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Approach to a picky eater

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Background

Picky eating is a trait common amongst toddlers. Contrary to what many parents may think, most children who exhibit such eating habits show no long-term consequences in regards to growth. Because the toddler is not growing as rapidly as he or she once was during the first year of life, a decreased appetite is actually a natural occurrence in pediatric development. Children have a form of self-regulation, which involves an ability of gauging how much they need to ingest in order to sustain growth.

Parental concerns usually peak when children demonstrate food neophobia, an unwillingness to try new foods. Between four to 24 months of age, the percentage of children who are picky eaters increases from 19 to 50 percent.

Presentation

  1. Children who only eat a few types of food
  2. Children who gag on solid foods
  3. Children do not eat certain foods
  4. Children who do not want to eat anything at all
  5. Children with texture aversions

Questions to ask

  • When did the picky eating habits start?
  • What new foods have been introduced into the diet?
  • What types of food is the child willing and unwilling to eat?
  • Has the child always disliked food X or has it been a more recent occurrence?
  • What is the rest of the family’s eating routine?
  • Has the child been sick lately?
  • How is the child’s energy level?
  • How often does the child go to the bathroom? Constipation?
  • Has the child been passing excessive gas?
  • Are there sores in the mouth or gums?
  • Is there difficulty swallowing?
  • Is the food being kept down? Is there vomiting after meals? If so, how soon after meals?
  • Is the abdomen tender in any area?
  • Does the child seem distressed?
  • Any recent changes or major events that have occurred?

Physical exam

  • Vitals and growth parameters – plot on a curve (ask family doctor for any previous growth curves to observe the trend)
  • General appearance – respiratory stability, colour, body habitus, dysmorphic features
  • Head and neck: scleral icterus, oral health, jaw range of motion, swallowing difficulties, lymphadenopathy
  • Chest: cardiac exam noting any murmurs, thrills or arrhythmias; respiratory exam noting any adventitious sounds (crackles, wheezes, stridor)
  • Abdomen: tenderness, organomegaly, ascites, bloating, fecal impaction
  • Periphery: pulses, clubbing

Differential diagnoses

  • Food Allergies – children may not understand what is causing their symptoms and may refuse to try new foods. For example, lactose intolerance symptoms are often delayed and parents may not always be able to make the connection
  • Viral Infection – A sudden onset of refusal to eat may signal a viral infection
  • Constipation – Ensuing stomach cramps may create a reluctance to eat more
  • Autism – autistic children may become fixated on certain foods and may even refuse to eat food with different textures or not prepared in a given way.
  • Emotional Distress –children often lose their appetite when they feel anxious or stressed
  • Swollen Tonsils or Adenoids
  • Gastroesophageal Reflux Disease (GERD) – food may come back up after swallowing and children may stop eating to prevent this unpleasant experience
  • Other Underlying Medical Condition – Many diseases that affect the kidneys, liver, or entire body can cause a loss of appetite in children.

Strategies to overcome picky eating habits

  • REASSURANCE – this is a very stressful time for parents!
  • Introduce a food several times before deciding that the child does not like it
  • Expose the child to role model eaters, such as older siblings or other family members
  • Change the way the food is presented
  • Avoid making juice and milk the main source of nutrition
  • Offer a wide variety of foods
  • Try giving the child smaller quantities of high quality food (smaller quantities may be less overwhelming)
  • Do not always give the child what he or she wishes; encourage the child to eat what the rest of the family eats
  • Do not use coercion, punishment or rewards to change eating habits
  • Referral to dietician if desired (may help to reassure parents as to adequate nutritional intake for their child)

References

  1. Carruth  BR, Ziegler  PJ, Gordon  A, Barr  SI.  Prevalence of picky eaters among infants and toddlers and their caregivers’ decisions about offering a new food.  J Am Diet Assoc.  2004;104(1 suppl 1):s57–s64.
  2. Cathey M and Gaylor N. Picky eating: a toddler’s approach to mealtime. Pediatric Nursing 2004; 30(2):101-107.
  3. Ernsperger, Lori, Ph.D. and Tania Stegen-Hanson, OTR/L. Just Take a Bite: Easy, Effective Answers to Food Aversions and Eating Challenges. Future Horizons, Arlington, TX.
  4. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Hepatitis B Vaccine. Accessed online 2/26/2011. http://www.naspghan.org/user-assets/Documents/pdf/diseaseInfo/2008%20Revisions/Hepatitis%20B%20-%20Reviewed%20August%202008.pdf

Acknowledgements

Writer: Michelle Lai

Edited by: Francine Ling

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