Amy LovellPaediatric Dietitian

Starship Hospital

Professional Teaching Fellow

University of Auckland

14:00 - 14:55 WS #51: Fussy Eaters and Food Fads in Kids

15:05 - 16:00 WS #63: Fussy Eaters and Food Fads in Kids (Repeated)

DISCLOSURE

My PhD research (2014 – 2018) was part of a wider three year

research project that received an investigator-lead grant from

Danone Nutricia

No other conflicts to disclose

THE FIRST 1000 DAYS: A T IME OF RAPID GROWTH AND DEVELOPMENT

* McMullen, 2009

BreastfeedingPregnancy Weaning Toddler

The period from the moment of conception to when a child is aged 24 months

What you do, eat or experience

during the first 1000 days has lifelong consequences for your health.

WHO Growth Standards, 2006

22

20

18

16

14

12

10

8

6

4

gram

per

day

-9 months to 2 years10

Age (years)AdultTeenagers

The fastest speed of growth occurs between -9m (conception) and 2 years

THE SIGNIFICANCE OF THE FIRST 1000 DAYS: A T IME OF RAPID GROWTH

Cognitive development

Immune maturationDigestive system

Metabolic organs Body composition

… AND A TIME OF SIGNIFICANT DEVELOPMENT

CRITICAL WINDOW OF OPPORTUNITY

Birth-9 months Weaning Adults

Healthy Adults

Optimal Growth

Altered growth

Disease

… WITH AN IMPACT ON LATER LIFE HEALTH

DEVELOPMENT OF FEEDING SKILLS & TASTE

• Suck /Swallow

• Taste

• Environmental (Addessi,

Galloway, Visalberghi & Birch, 2005;

Breen, Plomin & Wardle, 2006)

• Swallow

• Taste

• Genetic (Wardle & Cooke 2008)

• Environmental (Addessi, Galloway, Visalberghi

& Birch, 2005; Breen, Plomin & Wardle, 2006)

IN UTERO AT BIRTH

Physical growth Cognitive development Immune maturation Digestive maturation

FOUR KEY DEVELOPMENTAL STAGES IN EARLY CHILDHOOD – ALL SUPPORTED BY NUTRIT ION

• 1 cell to 500 trillion cells by three

• 1st year: triple birth weight

• Greatest period of growth

• By three years of age:

− 80% adult brain mass

− 3x ↑ in brain weight

− 900 words

Neonate Age 25

• By two: development of gut

barrier (immune function)

• Crucial early colonisation with

bacteria

• Influenced by the mode of

delivery & nutrition

• Born with immature gut.

• The digestive & absorptive

capacity develops in early

life

© Gluckman, 2013

THE ENVIRONMENT HAS A GREATER IMPACT ON OUR HEALTH IN LATER LIFE THAN GENES

WEANING

1Mennella, JA et al (2001) 2Sullivan & Birch (1994) ; 3Scaglioni S et al. (2011).

Solid foods exposure2

Fluid sensory experience1

Social environment3

Food preferences and behaviour

Flavour, taste… Appearance, taste, texture… Mother-child interaction….

DEVELOPMENT OF HEALTHY EATING HABITSSTARTS IN UTERO AND CONTINUES IN EARLY L IFE

✓ Fruits tend to be better accepted than

vegetables

✓ Variety and repetition is an effective

strategy

✓ Delayed introduction to textures may

increase chances of ‘fussy eating’

✓ Healthy eating habits formed early in

life track into childhood and beyond

DEVELOPMENT OF HEALTHY EATING HABITS

© www.activebabiessmartkids.com.au

TODDLERS

WHO Growth Standards, 2006

115

105

95

85

75

65

55

45

351 2

cm

Age (years)

22

20

18

16

14

12

6

01 2

97%

kg

Age (years)

3%10

8

4

2

Height Weight

RAPID GROWTH DURING TODDLERHOOD>15% IN HEIGHT & >25% IN WEIGHT IN 1 YEAR!

The equivalent of a 70 kg

adult putting on 17 kg of

weight in one year!

IRON

x 6.5

VITAMIN D

x 5.6ENERGY

x 3.2

SMALLER STOMACH CAPACITY

X 5

Per kg of body weight (for reference adult of 70 kg)

NHMRC. 2006. Canberra, ACT

YOUNG CHILDREN HAVE SPECIFIC NUTRITIENT NEEDS

Baird J. BMJ 2005; 331 (7522):929European Food Safety Authority. EFSA Journal. 2013; 11(10):3408Grant CC, Wall CR, Gibbons MJ, Morton SM, Santosham M, Black RE. Journal of Paediatrics and Child Health. 2011; 47(8) 497-504WHO. Ata Paediatrica 2006; (450):27

IRON

VITAMIN D

DHA

ALA

IODINE

Too Little

Too Much

Childhood diet

PROTEIN

ENERGY

… THE REALITY OF NUTRITIENT INTAKE

COMMON ISSUES IN TODDLER NUTRITION

Milk

Constipation

Limited variety

Independence

Food BehavioursFood Neophobia

Fussy or picky eating

… HOW COMMON?

25 - 45%

in normally developing children

13 - 80%

in developmentally disabled children

Ex premature (<37 weeks)

GORD

Respiratory problems

Cerebral Palsy

Developmental delay

ASD

Tube feeding

The ability to keep and manipulate food or

fluid in the mouth and swallow it.

The process of setting up, arranging and

bring food or fluid from the plate or cup

to the mouth (self-feeding).

20

EATING

VS.

FEEDING

21

FEEDINGAll organs

All muscles

Learning (style/capacity/history)

Development

Nutritional status

Environment

PICKY EATER VS. PROBLEM FEEDERDecreased range/variety

Will eat ≥30 foods

Foods lost due to “burn out” usually regained after 2 weeks

Tolerates new foods on plate (can touch and taste)

Eats ≥1 food from most texture groups or nutrition groups

Able to add new foods to repertoire within 15-25 steps

Eats with family, but usually different meals

Sometimes reported as a “picky eater” at well child check

SOS Approach. Kay A Toomey, Erin Ross 2002/2010

Restricted range or variety

Will eat <20 foods

Foods lost are not re-acquired

Cries/falls apart with new foods

Refuses entire categories of food textures or nutrition groups

Adds new foods in >25 steps

Eats different foods to family, often eats alone

Persistently reported to be a “picky eater” across multiple well child checks

HOW DO YOU KNOW THERE’S A PROBLEM?

✓ Poor weight gain

✓ Faltering growth

✓ Significant meal time tantrums

✓ Meal times taking longer than 40

minutes

✓ Refusal to feed oneself

✓ Eating fewer than 12 foods

(extreme picky eating)

REPEATED EXPOSURE….BUT HOW OFTEN?

Number of exposures required for acceptance of a new food or flavour

• Very few in infants

(Maier et al., 2007; Sullivan & Birch, 1994)

• 5 – 10 in toddlers (Birch & Marlin, 1982; Birch, McPhee et al., 1987)

• Up to 15 in 3 – 4 year olds

(Sullivan & Birch, 1990)

… Initial rejection is commonly interpreted as genuine dislike for foods being offered (Cooke, 2007; Cooke et al. 2004; Skinner et al. 2002)

THE DIVISION OF RESPONSIBILITYELLYN SATTER

Parent’s Responsibilities

✓ WHAT foods are offered

✓ WHEN foods are offered

✓ WHERE food is offered

(no distractions)

Child’s Responsibilities

✓ HOW much to eat (as many

servings as they like)

✓ IF they will eat (they may

choose not to eat)

© www.ellynsatterinstitute.org

Role modelling is an essential part of this relationship

CHILDREN’S

EATING JOBS• Children will eat (if there are no

underlying issues)

• Children will eat the amount they

need

• Children will learn to eat the food

their parents eat

• Children will grow predictably

• Children will learn to behave well at

meal times

PARENT’S

FEEDING JOBS

• Provide regular meals & snacks

• Make eating times pleasant

• Show children how to behave at meal

times (lead by example)

• Be considerate of children’s lack of

experience without catering to likes

and dislikes

• Avoid food or beverages (except

water) between meal & snack times

• Let children grow up to get bodies

that are right for them

Each meal should have a beginning (transition activity, sit at table),

middle (family style serving, focus on modelling, reinforcement,

exposure) and end (clean up, dishes, wash hands)

ROUTINE

Match the food offered to the child’s oro-motor

development

PRESENT IN MANAGEABLE BITES

Use the same cues to eat, placemats, table settings

STRUCTURE MEALS & SNACKS

Avoid grazing

Avoid substituting uneaten meals with milk, treats, other

foods

CREATE A FEEDING SCHEDULE

Ensure postural stability at the table

90°- 90°- 90°

POSTURAL STABILITY

04

05

02

01

03

TIPS FOR MANAGING FUSSY EATERS

Several foods on the table for exposure

Offer sweet tastes at the end of the meal to avoid appetite suppression

EXPOSURE

Limit meal durations to 30 minutes

Limit snack duration to 15 minutes

E.g. Dinner Family serving style (5 mins) + eating (10 mins)

+ clean up routine (5 mins)

LIMIT EATING OCCASIONS

1 x protein + 1 x starch + 1 x fruit/vegetable

For each meal or snack

1 tablespoon per food per year of age (up to age 10)

THREE FOODS AT ANY ONE TIME

If given permission to spit = more likely to taste

Spitting is a normal part of learning to eat

Children that don’t spit will gag/choke/vomit

TASTE & SPIT OUT

Some volume needs to be eaten

Make ONE meal (combinations don’t have to make sense!)

ONE PREFERRED FOOD AT EVERY MEAL

09

10

07

06

08

FURTHER SUPPORT

ACTIVEating ProgrammeAdvancing Children Therapeutically In

Variety Eating

An evidenced based programme, which incorporates

NZ food and nutrition guidelines to address feeding

issues in children who highly restrict the foods they

eat

The University of Auckland Clinics

Nutrition and Dietetics Clinic

OR

Speech and Language Therapy Clinic

CONCLUSIONS

✓ The first 1000 days offer a unique window of opportunity to build

long-term health. The right nutrition during this critical period

really matters.

✓ Toddlers have specific nutritional needs that may not be met by

adult diets (at risk nutrients: iron, vit D, essential fatty acids)

✓ Feeding a toddler can be challenging for parents. ‘Neophobia’

(the fear of new foods) may occur from 18 months of age, and a

toddler may be a ‘ fussy eater’.

Guidance, reassurance and support can give parents the

confidence to change toddlers’ mealtime routines.

CASE STUDIES

ANNIE: 18-MONTHSL I M I T E D D I E T

• Breakfast: Rice bubbles with milk

• Lunch: jam sandwiches (white bread)

• Dinner: fish fingers, pasta, stewed apples with yoghurt

Additional history:

• Problems with firm textures, lack of variety (but when asked, Sarah

reports she eats approximately 25 foods)

• Will only sit at the table for 10 minutes max

• Her Well Child book indicates she’s tracking on the 25th centile for weight

and height

Current strategies at home:

• Top up with milk after meals to avoid being hungry + 2 x 200 mL bottles

of toddler milk before nap/night sleep

• Sarah feeds Annie at every meal

Annie’s mum (Sarah) comes to see you because she’s worried that

her daughter is a ‘fussy eater’. She gives you a brief diet history of

what a usual day looks like:

• Limit milk intake

• Try new foods/textures with familiar foods

• Finger foods as often as possible.

• Finish the meal within about 20-30 minutes

• Positive reinforcement (not food)

You are confident that there is no medical cause for Annie’s apparent fussy eating, and in light of her

consistent growth along the 25th centile, you feel comfortable giving Sarah advice.

… STRATEGIES FOR ANNIE’S MUM

• Charlie started to show interest in food at around 5.5 months

• She never liked being fed, but wanted to touch the food and hold the

spoon

• At 6 months, Charlie gagged on some rice cereal fed to her by mum

(she now gags on any foods with texture)

• Charlie’s mum is particular about mealtimes, including cleanliness and

getting Charlie to eat exact amounts of food

• Mealtimes are stressful for both Charlie and Mum

• At the last few Well Child appointments, it is noted that Charlie is

losing weight (a drop from the 50th to the 25th with a continued

downward trajectory)

• Charlie often refuses to eat and mealtimes can take 45 minutes

• Charlie doesn’t show any overt signs of being ‘hungry’ between meals.

• Charlie has 600 mL infant formula a day

CHARLIE: 9.5 MONTHSFO O D R E F U S A L

Charlie’s parents come to see you because their 9.5 month old

child is refusing food.

They give you a brief history of Charlie’s experiences with food:

• Refusal to eat adequate amounts of food for at least ≥ 1 month

• Onset when starting complementary feeding (~6 months)

• An episode of choking/gagging

• Charlie rarely communicates hunger, lacks interest in food

• Growth deficiency

… WHAT’S THE BEST WAY FORWARD FOR

CHARLIE?

You identify areas of concern given Charlie’s presentation and history, these include:

… THE BEST WAY FORWARD FOR CHARLIE

Further investigations:

• Rule out nutritional deficiency such as iron deficiency as a cause for poor

appetite

• ? Referral for assessment by a paediatrician for any underlying cause for

progression towards faltering growth

• ? Referral for assessment by speech therapist for any medical cause for

feeding difficulties and choking/gagging episodes

• ?Referral to a dietitian to guide feeding progression and facilitate growth

… SIMPLE FIRST LINE STRATEGIES✓ Minimise pressure to eat and encourage feeding independence

✓ Accept that food exploration and messy play is a normal part of learning to eat

✓ Offer small portions and allow child to ask/indicate for more

✓ Limit meal times to 20-30 minutes

✓ No distractions during meal e.g. toys or TV

… ENLIST OTHER HEALTH PROFESSIONALSE .G . D I E T I T I A N✓ Importance of graded experiences to promote oral motor skill development and texture progression

✓ Provide mum with strategies for managing the ‘mess’ with self-feeding

✓ Create stronger hunger cues – feed every 3 – 4 hours, no snacks

✓ Ensure formula intake doesn’t displace appetite for foods

✓ Avoid giving attention to Charlie when gagging maintain social enjoyment of meals

✓ Guidance on texture progression, nutrient prioritization and regular growth monitoring

✓ Support for Charlie’s parents