Approximately 25 percent of otherwise normally developing young children experience feeding difficulties. These may not only be disruptive to the child's physical and emotional development, they also may affect the whole family. In When Your Child Won't Eat or Eats Too Much, author Dr. Irene Chatoor teaches parents how to navigate the challenges of early feeding development and help their children establish healthy eating habits. Based on clinical experiences and research studies, Chatoor helps you understand your child's specific feeding problems-whether your child has difficulty feeling hunger, has difficulty determining fullness, refuses to eat certain foods, or is just plain scared to eat. When Your Child Won't Eat or Eats Too Much presents specific suggestions and practical tips on how to understand and manage each of these feeding problems while promoting a healthy eating environment for the whole family. It also describes how feeding difficulties can be prevented and how discipline can be established without resorting to coercive measures. Chatoor, a pediatric psychiatrist who has made fundamental contributions in her field, helps parents better understand and deal with the challenges of early feeding development and the special feeding issues of their children.
When Your Child Won't Eat or Eats Too Much
A Parents' Guide for the Prevention and Treatment of Feeding Problems in Young ChildrenBy Irene ChatooriUniverse, Inc.
Copyright © 2012 Irene Chatoor, MD
All right reserved.ISBN: 978-1-4759-1245-6Contents
Foreword.................................................................................................xiAcknowledgments..........................................................................................xiiiIntroduction.............................................................................................xvHow to Use This Book.....................................................................................xixChapter 1 The Challenges of Early Feeding Development....................................................1Chapter 2 Facilitating Healthy Eating Habits.............................................................14Chapter 3 The Two-Year-Old Executive in the Family.......................................................26Chapter 4 The Child Who Rarely Shows Signs of Hunger: Infantile Anorexia.................................40Chapter 5 Selective Eaters...............................................................................58Chapter 6 The Child Who Is Afraid to Eat: A Posttraumatic Feeding or Eating Disorder.....................96Chapter 7 Children Who Have More than One Feeding Disorder...............................................107Chapter 8 Children Who Eat Too Much......................................................................116Chapter 9 Get Everybody on Board!........................................................................135References...............................................................................................143
Chapter One
The Challenges of Early Feeding Development
During the first few years of life, infants and young children have to learn to transition from drinking milk only to eating solid food. They also have to learn to feed themselves and to recognize signals within their body, such as when they are hungry or full. Additionally, they have to learn how to deal with their emotions.
Whereas for most young children these early developmental functions seem to evolve without problems, others have more difficulty in mastering these new experiences. Actually, 25 to 50 percent of parents of young children report encountering difficulties feeding their children.
The Introduction of Solid Food
In general, pediatricians recommend that parents gradually introduce their infants to baby cereal around six months of age and then add baby purees, fruits, and vegetables to the infant's diet. By the age of ten months, many infants are introduced to the thickened type of purees with a meaty taste and with lumps in it. This transition to baby foods can become a very challenging experience for some infants and their parents.
It is generally recommended that parents introduce only one new baby food at a time and wait for a few days or a week before starting to expose the infant to another type of food. This will allow you to observe whether your infant has any allergic reaction to the new food, such as a rash or loose stools, but it will also allow your infant to get used to the new taste of the food. Some infants may be cautious with new tastes and textures of baby foods. They may not like some types of baby purees on first exposure and not open their mouths for the second spoon filled with the new food, but the next time, they may be willing to take the new food again and gradually get used to it and even like it. It may take up to ten or more exposures on different days until your infant begins to like the new food.
However, there are some infants who are very sensitive to the taste, texture, temperature, or smell of certain foods, and they may experience strong aversive reactions when first exposed to certain foods. If your infant grimaces and turns her face away from the spoon, you may try the food at another time in a small amount and follow it with one of your infant's favorite foods. Gradually, you can increase the amount of the new food until your infant can tolerate it without grimacing. Eventually, after several exposures, your infant may even like the new food.
On the other hand, if your infant spits out the food, gags on it, or even vomits, I recommend that you do not offer that food again. In my experience, young infants seem to retain feeling memories, and they become scared when they see the food again or any other food that reminds them of it. Infants and young children seem to generalize by the color or appearance of the food. If your infant had an aversive reaction to a green vegetable puree, she may not want to eat any more green foods.
Some infants are especially sensitive to the texture of food and show strong reactions, such as gagging and vomiting, when you introduce them to purees with lumps of other food mixed in it. I have seen so many young children whose feeding disorders started with the introduction of these mixed-texture baby foods that I strongly recommend that you skip them altogether and advance your child to soft table foods if your child has any aversive reaction such as gagging or vomiting.
The Transition to Self-Feeding
Variations in temperament and culture
In the first year of life, infants and parents learn to establish a mutual communication system by which the parents learn to read their infants' signals of hunger and fullness and feed the infants accordingly. As early as eight to nine months of age, infants become more competent. They learn to sit up independently and begin to use the pincer grasp to pick up little things with their thumb and index finger. At this age, many become interested in the feeding process. They may grab the spoon and other feeding utensils, play with them, throw them, and generally get in the way of the parents' feeding efforts. This is the beginning of a challenging period when during each meal, parent and child need to negotiate who is going to place the spoon into the child's mouth.
During this transition to self-feeding, I have seen big variations among individual children and among parents from different cultures. In the North American culture, most children are transitioned to self-feeding between nine and eighteen months of age. However, there are strong individual differences among children with different temperaments. There are those who grab the spoon at nine months of age and refuse to open their little mouths when their mothers try to feed them, and there are those who still like to be fed when they are two years of age or older.
The following is an example of a child who insisted on feeding herself early, at only nine months of age, and how her mother dealt with it.
A friend and colleague of mine brought in a videotape of her nine-month-old daughter who screamed at the top of her lungs when her mother approached her with the spoon, and my friend said to me, "You would think that I had a weapon in my hand, the way she screams." She told me that it was impossible for her to continue feeding her daughter with the spoon because her nine-month-old wanted to do it herself. My friend gave her daughter finger food and bottles with milk while she practiced holding the spoon in a way she could get some of the purees in her mouth. It took three months before her daughter was able to manipulate the spoon successfully. During this time, her daughter did not gain any weight. However, once she was able to feed herself successfully, her growth picked up and she grew up to be a lovely, bright child with a strong will and determination.
On the other hand, there are young children who prefer that their mothers feed them beyond two years of age. These are often children who are more dependent by nature or those who are having sensory problems not only with the taste and texture of certain foods, but who are also very sensitive to having food touch their hands or the area around their mouth. These children prefer that their parents feed them because their parents are more successful in getting the food into their mouth without their hands or mouth getting "messy."
The following example demonstrates a child who, at the age of five, still preferred to be fed instead of feeding herself.
One of my friends told me that while she was working long hours, her mother-in-law took care of When Your Child Won't Eat or Eats Too Much her daughter, which included feeding her. My friend was not aware that her daughter had any feeding problems until one day, soon after her daughter started kindergarten, she got a call from the teacher who told her that her daughter was not eating her lunches. The teacher reported that her daughter, like all the other children, would unpack her lunch box but then she would just sit there and not touch her food while the other children ate their lunches. When my friend asked her daughter why she did not eat her lunch at school, she replied, "The teacher does not feed me." My friend found out that grandmother was still feeding her five-year-old and that her daughter expected that the teacher would do the same. Her daughter said that she did not want to get her little hands "messy."
There are also different cultural expectations based on when children are supposed to learn to feed themselves. In my observation, Asian and Middle Eastern families are more comfortable feeding their young children until the age of three or sometimes until five years of age when they go to school, or even beyond. Some parents, especially if they come from cultures where children are fed up to school age, are often unaware that their young toddler wants to feed himself, and they assume that they, the parents, are much more efficient than their young child in getting food into his or her little mouth. They ignore the child's efforts to get hold of the spoon or the dish with the food, and sometimes, they end up in a battle for the spoon with their young child. Some end up force-feeding their child, and consequently, the child becomes angry and fearful of feedings.
Different cultural expectations can also cause difficulties for families from Asia or the Middle East who move to the United States. I treated a four-year-old girl whose parents were from South Asia.
The parents had brought her for an evaluation because she refused to eat any solid food. The parents pureed all the food and fed her with the spoon, which was a struggle during every meal. After I had completed the assessment and observed the intense conflict between the child and her parents, I suggested to the parents that one of the first goals should be to help their daughter to learn to feed herself. The mother looked surprised and asked me, "Why?" I was just as surprised by her question and responded that she seemed surprised by my suggestion of helping her child learn to feed herself. The mother then explained to me that her grandmother had fed her until the age of nine years, and her daughter was only four years old.
I explained to the mother that her daughter struggled during the meal to get hold of the spoon and seemed to want to have control of it. In addition, I tried to help the mother understand that her daughter was growing up with American children who are usually transitioned to self-feeding by two years of age. Therefore, when her daughter went to preschool and was not able to feed herself, she would feel helpless and insecure during group lunches.
How to navigate the transition to self-feeding
As I described above, both temperament and cultural expectations have an important influence on how early or late children are transitioned to self-feeding. This is important to keep in mind because this transition can be the beginning of ongoing conflict between children and their caretakers. A child who is determined to get hold of the spoon and feed herself needs to be given the opportunity to practice learning to manipulate the spoon successfully and should not be held down or restrained in order to force the spoon into her mouth. On the other hand, a child who is afraid of getting "messy" needs encouragement to touch the food and in getting used to having some food on her hands instead of immediately wiping her hands when she gets uncomfortable. In either case, it is important to observe and try to figure out the motivation behind your child's behavior and to work with your child's temperament in order to facilitate the transition to self-feeding.
As far as the timing is concerned, in my experience, most children become interested in self-feeding between nine months and two years of age. Parents who have been raised in cultures where children are fed beyond two years of age often do not expect this early self-feeding initiative by their infants and sometimes miss the child's cues for the desire to self-feed. Consequently, they unknowingly become engaged in power struggles with their children. Watching your child's interest in the feeding utensils or food, even if he is banging the spoon or playing with the food, are often early signs of the emerging interest of the young child to participate in the feeding.
When you use two spoons, one for you and a second spoon for your toddler, this allows your toddler to manipulate the spoon and will give him practice in getting the spoon to his mouth. While he is practicing with his spoon, he is more likely to allow you to feed him with the second spoon. It is also helpful to use a little bowl with a suction cup to keep it in place on the tray of the high chair while your toddler is learning new skills, like how to get and keep food on his spoon and get it to his mouth. Guiding your child's hand, if he allows it, bringing it to his mouth, or letting your child feed you are ways that can keep him focused and make feeding an enjoyable experience for you and your child. You can praise your child for successful attempts to get food into his mouth by saying, "What a big boy you are; you can get the spoon in your mouth and feed yourself," but you should not praise him for how much he eats or express concern about how little he may eat at another meal. You should not make the amount he eats a performance, because otherwise, he will learn to use eating or not eating as a way to manipulate your emotions.
Having Your Toddler Join the Family Table
During the first year of life, infants experience rapid development. Toward the end of the first year, they learn to crawl and walk, they learn to pick up little things with the newly developed pincer grasp, and they begin to form words and gestures to make their wishes known. They become toddlers!
This is the time to move their high chair to the family table and let them join in with the family during meals. They are ready to be introduced to finger foods, such as dry cereals, soft breads, cooked vegetables or fruits, or little pieces of pasta. This can be a challenging transition because at this age, playing with the food and tossing it from the tray can become a favorite pastime for the little one and can turn out to be quite a messy affair. At this age, toddlers work on understanding what happens when things disappear out of sight—do they still exist? They love to play hide-and-seek to practice whether Mommy and Daddy are gone when they hide or whether they can be found and will reappear.
While trying to figure out what happens when things or people disappear, toddlers like to practice in their high chair, dropping food or feeding utensils from the tray. They want to see where the spoon or the food goes and whether Mommy will make them come back. This can become quite annoying and tiring for the parents, whereas the toddler can keep up this game forever. It is best to leave the food and utensils on the floor until the meal is finished. A plastic mat under the high chair can catch the spills, and giving your toddler only one or two pieces of food at a time will make it more likely that he will put the food in his mouth instead of playing with it. If he gets too caught up with dropping food and utensils from the tray, you may set some limit and tell him firmly, "no." If he continues with his game, you ignore him and give him no food or feeding utensils for the next minute or two. He will understand that he did something that you do not approve of.
You should not feed him separate from the family because you cannot deal with the mess he makes when at the table. Having toddlers join in with family meals has important developmental and social implications. Toddlers intently watch how and what their parents and siblings eat, and seeing other family members enjoy their food makes them curious and interested to try the foods as well. This is particularly important for toddlers who have experienced aversive reactions with certain foods and who are afraid to try new foods. The comfort they observe in other family members while eating is reassuring for toddlers and gives them courage to want to try the foods as well.
However, socializing your toddler at the table can pose some challenges for parents. At this age, toddlers act like little rulers and expect that everybody goes by their wishes. The more you want them to do something, the more they resist; and the more you do not want them to eat something, the more they want to have it. Being aware of this, you need to find ways to make him feel in control and at the same time, set limits if his demands are unreasonable. Since their little teeth come in only slowly, you need to assess whether he can chew adequately before letting him have meats or hard vegetables that he sees on your plate and demands to try.
For example, if your toddler gets hold of a chicken leg and bites off a piece and without chewing much tries to swallow it, he may gag or choke, and after that become scared to eat any more chicken or other meat. Therefore, if he demands to have some of your food, which you consider not safe for him, you need to tell him that he can have it when he has learned to chew. I have been impressed at how advanced their receptive language is compared to their expressive language, and how much young children between the ages of one and two years understand, even if they cannot say much themselves.
As I mentioned earlier, having your toddler sit at the table and watch you eat is also a great opportunity to get him interested in trying new foods. If he had an aversive reaction to foods (spitting out the food, gagging, or vomiting) in the past, and he is afraid to try new foods, you may be tempted to put new foods on his plate and coax him or try to bribe him to eat at least a bite of a new food. However, the more you attempt to help him to try the new food, the more anxious your child will become. Some school-age children have told me that they get so tense when their parents put new foods on their plate that they can barely eat the foods that they like.
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Excerpted from When Your Child Won't Eat or Eats Too Muchby Irene Chatoor Copyright © 2012 by Irene Chatoor, MD. Excerpted by permission of iUniverse, Inc.. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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