Just Two More Bites! : Helping Picky Eaters Say Yes to Food

Solving the Puzzle of Picky Eating

Ralph and Katy Greene are committed to having family meals. They juggle work, long commutes, music lessons, and nap times so that they can share at least one meal a day with their three kids. Yet family mealtimes are not working out as planned.

Instead of warm, bonding experiences, they are nonstop battles. No matter what the food, the kids whine and complain. On any given night, one of them will refuse to eat.

Take pasta night. Eighteen-month-old Ned is the hardest to please. He eyes every food suspiciously. When he spots something he doesn't want, he'll scream, "No, no, no." Now and then, he simply says "Yuck" and drops food on the floor.

The two older kids are not much better. Three-year-old Drew doesn't like smooth rigatoni; he likes it with ridges. Naturally, his older sister, Beth, age four, wants smooth rigatoni. Even though Katy wants them to eat, she refuses to cook two different kinds of pasta.

To sidestep the pasta battle, Katy searched for the magical pasta shape both kids would eat. She tried everything from farfalle to ziti, without success. With each taste test, whenever Drew liked something, Beth didn't.

"It's enough to make you crazy," says Katy.

Instead of giving up, one day Katy and Ralph tried a new strategy. Drew and Beth would take turns choosing pasta. At first, neither child was thrilled, but soon it quelled their endless complaints. Katy and Ralph relish the truce (although they expect that one day soon Ned will start eating pasta too and upset the compromise). Still, they are perplexed. They describe themselves as "eating almost everything." Katy says, sighing in bewilderment, "We know it's not genetic. How did we end up with three picky eaters?"

Ralph and Katy are not alone. There are roughly nine million picky eaters under the age of five living in the United States today, and each one is picky in his or her own way.

While fussy eating is both common and normal in young children, some take it to amazing extremes, eating only a few select foods. More typical are kids who reject homemade chicken nuggets but eat store-bought, those who eat fruits but not vegetables, those who drink milk but refuse solid foods, or those who drink juice and refuse milk. The variations of what kids eat or don't eat are endless.

Day after day, some picky eaters eat little or nothing, while others eat well but only if offered one of a small number of foods they like. Whatever the pattern of saying no to food, the parents' struggle to help their children eat better is always the same.

Regardless of whether picky eating is a minor daily irritant or a potential threat to a child's health, it's natural for parents to worry. Most suspect there must be something they can do to make life easier for themselves and their picky eaters. Knowing exactly what that is, though, can be tricky. There are lots of pieces to the puzzle of understanding why a child refuses food. A maze of influences--developmental, biological, and environmental--affect a child's appetite and food choices.

Influences

Kids are different from one another and from one age to the next. Max refuses meat and chicken, loves salad and bread, and can't get enough cucumbers. Josh eats only pale-colored foods: cheese, yogurt, peeled apples, potatoes, and chicken. Amanda constantly drinks milk and juice but barely eats anything.

Can parents make sense out of their children's eating? In my work, the first step to finding solutions is to help parents recognize what is special and different about their child. To find the answer, I consider the influences of developmental stage, life experience, biology, and personality. Each one can support or interfere with healthy, hearty eating.

DEVELOPMENT

A child experiences mealtimes differently depending on his age and stage of development. For example, two-year-old Sam's parents were surprised and worried when his eating pattern changed. They said, "Things aren't the same. Sam was fun to feed when he was a baby. Back then, he ate everything. Now he barely eats anything." Although difficult to live with, mealtime tantrums are normal behavior for contrary two-year-olds.

During the second year of life the growth rate slows down and awkward attempts at independence begin. Not only do toddlers eat erratically when they do eat, but they want to do it their way.

The classic advice to ignore your child's food refusals applies to toddlers. Many parents justifiably find this impossible. Toddlers can be tough to ignore. The key to making the advice work depends on learning how to act like you don't care. Chapter 5, "Fussy Toddlers and Preschoolers," describes the details about how toddlers demand attention and how best to respond.

For most toddlers, picky eating is an obnoxious but normal stage. Two simple rules apply: give toddlers choices and set limits.

PARENTS BEWARE: TODDLERS HAVE MULTIPLE WAYS OF SAYING NO TO FOOD

The "no" stage lasts about a year and moves through three stages:

-Nonsense "no" is playful and experimental. It doesn't necessarily express dislike or resistance. It's more about seeing what happens with a response of "no."

-Defiant "no" is a test of limits and power. Giving a child appropriate choices empowers her to express appropriate preferences and avoids potential showdowns.

-Reasonable "no" is less common, less intense, and does express personal preferences. At this stage, it's good to dig deeper. Talk to a child and find out why she said no.

With babies, handling picky eating is less straightforward. When food refusals start at an early age, immature eating skills are often to blame. In order to eat, babies first need to learn how. Some do it easily and happily while others resist and struggle. Young children vary a great deal in their readiness for solid foods.

Babies born early and those with medical complications are at risk for immature development. They often don't follow the typical schedule for such learning skills as walking, talking, and eating. Regardless of the cause, a child with a lag in eating or self-feeding skills is more likely to reject food.

Parents who realize there's a lag in a child's eating skills may be tempted to push harder to help their child catch up. Oddly enough, this often makes things worse. If a baby resists eating food from a spoon, holding down his arms in order to pry in extra spoonfuls isn't the solution. If a baby gags when eating stage three baby foods, giving these and other difficult foods won't help. In fact, it is likely to increase the gagging and may possibly lead to vomiting. When a child has immature eating skills, a gentle approach works best.

Meals are happier and more productive when parents are able to recognize typical behaviors for their child's development stage and adjust the pace of feeding to match the child's comfort level. Sometimes this means advancing food textures through smaller steps instead of big leaps. Even though timing varies, children eventually learn how to eat. In the meantime, keeping early eating experiences positive avoids negative associations with food. Chapter 3, "Feeding Skills," and chapter 8, "Food Textures and Flavors" offer suggestions.

Handling food refusals in children with developmental delays, aversions, or other special needs is also less straightforward. Parents may find that

-it's harder to distinguish the difference between a child who needs help and one who is testing limits.

-picky eating patterns are more extreme. Instead of changeable and time-limited food jags, food preferences are narrow, fixed, and longer-lasting.

Autistic children often adopt rigid food routines, eating the same ten foods day in and day out. Chapter 12, "Feeding a Child with Special Needs," describes some of the strategies used to overcome slow food progressions or rigid food preferences.

BIOLOGY

From a medical perspective, poor growth, not poor appetite, is the classic sign that a child needs help. Although poor appetite and poor growth usually go together, there are exceptions.

Three-year-old Adam amazed everyone with his giant-size appetite, eating twice as much as other kids his age. Still, he remained the smallest in his group. The mountains of food Adam devoured did not help him. Adam's problem was digestion, the leading biological cause of poor growth in children.

The classic signs of a digestive problem are diarrhea or vomiting. It turned out that Adam had celiac disease, which caused him to have diarrhea whenever he ate food that contained the protein in wheat--gluten. That meant it was necessary to avoid a long list of common foods, including pasta, bread, and most crackers and cereals. Once he eliminated all foods that contained gluten, Adam's diarrhea stopped and he began to gain weight.

Of course, a serious condition is not always to blame. Because babies and young children have immature digestive systems, they are very susceptible to digestive problems--short bouts of diarrhea and vomiting are common. Fortunately, because of the short duration of these bouts, they rarely have a lasting effect on a child's growth or appetite.

It's long-term conditions that are more problematic. Any ongoing condition that causes a child to associate pain or discomfort with eating can eventually lead to food refusals. This can happen with mild digestive problems, such as reflux, constipation, or, in some cases, allergies, as well as with mechanical problems involving eating or swallowing. These are discussed in chapter 11, "Food Allergies and Digestion Problems."

Children with serious growth or feeding problems often have an underlying medical condition. Researchers report that a high percentage of children seen in medical specialty clinics such as pulmonary and GI (gastroenterology) have feeding problems. This is not surprising. Any number of medical conditions increase a young child's risk for problems with feeding or growth. Obvious problems such as cleft lip or cleft palate make eating more difficult. Less obvious are conditions that increase a child's calorie needs. These include prematurity, cerebral palsy, cystic fibrosis, and some congenital heart problems.

Because the number of children with feeding problems and medical risks has increased in recent years, more services are available. Human biology is complex. Understanding how much of a child's growth or feeding problem is inherent rather than acquired is always a challenge, but more so when a child has a medical condition.

BEYOND DIGESTION

Physiological conditions that can affect a child's eating are

Prematurity

Allergies

Cerebral palsy

Chronic infections

Cystic fibrosis

Congenital heart disease

See chapter 12, "Feeding a Child with Special Needs," for details.

PERSONALITY AND LIFE EXPERIENCE

In one study, parents of picky eaters cited personality traits that are common among difficult-to-feed children. Again and again, different parents used the same words: "stubborn," "moody," "socially intense," and "easily distracted."

Such common personality traits among difficult-to-feed children suggest that some are born to be fussy eaters. Of course, this knowledge doesn't help parents deal with day-to-day issues. In this study, learning techniques for handling food refusals eased the problem. (For examples of these techniques, read chapter 10, "Mealtime Do's and Don'ts." There's no doubt that biology influences a child's personality. From an academic perspective, the problem is pinpointing where this influence begins and ends.

Generally, researchers point to how life experiences affect eating. These experiences begin at birth. Miraculous, life-saving experiences for newborns and young children are more common than ever. But there is a downside. Medical interventions around the mouth (ventilators, tracheotomies, or nasogastric tubes) can cause discomfort that leads to kids rejecting food or anything that comes into or near the mouth. Professionals call this avoidance behavior. To help children overcome food refusals, therapists often use techniques based on theories of sensory integration dysfunction. For more information on how sensory integration affects eating, see chapter 8, "Food Textures and Flavors."

Family, Friends, and Peers

Defying a long-standing family tradition, five-year-old Song Woo turns up her nose at rice every day. Despite generations of rice-eating ancestors and years of bribes and threats, Song's refusal to eat rice is still going strong. She prefers pizza and spaghetti.

Song's family can't understand why she refuses rice when everyone else in her house eats it daily. Her grandmother won't give up. She uses various tactics to entice Song. Most of the time, her grandmother employs a simple bribe: "If you eat your rice, I will buy you a toy."

Song Woo's grandmother is not alone. Countless caregivers use games, tricks, and bribes to help a child eat, and in the short term they often work. But those well-intentioned bribes and cute games have unintentional consequences: over time, these kids tend to turn away from the food again. Song Woo's grandmother may convince her granddaughter to eat rice in order to get a new toy, but in the long run it increases the odds that Song will like toys and dislike rice.

For young children, eating is never solely about food or nourishment. Meals are a setting for social and physical development. Children learn whether eating is pleasant or unpleasant, which foods to like or dislike, and the consequences of eating or not eating. Sometimes adults teach these lessons without knowing it.

-If a father consistently ignores his baby's signals for "no more" and persists in prying extra spoonfuls of peas through his pursed lips, the baby learns that eating is no fun. He associates tension and discomfort with eating peas, and possibly eating in general.

-If a toddler refuses waffles and his mom offers cereal, or if when he refuses peas his mom offers carrots, a pattern emerges. Soon a toddler learns that if he refuses one food he will get another.

-A preschooler realizes that if she doesn't finish her pancakes, her mother becomes upset. This makes it harder for her to recognize whether she should eat the pancakes because she is hungry or to please her mother.

Even before they begin to talk, young children learn by watching and listening, and are amazingly aware of the social rules and expectations surrounding food. Most two-years-olds recognize cake as a party food and know that desserts are eaten after vegetables. They know which foods are popular in the family and learn the consequences of eating or refusing foods.

Because children learn about food by mimicking others, role models are important. Young children often act as mirrors, reflecting back what they see or don't see. When parents want to make meals better, watching what a child reflects back is a good place to begin.

One mother, Lisa, came to see me when her fourteen-month-old son, Gregory, was not attempting to feed himself like other children his age. From talking to her friends, she knew that other children Gregory's age behaved differently at meals; they were at least trying to eat by themselves. Gregory's play skills were typical for his age, suggesting he had the motor skills he needed to feed himself. Yet when Lisa described Gregory's meals, it seemed that Gregory rarely watched anyone else eat.