Because we talk about healthy and unhealthy things at home a lot, he agreed to eat some broccoli (bear with me, folks – this green food took over 5 years to happen. It was not easy and I consider it a huge victory that will likely be short-lived).

My daughter refused all the broccoli and all the fruit. Not havin’ it.

My son ate 3 pieces of broccoli, two bites of neon orange, licked every ranch molecule off the plate, and then asked for the 4-month-old Oreos in the pantry.

Yogurt ranch for the win.

They both drank milk. Score. Protein.

Dad worked late. Two working parents. We didn’t sit at the table together today.

There was a lot of talking and distraction by: counting to 100, temporary tattoos, our cats howling, and arguing about what 6+6 equals (9, in case you didn’t know). Also someone threw a strawberry and someone cried because there was no “real dessert”.

Even your pediatrician worries about her kids’ nutrition, and even your pediatrician doesn’t follow her own rules sometimes. And this picture doesn’t represent what my kids actually got in their stomachs. And every meal looks different at my house.

I used to be that childless pediatrician who always said, “I’m never gonna have the kid that only eats a couple of things! My kid is going to eat a wide range of nutritious foods! I’m a pediatrician, for crying out loud!”

Then God and Mother Nature got together and decided I needed to be taught a lesson, and gave me my firstborn child. Cue the Uncrustables.

There is no topic I talk about more in my office than picky eating. Well, maybe poop. But seriously - you’re all worried about it. And you should know that you’re not alone.

GENERAL INFO:

• Picky eaters are often children who are sensitive to their surroundings, to tastes, and to textures. Some are anxious kids in general. Some have sensory problems and are sensitive to other things like loud noises, certain smells or how clothes or shoes feel. Some are children on the autism spectrum. These kids may have heightened awareness of these senses, thus making new foods a challenge.
• Most kids who are picky are “just normal kids” though.
• The majority of kids I see who are picky will grow up to be TOTALLY NORMAL AND FUNCTIONAL EATERS (shout-out to my sister Christina who used to only eat cereal and Fritos as a kid and who now makes quinoa and kale salads for fun.)
• Picky eating may be pre-programmed in us. Think about it. Maybe we are avoidant of bitter things (like some vegetables) in our youth in order to self-preserve? Caveman toddlers needed to know to avoid the poisonous plant or fruit, which often had a bitter taste. This might be a partial explanation for why so many kids are picky.
• It is very normal for children, especially toddlers, to only eat the same thing for awhile. My daughter lived on blueberries and yogurt for a solid two weeks once, even though other things were offered to her.
• It is very normal for small children to only eat a few bites of food some days, and eat giant meals on other days.
• Milk is a great source of protein for picky kids. An 8 ounce glass of milk has 8 grams of protein in it. Try to keep it below 20-24 ounces a day for your picky eater though. Kids who just depend solely on milk for nutrition and avoid other foods can get anemic.
• Giving your picky kiddo a multivitamin with iron daily is a great idea. It's not gonna be as good for them as the nutritionally dense veggies and fruits are, but it won't hurt.

WHEN DO I WORRY?

• If a child completely refuses an entire food group, I worry. If they shun all dairy, I worry they won’t get enough calcium for their bones. If they refuse all fruits and veggies, I worry that they’re gonna get constipated or have a nutritional deficiency (these typically only develop in the most severe cases and over the long-term).
• If a child is extremely picky and is a very small kiddo, I worry.
• If they are losing weight, I worry.

Most picky eaters are your run-of-the-mill “chicken nugget and mac and cheese” type. They gag sometimes with new foods, and often don’t want to stray from the 10-15 foods they’re “OK” with. The majority of your kids will fall in this category.

But some kids are extremely picky. These kids may have something called Avoidant Restrictive Food Intake Disorder (ARFID). The diagnostic criteria are here.

If your child meets any of these criteria, it’s best to talk to your pediatrician. Your kiddo might need therapies that can help with introducing new foods and could benefit from seeing a nutritionist as well to assure they’re getting the nutrients they need.

“Children Will Eat If They’re Hungry”

Yes, this is true. When I moved dinnertime from 5:30 to 6 p.m. in my house, there was a noticeable difference in how much they ate and how little they whined for snacks later on in the evening. But remember the other things that fill our kids up – sometimes that little handful of Goldfish crackers an hour ago was all that was needed to keep their dinner hunger cues away. Sometimes a cup of milk before the meal will cause lunch to end in a meltdown. Snacks and milk are fine if your kiddo needs them and is an easy eater, but I just wanted to open your eyes to how easily a picky kid’s hunger can be satiated so you can better understand the food refusal.

Healthy portion sizes for kids are typically much smaller than parents may think. Protein should be the size of a child’s palm (meats, fish, beans). Veggie/fruit portion – what they can grasp with two fists. Pasta or bread? One fist. This may change depending on a growth spurt or more hunger that day due to exercise. But it illustrates how little they may need sometimes. 4 green beans. 2 apple slices.

Kids are very good at knowing how much food they need to eat. In fact, they’re better than us at it. You put me in front of a box of donuts and I’m gonna eat way more than I need because…donuts. Small kids are great at stopping when they’re done with being hungry. They don’t loosen belts or overstuff themselves. In fact, I often guide older, overweight kids to watch their younger siblings when they eat – small kids usually stop eating when the hungry goes away, not when they feel really full.

Along those lines, don’t force kids to “finish your plate.” In a day and age when kids are bigger than ever, this is just antiquated and unhealthy. Give them small portions and allow for seconds if they’re having a hungry day.

Dips. Sauces. Do it. It’s fun, and different. Use Greek yogurt to make the creamy ones. Throw onion soup mix in there, or a ranch spice packet. Try hummus. Try salsa.

New illustrated plates. Fun spoons. Twirly straw for that veggie-packed smoothie. Kids love special stuff like that. And might be more willing to try something new if it’s fun.

I know it’s enticing, but try not to use dessert as a “reward” or “bribe.” It sort of sets the stage for associating sweets/treats with success. And we’re reinforcing that what was on the dinner plate isn’t as good as the dessert.

Again, remember that some kids do sit on the edge of the eating spectrum in the “severe” zone. ALWAYS talk to your pediatrician if you feel like your kiddo might be really struggling. If he’s small, eats fewer than 5-7 things, throws up and gags on a daily basis, or has very high anxiety with food, ask for help! Feeding therapy is wonderful. Our dietitian and nutritionist friends are so helpful to doctors and parents alike. We can get through it together as a team!

I barely scratched the surface here. Please speak up in the comments if you have any other advice or ideas!

Lettuce romaine calm,

Dr. Diane Arnaout

In cultures around the world the norms of infant feeding vary. In France the baby may start on broth, in Japan rice porridge and fish, in Argentina puréed vegetables. In the U.S., rice cereal flakes and jars of purees were the starting place for years.

Baby-led weaning came about as an alternative to the long time use of rice cereal and jarred food.

The idea is to let your baby feed herself food that she can pick up at independently at mealtimes with the family. There is a lot of good in this – the baby is part of the family meal, she is not limited to bland purees. The goal is for a toddler who eats a variety of foods – it is meant to combat picky eating. Does it work? The answer is – sometimes.

Many babies that eat a wide variety of foods at 1 year still go on to be "picky" eaters in toddlers. This can do with the toddler wanting to be in charge, or on the go or just that toddlers are growing more slowly than infants and so don't eat as much food.

When I talk to parents about infant feeding I advise a mix of purees and baby-led weaning style feeding. A baby can be fed both ways. I like offering pureed or smashed cooked vegetables as early as 5 months of age.

At this age babies are open to new tastes and it is a time for fun and trying foods like squash, green beans, sweet potatoes and avocado. If your baby loves it, great, then offer tastes 1-2 times per day at family meals. If your baby isn't interested that is OK. It is not for nutrition yet.

Once your baby is a strong independent sitter, usually around 7 months old, then add soft solids that your baby can try to pick up and feed herself. You can still offer purees with meals. Don't worry about feeding soft foods made with some spices or olive oil--flavor is good. Feed your baby soft bits of what you eat – soup, soft noodles, pieces of soft fruits and vegetables. Be creative – hummus, mild guacamole, stew.

Finally, start offering water at meal times. Teach your baby to drink water with meals, nothing sweet is needed – no juice.  

Using pureed vegetable and fruits together with baby led weaning is my favorite way to start your baby on solids – but not the only way.

But do they feel welcome at your table?

Just like my patients' moms I have lived all of the small daily rituals, frustrations and love that is being a mom. I know that it has made me a better pediatrician and will continue to do so.

I am a better pediatrician because I have experienced life as a mom. I know the tears and tiredness of a new mom and so when she cries at the new baby check I can tell her it's normal and she believes me. I have lived with picky eater and so can give realistic plans for parents to overcome it. Siblings fighting is a weekly event in my home and so I can help with strategies for everyone to get along. I have seen my child limp for days and wondered if it is some terrible illness and so when a mom brings in her child with leg pain I understand what her deepest fear is.

It is all of these and the hundreds of other mom experiences that give me empathy for the moms of my patients. It has made being pro-mom one of my overarching themes in practice.

Remember, on Mother's Day to go and look at your children while they are sleeping. It gives you an immediate feeling of love and peace. Thank you to all the moms that trust me to care for their children.

Happy Mothers Day.

Dr C

You may be thinking, “Am I the only parent in town dealing with dinner drama every night?”

The answer is no. It is reported 25 to 45 percent of typically developing children experience feeding and swallowing problems, while a staggering 30 to 80 percent of children with developmental delays struggle with mealtime (Arvedson, 2008).

Now for the million dollar question: what causes feeding problems? There are several factors that can impede a child’s ability to develop a happy, healthy relationship with food, including: sensory processing disorders, gastrointestional complications, prematurity, and dysphagia.

Food should be fun. And for most of us, it is just that. But children may not see eye to eye with us when it comes to mealtime, causing this to become a stressful time for the whole family. Little ones can be incredibly stubborn when it comes to food choices.

Most parents have described their children as picky eaters at least once or twice. However, it is important for parents to know the difference between “picky eaters” and true problem feeders and when to seek assistance.

Picky eating can be a typical stage in normal development. Ready for the skinny on picky eating?

A picky eater will typically:

• Accept approximately 30 foods. That may sound like a lot, but it’s really not.
• Tolerate a new food on his or her plate and may even taste it once or twice. This new food may become a new favorite. But then again, it might get tossed on the floor. This truly depends on the child’s sensory reaction to the food in question.
• Eat meals with his or her family, but requires different preferred foods.
• Eat only one food from each food texture category (puree, crunchy, solids,etc).
• Consume one preferred food consistently, and then suffers “burn out” and refuses to eat this food for a period of time (picky eaters will usually begin to accept this food again after a brief break).
• Eat new foods after frequent exposure.

So, how can you nudge your picky eater toward the leafy greens and save your sanity? Here are a few simple suggestions for success at the dinner table regardless of whether you’re serving pizza or brussel sprouts.

1.Develop a routine and stick to it. Offer meals and snacks at about the same time each day

2.Don’t force feed or bribe your child to eat. This will likely increase refusal behaviors or even worse, bring on a power struggle.

3.Offer a variety of foods, including 1 to2 of your picky pumpkin’s favorite items, at the family meal.

4.Persistence is key! Remember not to shy away when he shudders at his first taste of peas. You may need to offer those peas up to 20-25 times before he will tolerate them.

5.Explore food with your child. Talk about the way it looks, smells and feels. Invite her into the kitchen to help you prepare the foods. Bring her along to the grocery store or farmer’s market to choose a new fruit or vegetable. Star fruit? Why not?! Eggplant? Coming right up!

6.Make it fun! Serve fruits and veggies with dips. Use cookie cutters to make a Shamrock Sandwich for St. Patrick’s Day or Santa for Christmas. Eat dinner by candlelight. Serve breakfast for dinner. Better yet, have everyone put on their coziest jammies for a pancakes and PJ’s party. Get creative!

7.Practice what you preach! This means you, parents. If you want your little ones to eat salad for dinner, you will need to dive into that bowl of greens yourself and forgo the drive-thru on your way home. Our children are always watching and learning from our actions and habits.

8.Don’t become a short-order cook. If your child refuses the family meal, it can be tempting to head back to the kitchen to whip up the macaroni and cheese he is coveting. Resist! This may promote picky eating.

Now, let’s get down to business. While picky eating can be frustrating, it is a typical stage in normal development. However, problem feeding is a true disorder that requires specialized assessment and/or intervention and is downright disheartening for parents. A child that does not eat well can evoke feelings of anxiety, fear, and helplessness, leaving caregivers struggling for a solution.

A problem feeder may:

• Eat fewer than 20 foods.
• Refuse the bottle/breast or drink a small amount and then refuse during infancy.
• Refuse an entire texture category (for example, a problem feeder may refuse to eat all pureed foods).
• Not accept new foods on his plate and may cry, scream or tantrum at the sight of a new food. Problem feeders may even gag or vomit at the sight of an offensive foods.
• Be unwilling to try new foods, despite multiple exposures.
• Eat the same food over and over, but once he experiences “burn out,” he will most likely not go back to eating that food. This will cause him to slowly, but surely, shrink his group of tolerable foods.

If your child is showing symptoms of problem feeding, talk to your child’s pediatrician regarding a feeding evaluation by an occupational therapist or speech-language pathologist. A thorough evaluation is necessary to determine the best course of individualized treatment for your child.

Hang in there, parents. There IS hope! Our feeding therapists are trained to help your child with a wide array of feeding difficulties.

References:

http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589934965§ion=Incidence_and_Prevalence

http://www.sosapproach-conferences.com/articles/picky-eaters-vs-problem-feeders

Resources for Parents:

www.feedingmatters.org

www.yourkidstable.com

About the author

Amanda Fyfe is a speech-language pathologist at Cook Children's in Arlington and Mansfield. Speech/language pathologists focus on oral motor, speech, language and communication skills to enhance development, restore function and to prevent disability from pediatric conditions, illness or injury. Click here to find the closest Cook Children's Rehabilition Services near you.