Veronica Montanaro, Speech and Language Pathologist

Food is one of the greatest pleasures of life unless you have a child who is a picky eater. Then, mealtimes can look like a battleground, often leaving parents feeling defeated and concerned about their child’s nutritional intake. Of course, it is hard for families, especially for parents who spend a lot of time preparing the food.

What is the difference between a picky eater or problem feeder anyway?

Picky Eater

  • Decreased range or a variety of foods that will eat = 30 foods or more
  • Foods lost due to “burn out” because of a food jag are usually re-gained after a 2-week break
  • Able to tolerate new foods on the plate and usually can touch or taste a new food (even if reluctantly)
  • Eats at least one food from most all food texture groups
  • Frequently eats a different set of foods than the rest of the family, but usually eats with the family
  • Will add new foods to the repertoire in 15-25 steps on Steps to Eating Hierarchy
  • Sometimes reported by parent as a “picky eater” at well-child check-ups

Problem Feeder

  • Restricted range or a variety of foods, usually less than 20 different foods
  • Foods lost due to food jags are NOT re-acquired
  • Cries and “falls apart” when presented with new foods
  • Refuses entire categories of food textures
  • Almost always eats different foods than the family
  • Adds new foods in more than 25 steps
  • Persistently reported by parent as a “picky eater” across multiple well-child check-ups

This table, taken from the SOS feeding Programme of Dr Kay Toomey, outlines the difference between when a child is a picky Eater vs a problem feeder.

We often see parents reaching out to other parents about their child’s eating habits, often desperate for ideas to introduce new food items. Adding new food items takes place through a process of presenting food to the children, over and over again, alongside positive reinforcement for any interaction with the food. It is easy to mistake the first rejection of food as the child not liking the item. It is fundamental to keep in mind that it takes more than 10 repeated presentations of new food with positive reinforcement before a child will begin to eat that food regularly.

Family meals are salutary to providing children with several opportunities to learn about eating. This also means that we need to be very good role models. It is crucial to consider that punishment can increase a child’s adrenaline and in turn, reduce a child’s appetite. A common problem we see is a child being offered foods they really cannot manage to eat. Presenting a 2-year-old child with a full hamburger, plus potato, plus vegetable on their tray can be overwhelming, frustrating and defeating. Letting the children get messy is all part of the fun. Wiping a child’s face too quickly with a baby wipe may make them associate food with the taste of the baby wipe, rather than with the taste of the food.

Here are a few strategies that may improve your child’s feeding experience.

–    Positive reinforcement: With new foods, it is helpful to make the food less “new” by first introducing it to the child on the table only. Then you can put it on their plate. Remember, new foods need to be presented repeatedly with positive reinforcement for any interactions with the new food.

–    Making foods manageable: Have your child help you prepare foods (at a developmentally appropriate level- may be stirring, pouring, etc.)

Foods must to be in small, easily chewable bites or in long, thin strips that the child can easily hold. Also, the rule of thumb is to only present a child with a total of 3 foods on their plate at any one time. There should be 1 tablespoon per each year of your child’s age of each of these 3 foods, making sure there is one highly preferred food at every meal.

–    Social modelling: Model good feeding behaviours with your eating patterns. It is essential to eat a typical family meal and wait to do any feeding programs until you are done with your food (but don’t forget to keep a little food aside so you can be a good role model during the program time of the meal). During the meal, make sure that ANY interaction with the food is rewarded. Verbal praise is the ideal and most natural reinforcer. However, a smile, a touch, a cheer, clapping are all other options. The level of reward needs to be geared to each child.

–    Structure: Having a routine to meal times, eating in the same room, at the same table, with the same utensils are all things which capitalize on the need for repetition in learning. The more you can make things about the meal the same, the easier it will be for the child to learn. Also, the routine itself can help get the child primed and ready to eat. You can also discuss the food by colour/feature/taste/size (i.e., “The yoghurt is cold!”). You can also create a routine for meals and snacks (i.e., sit at the table, eat, clean up).

–    Making it fun:  Eating is meant to be a social, enjoyable, fun experience. Although refusal to eat is frustrating and can be frightening for parents, encourage your child to have positive interactions with foods. “Playing” with food is an excellent way for your child to explore foods, so provide them with those opportunities! For example, if your child is working on eating yoghurt, use your finger to draw a picture or letter in it to make it more fun! You can also utilize your child’s level of cognitive functioning to help him, or her understand the food and his or her own body (i.e., “The round grape goes in our mouth!”).

When should parents seek help?

Parents should seek professional help if there is:

  • History of a traumatic choking incident
  • Ongoing poor weight gain (rate re: percentiles falling) or weight loss
  • Ongoing choking, gagging or coughing during meals
  • Ongoing problems with vomiting
  • More than one incident of nasal reflux
  • History of eating and breathing coordination problems, with ongoing respiratory issues
  • Parents reporting the child as being “picky” at 2 or more paediatric visits
  • Inability to transition to baby food purees by 10 months of age
  • Inability to accept any table food solids by 12 months of age
  • Inability to transition from breast/bottle to a cup by 16 months of age
  • Has not weaned off baby foods by 16 months of age
  • Aversion or avoidance of all foods in specific texture or nutrition group
  • Food range of fewer than 20 foods, especially if foods are being dropped over time with no new foods replacing those lost
  • An infant who cries and/or arches at most meals
  • Family is fighting about food and feeding (ie. Meals are battles)
  • Parent repeatedly reports that the child is difficult for everyone to feed
  • Parental history of an eating disorder, with a child not meeting weight goals (parents not causing the problem, but may be more stressed and in need of extra supports)

References

  • The SOS (Sequential-Oral-Sensory) Approach to Feeding Program was developed by Dr Kay Toomey and is used worldwide to treat feeding issues in infants, children, and adolescents. For more information about SOS Approach to Feeding, visit the Toomey & Associates – SOS Approach to Feeding website.

About the author

Veronica Montanaro studied Communication Therapy at undergraduate level at the University of Malta. Upon receiving her degree, she worked as Speech and Language Pathologist with a local NGO and the Disability Support Unit at the University of Malta. From 2008 till 2015, she worked with the Speech and Language Department (SLD).

Ms Montanaro was awarded an M.Sc in Language and Communication Impairments in Children with the University of Sheffield in 2014. She is the service coordinator at TAASC, a private Multidisciplinary Team, where she is also responsible to carry out the speech, language and communication assessments. Veronica is trained to administer: the SOS Feeding Approach, TEAACH, ADOS; Hanen: It Takes Two to Talk; Picture Exchange Communication System (PECS); Nuffied: Dyspraxia, Communication Mats, PODD, and; Lis ‘n’ Tell: Inclusive Story-Telling. She is also an Elklan Certified Tutor. 

FB: https://www.facebook.com/TAASCmalta/

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