eating problems, there is valuable information in each of these chapters that will help you understand how your child interacts with food, as well as strategies to help him become more comfortable with food and improve his diet.

As eating problems can begin at any age and last indefinitely if left untreated, Food Chaining is designed to help children from birth through early adulthood. If you have an infant less than one year of age, he may qualify for the pre-chaining program we describe in chapter 7.

Food Chaining was written specifically for the parents and caregivers of picky and problem eaters. However, the information and strategies offered in these pages will also be helpful for parents who wish to help their kids avoid potential feeding problems and medical professionals who work with children with feeding problems. Though we’ve kept our use of medical terms to the absolute minimum, you may come across some that are unfamiliar to you. For easy reference, we’ve provided a glossary of these terms and they are printed in boldface the first time they appear in the book.

WHAT IS FOOD CHAINING?

Food chaining was created by Cheri Fraker in the course of treating an 11-year-old boy named Eliot. Eliot’s problems with food started at age 18 months, when he began demonstrating a pattern of picky eating, and more and more foods dropped out of his diet. By the time he reached childhood, his diet consisted only of peanut butter, white bread, and large quantities of milk. He refused to try any new foods, and was very sensitive to the smell of meat.