Post-traumatic experience leading to feeding difficulties

Today will be my last entry on the causes of feeding difficulties. The last cause is a traumatic experience with food, that on either parent or child’s side causes the avoidance of foods. The most common reason I see for feeding difficulties related to trauma, is following a choking episode on certain foods. It does sometimes happen that with the introduction of lumpier textures, a child gags, becomes quite red in the face and in some cases vomits. Some parents experience this quite traumatic and this can lead to a reluctance to introduce textured foods, which means that it can lead to a delay in the acceptance of texture. If this were to happen to your child there are a few simple steps you can take. First of all, I usually advise parents to do a first aid course just to provide them with the comfort that they will be able to hand a situation like this.

Most importantly, do not give up on texture. Melt-in-the-mouth foods  (like the maize puffs for children) are often a really good first step to get texture into a child after a negative experience. These foods help with feeling texture and chewing (an essential skill), but before a child can choke/gag they melt and become a puree. I have often also suggested the use of a teething net (you place food in this net and your child can chew) for a week or 2 with food, just to get your confidence. Remember, there is a window of opportunity of introducing texture and that is before 10 months of age, after this it can be really difficult and some children become texture hypersensitive.

Children can also have traumatic experiences with food, which often leads to food refusal. Choking can be just as traumatic for a child as a parent. In addition, children that experience allergic reactions to foods often avoid those foods and foods that look the same/have the same texture/taste. It is therefore important when a child has a negative experience with food, to ensure you do not complete avoid the food (outside of a real food allergy of course)/similar foods but to offer food on the table of the high chair in a non threatening way, so that they still see the food is in front of them and get the message, that the food is safe and in their own time they can trial this again.

Most importantly, the reaction of parents to a food-traumatic experience can deter a child from having this food again. So if you see your child is gagging and spitting out foods, although it may be very stressful for you as a parent, try to handle this in a calm manner as a child will try to avoid similar feeding situation like this, which may entail avoiding foods.

 

Advertisements

Mechanistic feeding as cause for feeding difficulties

I am all for a child having a routine, in particular if this means children get all their nutrients and parents feel relaxed that they have had enough food.

The problem is, when feeding becomes so scheduled that it ignores the natural appetite and satiety of a child. If you were to perform a search on “Dr Google” on feeding schedules for babies, you will find anything from a 3 meal to a 9 meal schedule with breast or bottle feeds in between.

It is important to get to know your child’s appetite and satiety, instead of following a schedule that has been put together without taking your child’s appetite into account. Some children need only 3 meals per day and snacks reduce the meal volume and other actually do better with 3 smaller meals and 3 snacks. What is crucial is to listen to what your child is signalling. Trust your baby, they will signal hunger and satiety and show you when they are hungry.

Evidence has shown that if you “disrespect” the satiety of your child and feed just according to a schedule (i.e. “they must eat at a specific time”), that eating becomes a negative experience. In addition, we do not want to teach our children to override natural satiety as this has bearing on portion sizes in later life.

What I am certainly not saying is to through routine out of the window! Have a routine, but be flexible to adjust this, if your child is never hungry mid-morning for a snack, then do not force it on them. Cut it out and just provide lunch, they will signal if they get hungry in between and then you can bring in a snack. Equally, it may be on days that lunch is not such a successful meal, but dinner is great. This is fine, keep the routine but do not obsess about the success of the meal as most children will make up for poor intake in their next meal. Mechanistic feeding addresses feeding like a machine, which it obviously is not.

Please note: for those children with diagnoses affecting the gastrointestinal tract, hunger and satiety is often affected so the advice above, is for children without any underlying medical diagnoses.

 

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

 

Feeding difficulties in Children

Every week I see children with feeding difficulties of varying degree in my clinic. What I can tell parents is that it is common, you are not abnormal and that it is very difficult dealing with a child that does not want to eat. I do want to focus a couple of blog entries over the next weeks on this topic, as I think there are some simple tips that may help and most importantly its you as parents want to know when do you need to see a healthcare professional.

Lets start with what are feeding difficulties.Generally if a child has one (or a combination) of the below they are classified as having feeding difficulties

  • extended mealtimes (if they take > 30 min)
  • sealing of the mouth/pushing food away
  • gagging on solids
  • spitting food out – every meal and all foods
  • dream feeding – so refusing to feed from the bottle if awake and only taking it whilst asleep

There is a lovely acronym summarising all triggers for developing feeding difficulties and it is called “STOMP”.

S – Size: the natural response to a child not achieving optimal growth is to try harder, to feed more, increase volume or frequency of foods and all of this leads to an increase in stress in mealtimes and as a result feeding becomes something your child (and you) want to avoid.

T – Transitioning: transitioning from breast to bottle, from puree to textured foods can can also lead to problems. For example the first time you provide some lumpier textures your child gags (which normally looks like they are choking but is not that bad), you get a fright and as a result do not move on with textures. If textured foods are not introduced by 10 months of age, it becomes very difficult as a critical window of opportunity has been missed.

O – Organic disease: there are many medical reasons why a child does not want to feed. That may be related to an anatomical problem with swallow/stomach, reflux or food allergies. It is therefore important to ensure that medical causes are ruled out. I will in a future blog highlight exactly the medical “red flag sign” that should not be ignored with feeding difficulties.

M- mechanistic feeding: the most common question from parents is that they want an exact schedule (including timing) for when their child should have a bottle, when they should have a snack and meal. So meal times become “mechanistic” rather than responsive to your child’s needs. Feeding a child or lets say trying to feed a child when they are not hungry but just according to the clock may also feed into the development of a feeding difficulty.

P – post traumatic: this can happen for example with a severe allergic reaction. For example your child had some egg, started swelling up in the mouth, was rushed to the emergency room and as a result is not only refusing egg but any foods that have a texture like egg. Another example is chocking (and I mean really choking) on food, which is very frightening for parents and the child and can put children off having pieces in future because they are scared of choking.

I will write next week on who size can impact on feeding difficulties and what you can do

 

 

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 !

 

Food Pouches for Babies and Toddlers

I have been meaning to write about this topic for some time, as I see more and more toddlers just sucking food from commercial food  or refillable pouches.

Undoubtedly, when baby weaning foods  in pouches were introduced many years ago, it revolutionized feeding infants. These pouches were not only better for the environment, but they were lighter, easy to travel with and looked kinda cool. What has suprised many of us working in paediatrics however, is how baby food in pouches has changed the way children are being fed. Suddenly a spoon was not required anymore, because the baby could just suck it directly from the pouch and parents were happy that it did not cause any mess. We now even have companies making refillable pouches and their clever advertising feeds into our aversion with mess.

It seems to be forgotten that there are essential developmental steps that need to occur for a baby/toddler to learn how to eat and allows them to have a normal relationship with food. Sucking, is a reflex a baby gets born with, so this is something that they know how to do, but chewing is something they need to learn and letting a baby/toddler just suck out of a pouch certainly does not help teach them this skill. In addition to this, there are important fine motor skills like holding a spoon and bringing this to the mouth that are important.  Outside of the mechanical side of eating, eating is a sensory experience. When the food is sucked from the pouch, they do not see how the food looks, what it smells like and they just feel the texture. No wonder they then refuse home cooked food when it comes in a plate – because they used to sucking it from a pouch.

Mess is such a crucial part of getting used to foods, accepting flavours, textures and tastes. The most common therapeutic advice we give in children with feeding difficulties is to allow mess, let them play with textures and allow them to explore foods. Letting a child suck from a pouch means, we are side-stepping this very important developmental step and it can actually lead to a feeding difficulty later.

Of course, there are exceptions which I always discuss with parents – you are stuck on a plane, in a car or visiting friends with a white sofa, so in these circumstance by all means allow them to suck from the pouch, but this should not be the norm. Let them explore food in all its colour, texture and taste.