Dear Healthcare Professional: What You Need To Learn About Feeding Children

Dear Healthcare Professional:

Recently, we visited your office about our child’s selective eating. We asked for help on weight, nutrition and feeding. Unfortunately, you seemed unable to answer our questions and instead attempted to address development, behaviour and your opinion about what our child should be eating. While these issues may be relevant to our case, your suggestions of “he won’t starve himself,” “just feed him fruit and vegetables for snacks,” and “he’ll get hungry eventually” contradict the best practice guidance I have been investigating since we met.

First, you did not seem to be aware of the DSM-V diagnosis of “Avoidant and Restrictive Food Intake Disorder” (ARFID). While a diagnosis is not in itself particularly useful, it does highlight that certain cases of “fussy eating” may be on the extreme end of normal or indicate the need for more rigorous analysis than the more straightforward cases you might commonly see. Regardless, there is always a reason why a child struggles with eating and very rarely, if ever, is it because the child is using food to manipulate the parent.

Second, you may not be aware that issues such as sensory aversions, post traumatic stress, anxiety and temperament are very relevant. In such cases, behavioural approaches can do more harm than good. You may also not be aware of studies by Dr. Irene Chatoor that show coercive and pressured feeding approaches are more likely to exasperate feeding issues. I also strongly recommend the work of family therapist and registered dietitian, Ellyn Satter, creator of the Division of Responsibility in Feeding and her approach to developing Eating Competence as a proactive and preventative model for your clients. Learning to feed our family from a place of trust has benefited not only my child, but our family as a whole.

Parents coping with a feeding challenged child live in a state of long term stress and anxiety themselves. I respectfully ask you to reconsider encouraging coercive feeding methods and to acknowledge the impact feeding struggles have on the entire family. We were unable to follow much of the advice you gave us, as your recommendations increased my child’s anxiety around food, and elevated the overall family stress to intolerable levels. I sincerely hope you find the linked references useful and beneficial as part of your continuing professional development.

Mealtime Zen: Experimenting with Novel Food

Experimenting with novel food for personal reasons is at the higher end of the eating competence scale. It means I am certain of finding acceptable food in sufficient quantity, and I am not stressed about wasting a little food to try something I’m not familiar with. I trust that if I eat a variety of food that appeals to my senses, in satisfying amounts on a regular basis, I will very probably do quite well supplying my caloric and nutritional needs.

Further down the eating competence ladder, I have a child who is confident about finding enough to eat, and comfortable with finding acceptable food. Life, in all her sadistic irony, has hinted that gluten might not have a future at our table, conveniently as TJ starts to experiment with food that tastes good.

TJs anemia might be it’s own unique thing, or it could be the symptom of another issue, such as an inability to absorb iron. This complication is common with gluten intolerance and celiac disease.

TJ eats a lot of gluten. Croissants, crackers, bread, bagels, muffins, pizza… Gluten is a HUGE source of calories! I am not willing to sacrifice his trust in a reliable food source by eliminating gluten from his diet on a hunch. However, should this become something we need to take seriously, I would like to prepared.

I spent some time this weekend looking at gluten-free flours, determined to have a few recipes in my arsenal should we need them. There is quite the variety to choose from, one that I found especially interesting is chia.

Chia flour (or seeds ground into a powder) can replace the flour in a recipe 1:1. (BTW, chia can be used in place of eggs.) This is one concern already solved, as gluten-free to wheat flour conversions involve more math than I want to commit to. I can’t seem to get around the expense factor of avoiding gluten – a small bag of ground chia seeds (about 1 3/4 cups) is $14.99 at my local supermarket. (yeesh)

Chia seeds are marketed as a nutritional powerhouse. They are rich in omega-3s and full of fiber. Recipes describe the texture of goods baked with chia flour as “light” and “fluffy”. You have my attention.

More than how nutritious any one ingredient is or how a combination of ingredients create nutritional paydirt, if it doesn’t taste good, no one is this house is going to eat it. Chia has a big responsibility if it’s going to become a welcome part of the kitchen contents:

  1. Chia seeds must meet or exceed stringent criteria to pass critical assessments of texture and taste, and
  2. It must achieve this high standard using wheat flour’s crowning creation.

Chia PowerHouse Banana Bread

1 cup softened butter
2 cups sugar
3 eggs
4 frozen (slightly thawed and mashed) bananas

2 cups ground chia seeds (chia flour) *
1 tsp baking soda
2 tsp baking powder

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In a large bowl, combine butter and sugar until smooth. Add eggs and bananas. Mix well.

In another bowl combine chia flour, baking soda and baking powder. Add to banana mixture and mix well. Let stand for 15 minutes. Use this time to pre-heat oven to 350F and grease 3 loaf pans.

Pour batter into loaf pans 2/3 full. Bake for one hour.

* * *

* In defense, this is my first attempt with gluten-free baking and the bread didn’t set quite as well as I had hoped. I had to use 1 3/4 c chia flour + 1/2 c quinoa flour because I didn’t have enough chia on hand. (I am holding quinoa responsible for the goo-factor). My wheat-flour banana bread is a moist, mouth-watering, world-renown delicacy (for reals). This, despite the flour quantity and my inexperience, was surprisingly close. Some recipes call to let the batter stand and give the seeds time to absorb the liquid, which I’ve added to the instructions.

Adjustments to perfect this recipe are welcome. Enjoy!

The Mealtime Hostage Pantry: Add Zen To Your Table

Feeding your family well starts with a relaxing and enjoyable environment. The Mealtime Hostage Pantry has an assortment of items dedicated to putting the zen into family feeding.

In the Pantry, you’ll find an assortment of tableware, utensils, cast iron pots and pans, highly recommended reading and more. The cost is the same to you, but when you purchase items through the Mealtime Hostage Pantry, a small portion of the sale helps us continue to support families with feeding struggles around the world.

I’m loving the lazy susan that makes serving meals buffet style not only functional, but also fun. Click here to visit the Pantry and find some zen for your table.

lazy susan

Welcome to Anemia

One of the most common parent concerns with a selective eating child is the lack of protein in their diet. Protein, as a macronutrient, is relatively easy to come by. It’s in almost everything – grains, dairy and of course meat and alternatives. Usually, when a parent says “I’m concerned about the lack of protein in my child’s diet”, they are referring to the absence of meat options. Parents have good reason to be concerned. Meat is an excellent source of iron, and iron is required to help oxygen rich blood circulate around the body.

When meat and vegetables aren’t part of the dietary rotation, iron can become a concern, as it is for us. TJ’s recent bloodwork shows levels of ferritin (stored iron) are slowly on the rise. Hemoglobin, hematocrit and red blood cell counts, however are all ‘abnormal’ (low) and have peaked my interest in learning more about anemia.

Anemia has some interesting symptoms, all of which are concerns that have been brought up at one time by teachers, psychologists and myself; the ‘ignoring instructions’, the ‘not listening’, the behaviour that looks like ‘defiance and aggression’.

The most common symptoms of iron deficiency anemia are:

  • lack of energy, or tiring easily (fatigue)
  • difficulty concentrating
  • irritability

Fatigue, difficulty concentrating and irritability would explain the ‘ignoring instructions’, the ‘not listening’, the ‘defiant and aggressive’ behaviour. Of note, the days when TJ has been described as being the most challenging at school are also the same days he falls asleep on the (very short) car ride home.

While I can appreciate how challenging it is for a teacher to have a child who isn’t mentally and/or physically up to the task of learning, it concerns me how often I’ve been approached by educators with their diagnostic opinion. “Is he on medication for his behaviour?” “My son has ADHD too.” “Oh, he’s a very picky eater, he’s probably on the spectrum.” Those in the know, the educated mental health professionals, have not been able to explain TJ’s behaviour with a diagnosis, (a) because he doesn’t neatly fit any specific diagnostic criteria, and (b) he’s a child using behaviour as a communication tool. The question everyone needs to be asking is what is creating the behaviour.

The new school is making sure that TJ’s psychological, sensory and learning needs are in competent hands, while I search for medical answers. One possibility could be that TJ doesn’t have enough red blood cells to carry sufficient oxygen for his growing body’s needs. Most of the literature on iron deficiency anemia states that iron stores correct within a few months with supplementation. Ferritin levels are within the range of normal, but after a year of supplementation, ferritin remains on the low end of this scale. Is that what is meant by ‘corrected’? Are low iron stores normal or just not a medical emergency? 

Hemoglobin, hematocrit and RBC are all lower than last year’s measurements despite the daily iron supplement. These are the three (according to what I’ve read) that determine anemia, and indicate how well the blood transports oxygen. Are these numbers lower because iron stores are rising? Do we need to know why all of these numbers are decreasing? Is this a chronic problem, indicative of an underlying condition? Is my son okay!?!? Google is far to vague and scary for me to learn about anemia so I booked an appointment with our family physician to discuss the results and get some answers.

The doctor says he doesn’t see anything that concerns him. He is evasive with my questions, only telling me that we need to continue with the iron supplement.

Me: “Doctor, we’ve been giving TJ the iron supplement for a year now, but his numbers are still low. Now that you’ve seen two comparative readings, do you recommend increasing the dosage?”

I thought it was a very reasonable question, and I thought I could expect an equally sensible answer.

Doctor: “He needs to get his iron from solid food sources. Beef, broccoli and other green vegetables.”

Me: “But he doesn’t eat any meat or vegetables.”

Doctor: “Oh, he is a selective eater?” He uses the lingo. Maybe our doctor knows what he’s talking about?

Me: (hopeful) “Yes, he is a selective eater.”

Doctor: “You have to make him eat his food.” Did you hear a ‘pop’? I distinctly heard the ‘knows-what-he’s-talking-about’ bubble pop.

Me: “How… um… exactly do you propose I ‘make’ him eat?”

Doctor: “You take his privileges away. No TV until he eats what you tell him to. And he gets nothing else until he learns to eat the food you serve him.”

Me: “And how long am I supposed to do this for? ‘Selective’ … remember? He will not eat meat and vegetables, and if I offer nothing else, he will not eat. At all.”

Now, blogging as I do, and through chatting with other parents, I’ve heard of doctors saying some pretty stupid stuff. Like off-the-scale-of-ridiculous stupid. Are you ready? 

Doctor: “He can go for two weeks without solid food. Then he will learn to eat properly.”

Whaaa….??

I’m not a doctor, but wouldn’t a physician want to be reasonably certain that what he says is based in fact, or at the very least, true? As a parent, and one who is very familiar with selective eating, I can tell you confidently, there are no facts or truth to support starving a child into dietary compliance.

Imagine for a moment, that I believed this irresponsible hogwash, because the doctor says ‘eventually, the child will get hungry.’ This would not only backfire spectacularly, it would put the health of my child in jeopardy. Most important, I would lose something absolutely essential to feeding a child who is cautious about food. His trust in me to feed him.

I refuse to be as abusive as our physician suggests, and I don’t hide my ‘wtf’ well. In the public hallway, the doctor ducks into another exam room, calling after me to, “Just keep giving him the supplement” as he closes the door between us.

But when? And how much? Why can’t you just answer my damn question!!??! Or admit that you don’t know! Aaaarrgh!

That’s when I realize that TJ has overheard this entire exchange. He turns to me, horrified and clearly frightened by the doctor’s advice. I assure him there is no way this is going to happen. “Oh, thank you, Mommy!” he says, squeezing my torso in grateful relief…

… and then takes the edge off the tension with, “That doctor is dumb.”

Everybody has a talent, right?

I did let TJ know that, yes, there are foods that would help give his body the iron he needs, but he can try these foods when he’s ready. Together, we’ll figure this out, meaning I will continue to provide the opportunity and the atmosphere for him to decide if he wants to eat meat and veg and how much. Regardless, there will ALWAYS be food he can eat.

Even though our family doctor carefully avoided answering all of my questions, he was absolutely clear on one point. It’s time to find a new family physician.

ARFID and The Very Real Fear of Food

Last night, Amber Scott appeared on ABC’s documentary show 20/20 and explained her dysfunctional relationship with food to the viewing public.

ARFID (Avoidant Restrictive Food Intake Disorder) is one of the new additions to the DSM, and still has that unique strange affliction stigma attached to it. Even among the medical and psychiatric community, it is poorly understood. Amber did a great job explaining how difficult it is to get past the sensory qualities of food, and illustrates the potential for long term issues with food when children and parents are not properly supported with feeding.

Unfortunately, 20/20 made it a priority to zero in on the one food Amber feels most comfortable with, dismissing a very real fear of unfamiliar food as an “addiction” to French fries. It looks like the selective eating community shall endure that pungent stigma smell for a little while longer.

Amber is very generous with clues. Around 1:10 she mentions a traumatizing childhood experience with peas; at 2:28 she discusses how a limited diet is a living nightmare; at 4:20; she mentions the devastating fear of not being accepted; at 5:08 she describes sensory sensitivity and how food feels in her mouth. From 5:26 through to 8:24, we watch Amber’s agonizing distress over a bowl of plain white rice.

The host says “what happens next is shocking”. She obviously hasn’t been paying attention.

Up until this point, you hear both Amber and a nutritional therapist describe how the selective eater perceives food. It isn’t edible. It looks like bugs. Amber asks a valid question – what is that mechanism that tells us eating french fries or pasta is food and a stick or rocks is not? White rice is, as far as Amber is concerned, the same as a bowl of rocks.

This is a very common perception of food among selective eaters. One very expressive nine year old explains eating as “being in a dungeon with a wall of spikes about to close in.” This same child has also said “it’s like diving into a pool full of sharks. No matter how much I want to swim, I just can’t because of the sharks.”

With that in mind, witnessing Amber’s reaction to a few grains of rice really isn’t all that shocking. It’s actually very understandable. I wouldn’t do as well as she did in a pool full of sharks. The fact that she got a grain of rice into her mouth is nothing short of amazing.

Great-White-Shark-1

Kinda makes you want to jump right in… 10, 15, maybe 20 times, doesn’t it? I want you to reconsider the concept of forced exposure and that children need to taste a food multiple times before they will accept it. Amber tried a single grain of rice and as the video clearly states at 7:28, “Amber declares she won’t be trying a new food any time soon.” There is a valuable lesson to take away from Amber’s experience with rice – the importance of not pressuring (in this case, insisting) a child (or adult) has to taste food they aren’t ready to eat. Her struggle with a few grains of rice is palpable, and her display of panic and fear is very real. Tactics that insist someone (usually the child) eats as another (often the parent) demands only reinforces how ‘dangerous’ new and unfamiliar food can be.

At 8:00 listen to the shame and guilt Amber has endured, despite both her own and her physician’s statements that she is in perfect health.

As Amber so eloquently states at 9:06, “It’s a very old fashioned kind of mentality to tell your children you’ll eat what I made or you’ll starve.” It does sound very peculiar to insist someone jumps into a pool full of sharks or they will be denied dessert, or sent to bed hungry. If we want children to grow up eating as well as we hope they will, wouldn’t it be more useful to make eating a joy instead of an ultimatum?