When medical conditions cause feeding difficulties

Its been almost 3 months since my last post and I promised to go through the acronym STOMP as causes for feeding difficulties. This week in particular this entry seems important with the publication of a twin study from University College London on Fussy Eating and Neophobia, which has got the media going crazy.

Today’s entry is only about organic or medical causes of feeding difficulties. Those parents that have got children with food allergy, reflux of developmental delay (just to name a couple of medical diagnoses) will know that feeding difficulties are common when a child is not well. The question though is, when is your child’s feeding difficulty possibly a medical condition that has not been diagnosed.

There are a couple of “red flag signs” in regards to feeding difficulties that I would suggest requires a healthcare professional’s attention. These include:

  1. Dysphagia (difficulties in swallowing) – if you see your child has obvious difficulties in swallowing
  2. Coughing and spluttering every time your child has liquids (especially if you child has frequent chest infections)
  3. Gagging every time textured solid foods are given and this causing distress
  4. Apparent pain with feeding – in the young this often exhibits itself as refusing to drink breast milk or from the bottle
  5. Vomiting and diarrhea in association with feeding difficulties
  6. Growth faltering in association with feeding difficulties

If there is an underlying medical cause leading to the feeding difficulty, the problem is unlikely to be resolved without the medical condition being treated. It is therefore important to discuss feeding difficulties with somebody if they exhibit any of the above symptoms.

My next entry will be about mechanistic feeding as cause for feeding difficulties.




Size of a child as trigger of feeding difficulties

I promised last week that I would expand on each trigger of feeding difficulties. I will start with size – or growth of a child, which next to texture transitioning is one of the biggest causes of feeding difficulties.

First of all, it is important to get your child’s growth assessed on a regular basis. I want to define what is growth, because most people just think of weight, but in fact growth encompasses weight, length/height growth and in a child < 2 years of age head circumference. You can not assess how a child is growing only by looking at their weight, because the length of a child gives you important long term information on growth and so does a head circumference in the young. For example if your child’s weight has dropped a centile but the height is continues to grow well, then this is  much less worrying as your child may come from a taller skinnier family and this is genetically normal for your child. So if there is one message that comes out from today’s blog entry, is to get a length/height and head circumference (< 2 years of age) done before you start worrying that your child is not growing.

Now, why is growth a trigger for feeding difficulties? Usually if somebody tells a parent that their child is not growing it hits a very sensitive nerve that goes to the core of parenting. No parent can be blamed for not taking this personally! The knee-jerk reaction is to immediately start correcting this by feeding more food and increasing the frequency of feeding intervals. It makes sense that more food equals more energy and protein intake which means growth. However, your child may not want to have more and eat more frequently, which then leads to them refusing food, the parents becoming more distressed as they worry about their growth and the more distressed they are the harder they try, the more the child refuses……so you can see a cycle of feeding difficulties starting.

I would like to give some simple tips, but this does not replace professional advice.

  1. Enrich the food that your child is currently eating happily with cheese, cream, pureed lentils and other energy and protein rich foods. Ensure that you give full cream yogurt, provide a spoon of nut butter in the porridge your child is having or make a fruit smoothie with yoghurt and almond butter for example. Gaining weight is not just about energy but protein as well, so adding just oil is not going to do the trick.
  2. Do not increase sweets and chocolates – these are empty calories and do not contribute hugely to catch up growth. Food increases catch up growth which is more balanced and also for the future better for your child.
  3. Ensure that your child has sufficient vitamins and minerals which are co-factors for growth. This means, your body needs them to metabolise the energy they are consuming.
  4. Keep meal times to 30 min and no longer than this!
  5. Offer a manageable portion – this is psychologically important for parent and child
  6. If the can self feed – ensure that they have foods that are higher in energy and protein that they can self fed – cheese strips, falafel, home-made chicken strips, bread sticks and hummus, avocado and oat cakes as snack ect. This is often more successful.
  7. Respect your child’s signals of hunger and satiety – if they signal they are full, stop feeding
  8. Never force feed or feed when they are unhappy and crying


What do I need to do if I suspect my child has a cow’s milk allergy?

Last week I wrote a blog on cow’s milk allergy, which I had quite a bit of response on. I thought it is useful to follow this up as promised with a blog entry on what to do if you suspect your child has cow’s milk allergy. First of all, please do NOT remove cow’s milk out of your child’s diet without consulting with your doctor to establish whether there are other causes for the symptoms that your child is exhibiting. If a cow’s milk allergy is suspected an elimination diet of cow’s milk may be recommend to see if the symptoms improve.  This should ideally be done under the supervision of a dietitian. I know that I often get complaints that some of you do not have dietitians in your areas or that there is a long waiting list to see one. It is worth the wait as cow’s milk provides a lot of essential nutrient especially if in the young. The British Dietetic Association has some Fact Sheets that have been put together by the Food Allergy Specialist Group, that provide information, but they do not replace an individualised dietetic appointment.

I wanted to broadly discuss general treatment models for cow’s milk allergy. If you are breastfeeding your baby, please continue breastfeeding and get advice on how to optimally take out cow’s milk out of your diet without compromising your nutritional status and reducing breast milk quality. It is highly likely that a calcium and vitamin D supplement will be required. In some cases your doctor/dietitian may recommend that you remove not only cow’s milk but soya and other food allergens. Again, this should NOT occur unsupervised.

If your child is not on breast milk, but on formula milk you will be recommended a hypoallergenic formula. You get two types, an extensively hydrolysed formula and an amino acid formula. The majority of children with have full symptom improvement on an extensively hydrolysed formula, which is made from short chain peptide (cow’s milk protein chopped up in smaller building blocks) that your child’s body will not recognise as an allergen. In a small number of children an amino acid formula is required. These are formulas that contain amino acids only, the smallest building blocks of protein.

Its important to note that these formulas taste different, smell different and yes, will lead to your child’s stools to look different – dark green in the majority of cases. If they spit up, the smell of this will also be different and it will have a different texture. This is absolutely normal and related to the fact that these milks have smaller pieces of protein or amino acids.

Whilst writing on hypoallergenic formulas, its crucial that parents also understand that any milk from animals on 4 legs (goat, sheep, buffalo, donkey) should be avoided as the protein is very similar and over the counter milks like for example oat, quinoa and coconut milk should only be offered after 1 year of age and ideally after a review by a dietitian. You can though use them in cooking from 6 months of age.

I would like to finish off this blog entry by saying that what I have written above does not replace professional advice cow’s milk allergy and nutritional management. Advice is ideally tailored for the individual.

Baby Led Weaning (BLW) – When to use?

There is almost not a week going by without parents asking me about the BLW approach. For those of you that do not know this approach it was developed by Jill Rapley, a UK qualified health visitor that suggested starting with soft pieces of food from 6 months of age – meaning you jump the whole puree phase and babies just start by feeding themselves. She has published several books and has a website as well.

Initially it was seen as a craze from us as healthcare professionals, but since then this method of weaning has been studied by a couple eminent researchers. The studies have found that the majority of babies can feed themselves from 6 months of age using this approach and thrive, they learn how to regulate their own appetite better, have a preference for healthier foods and have a lower BMI  (Body Mass Index) when they are older . There are however babies where this approach may not be appropriate, in particular those children with developmental delay, with faltering growth and other medical problems where food needs manipulation due to a medical reason. In these cases it is better to consult a dietitian or if you are in the UK your health visitor to establish if this method is safe and would sustain growth and development.

Key to using BLW is to start it only at 6 months of age and really to follow your baby with introductions. It is amazing how quickly they learn to eat soft fruit and vegetables and I have plenty of babies who eat meat happily without any teeth. You will find plenty of You Tube videos if you are a “non-believer” of babies from 6 months of age chomping on chicken legs and other more complex foods.

The advantage for me in using this approach for children with no underlying medical conditions is that you get less feeding difficulties as the baby has to regulate their own appetite and will therefore eat what they want to eat, instead of you as parents feeling they need to eat a specific portion. Although this method is pretty new, it is possibly also that we may have less obesity using an approach where babies control their own appetite. Of course you still need to offer a balanced meal and for this I suggest that you look at my previous blog entries to help you out. Happy feeding !


Tastes, textures and colours during weaning

Eating for us and for babies is a sensory experience, which is often forgotten. I frequently hear that a food is rejected because of the taste, but it could actually be the texture, the temperature, the colour of the food and also the environment that leads to rejection. It is therefore important to take this into account when you feed your baby.

There is a “window of opportunity” when babies are more open to new tastes and textures, which is usually from (5)6-10 months. During this period, they will be open to trial new foods. It is therefore important when you start with weaning foods, to constantly introduce new foods and from 6 months on start introducing texture. Try to also change the temperature, that your baby is used to eating foods that are hot or cold. This may become very  useful, for those days when you are out and about and can not heat the food up to the perfect temperature. Most babies will prefer sweet foods; as such you should not be disheartened if they do not like your green bean and broccoli mixture the first time you give it to them. It is important to repeat these foods and repeat them a lot…..it takes at least 15 x before some rejected foods are accepted.

When it comes to textures, whether you follow the baby led weaning approach or the traditional approach, texture is important and by 10 months ideally children should have a good variety of foods they can feed themselves by hand. Of course you are not expecting them to spoon feed at this age! Finger feeding is a messy affair, but good to let them explore and mess as this is not only a way for them to discover textures but also to enjoy the meal and feel independent.

Remember that babies look at colour as well and often choose their foods on how they look. “Mush” may therefore not always be as attractive as the food on your plate (which they may try to grab), which is colourful and plated out separately. So if they reject their mix, do try finger foods separately.

Finally, it’s a myth that babies like bland food.  Of course that does not mean you are going to add salt to the food, but there is no reason for you to not use garlic, onion, basil, rosemary and all kinds of exiting herbs and spices. I often get parents that are surprised that their child likds olives or enjoyed some curry from their plate, but this is normal, depending on the mother’s diet they would have been exposed to flavours in the womb and through breast milk. Therefore, be adventurous and add herbs and spices that are normally part of your diet to their food.

Most importantly, let your baby enjoy meal times!

How do I get in the nutrients?

I wrote on Sunday about portion sizes in infants between 6-12 months and ratios of protein to carbs and vegetables/fruit. I often get also questions about ensuring that my child “gets everything they need” from food. Food intake is of course more than just achieving energy, protein and fat intake but also making sure your baby has sufficient vitamins and minerals. Without these your child can not achieve optimal growth and development (including brain, muscle, eye and others), in addition the immune system requires vitamins and minerals to function. When you plan a meal, think about the variety of colours of the foods you are giving – sounds mad, but it is easy and works. Fruit and vegetables of different colours tend to have different vitamins and minerals and complement each other. Red and white meat and white and pink fish also have differences in their nutrient content. For example, lamb with potato and carrots and spinach – here you have some protein rich in iron, a carbohydrate source and vegetable sources rich in vitamin A, iron, folic acid and vitamin C. Compare this to a meal of chicken, with potato and sweet corn and cauliflower – you do have a protein source that has iron and a carbohydrate source, but you do not have a vegetable source high in vitamin A (yellow/orange or dark green) for example. If you replace the cauliflower with broccoli you will make this meal much more nutritious….and also more colourful. Another example is pasta with peas and salmon – 3 colours and each provides totally different vitamins and minerals. Remember that 60% of eating occurs through the eyes. So its important to ensure that your baby is exposed to different colours of foods (including textures and temperatures) to develop their acceptance of different variety of foods in the future. Now what about fruit? Banana is a favourite for all mothers, as it is convenient and you can puree, mash or give it as pieces. I think it is a great fruit to always have as a back-up. You can use a banana as one portion of fruit per day, but you do not want to give three portions of bananas as fruit/day, because this would provide you with exactly the same nutrients. So again looking at colours you can vary the nutrient content easily – banana, mango and apple – 3 different fruit, different colours and different vitamins and minerals. Below is a photo of a baby bowl with different colours of foods at the ratios previously discussed.


What is a “portion of food” for a baby

Now the topic of food portions in young babies (6 months – 1 year) is very close to my heart, as I think most tears in my practice have been cried about my “baby not eating enough”. What is enough for a baby when it comes to food? Is it what the food companies put in a jar/pouch? Is it what as a parent you feel is enough for your child? I can tell you certainly that what is in a jar/pouch is not a portion, so do not worry if your child does not finish this. Also, what you are dishing up in most cases will also not be a right portion for your baby – because this is highly influenced by  your own eating habits (we measure our babies portion to what we would eat). It is a myth that for babies < 1 year of age you have a “magical portion size” for all foods, as sometimes a 6 month old baby can be 6 kg and sometimes 4 kg, surely you would not expect them to eat the same?

So what is a portion? Firstly between 6-12 months you are introducing solids and then expanding the variety, whilst milk intake slowly reduces as solid volume goes up. In the initial phase its all about tastes and textures and really ensuring that your child gets exposed to a wide variety of different flavours. Of course as the variety of foods increase, the nutritional contributions of weaning foods also increases. In the vast majority of babies, they have very good appetite and satiety control and generally when they signal hunger they will eat and they will stop when they are not hungry. The ideal feeding style for parents is therefore “responsive feeding” – which means you are listening to your child’s cues and respond with portions sizes according to their hunger. Other feeding styles include indulgent, controlling and neglectful feeding, which all have a negative impact on your baby’s feeding – I will discuss these further when we get to feeding difficulties. Hand in hand with a responsive feeding style goes growth monitoring, if your child grows well, you can be assured that you are getting sufficient energy and protein in, if weight gain is excessive, then they are getting too much. When you have introduced a good variety of foods into your baby’s diet you can start looking at proportions – 1/5 protein, 2/5 carbs and 2/5 vegetables. This will ensure that you have sufficient non-protein energy for the protein to be used for growth and development.

Of course there are always exceptions when it comes to a appetite and satiety. In a small number of young children there can be a disregulation of appetite and satiety where professional help is required. On the other hand when your child is unwell, their food intake is altered and  you need to respect that, because as adults when we are unwell we also do not want to eat. Can you imagine somebody sitting in front of you when you have the flu and forcing food down you?!! There are also medical diagnoses that affect appetite and satiety, including non-IgE mediated gastrointestinal food allergies (which I will discuss in another blog entry) and other gastrointestinal diseases. If your baby’s growth drops down centiles you definitely need to speak to a healthcare professional.

Now, for toddlers > 1 year of age there are some portion sizes,  which the Infant and Toddler Forum have published and they regularly tweet photos of portion sizes which help put your portions into perspective. Again, a big boy may eat more than recommended portion sizes whereas a petite girl may eat less, so looking at the portions is a great guide, but also take your child’s appetite and satiety into account.  I will write more on older children and food intake in future blog entries, as behaviour does set in when they are older so eating can often be a difficult.