When Your Child Won’T Eat or Eats Too Much: A Parents’ Guide for the Prevention and Treatment of Feeding Problems in Young Children

Contents

Foreword

Acknowledgments

Introduction

How to Use This Book

Chapter 1

The Challenges of Early Feeding Development

Chapter 2

Facilitating Healthy Eating Habits

Chapter 3

The Two-Year-Old Executive in the Family

Chapter 4

The Child Who Rarely Shows Signs of Hunger: Infantile Anorexia

Chapter 5

Selective Eaters

Chapter 6

The Child Who Is Afraid to Eat: A Posttraumatic Feeding or Eating Disorder

Chapter 7

Children Who Have More than One Feeding Disorder

Chapter 8

Children Who Eat Too Much

Chapter 9

Get Everybody on Board!

References

In memory of my mother, Maria Koch. Her love and sacrifices have allowed me to pursue my education and find a profession that continues to challenge me and enrich my life by seeing young children blossom in front of my eyes.

Foreword

In this volume, Dr. Chatoor makes available to all parents who are struggling to feed their children effective methods to resolve the difficulties they are confronting. Here, parents gain the benefit of a pediatric psychiatrist who through her systematic observations and original research has made fundamental contributions in this field. Dr. Chatoor’s appreciation of childhood development is the basis of her groundbreaking classification of feeding disorders. Her classification moves the medical profession beyond a simplistic separation of medical from behavioral problems to one that allows fundamental issues, such as appetite generation, excessive selectivity based on sensory difficulties, and fear of feeding due to traumatic experiences to be taken into account.

She has been supported by the National Institutes of Health in her research leading to the description and treatment of a group of children (those with infantile anorexia), whose physiological attributes impair the development of a normal hunger satiation cycle and predisposes them to conflict with their parents. She describes how feeding difficulties can be prevented and how discipline can be established without resorting to coercive measures. Furthermore, she has been instrumental in describing the adverse consequences of force-feeding in both well-nourished and malnourished children.

My confidence in this volume is based on the twenty-five years that I have had the privilege of observing Dr. Chatoor interact with parents and lecture to pediatricians and other health-care professionals. Her ability to take complex ideas and reduce them to functional models of therapy can be attested to by the great many children who have already benefited from her insights.

Benny Kerzner, MD

Emeritus Chief

Department of Pediatric Gastroenterology,

Nutrition and Hepatology

Professor of Pediatrics

The George Washington University

Children’s National Medical Center

Washington, DC

Acknowledgments

I would like to thank the many children and their parents whom I have seen over the last thirty years at Children’s National Medical Center in Washington, DC—especially those who participated in our research studies. They have shared with me their daily struggles and helped me learn how to best help them.

I also want to thank the many colleagues who have worked with me over the years. They have been members of our multidisciplinary feeding disorders team consisting of gastroenterologists, psychiatrists, psychologists, nurses, nutritionists, occupational therapists, and hearing and speech pathologists. I would like to especially thank Dr. Benny Kerzner, professor of pediatrics, who has challenged and supported me for more than twenty-five years, and Laura McWade-Paez, a nurse practitioner who has functioned as coordinator of our multidisciplinary team for almost as long and who has become an expert in feeding disorders in her own right. It has been through this multidisciplinary teamwork that I have been able to get a wider understanding of feeding disorders.

I also want to thank my friends who have shared with me their feeding experiences with their children, and two special people, Nicole Barber and Judith Kerzner Ross, who have critiqued and edited this book for me.

Introduction

In recent years, I have received many e-mails from parents from different parts of the United States and some from Europe asking for help with the feeding difficulties of their young children. Parents who read some of my articles have described that for the first time they understood their child’s feeding problems. Several parents have expressed desperation to get help for their children and told me about their anguish over not being understood by the professionals whom they consulted. These experiences have given me the impetus to write this book. I hope that by reading my book, parents can better understand and deal with the challenges of early feeding development and the special feeding difficulties of their children.

In the first chapter, I address early feeding development, how to introduce solid food, how to transition the toddler to self-feeding and have him join the family table, how long to keep him at the table, and how many foods to offer him at any one meal. In the second chapter, I describe specific feeding guidelines how to help young children develop internal regulation of eating and healthy eating patterns. In the third chapter, I discuss limit setting for the two-year-old executive in the family and how to teach young children self-calming. These first three chapters are helpful for all children to prevent feeding problems and later eating difficulties. They are critical to treat children who do not eat enough as seen in infantile anorexia, and those who eat too much, leading to obesity.

The following chapters address specific feeding disorders, how they develop, what we can learn from research to better understand them, and what parents can do to help their children with these feeding disorders. Specifically, the fourth chapter is centered on infantile anorexia, the child with a small appetite who rarely shows signs of hunger, who becomes underweight and often stunted in his growth. At the end of the chapter, I present two cases: the symptoms and the development of one child who did not receive any specific intervention and the course of another child whose parents successfully participated in our treatment study of infantile anorexia.

The fifth chapter deals with selective eaters. This is the most commonly seen feeding problem in young children. I explain the distinction between children who frequently change their food preferences versus those who consistently refuse to eat certain foods because of the taste, texture, temperature, smell, or appearance of the foods. I have described this feeding disorder as sensory food aversions. Using information from the research literature, I have developed a model to understand and treat this feeding disorder. At the end of this chapter, I describe the clinical picture and the treatment of a few children of different ages and with various degrees of severity of symptoms of sensory food aversions and other associated difficulties.

It is important to keep in mind that both feeding disorders—infantile anorexia and sensory food aversions—can be seen on a spectrum of severity of symptoms and that they can co-occur in the same child. As I explain in chapter 7, it is important that the intervention addresses both feeding disorders in order for the treatment to be successful. It is also noteworthy that the earlier the child’s feeding problems are recognized and dealt with, the better the outcome will be.

In the sixth chapter, I explain a less common feeding disorder: the child with a posttraumatic feeding disorder who is afraid to eat. This problem can occur at any age from infancy onward and has also been described in adults. Children who develop this feeding/eating disorder often struggle with underlying anxiety and frequently need professional help.

The seventh chapter deals with children who may have two or more feeding disorders at the same time. The most common combination is that of infantile anorexia and sensory food aversions, but other combinations can be seen as well, such as sensory food aversions and a posttraumatic feeding disorder. It is very important that each feeding disorder is diagnosed and addressed in order for the treatment to be successful. These complex feeding disorders are very challenging to treat and often require professional intervention.

The eighth chapter focuses on children who eat too much, and how we can understand their eating behavior and help them change. I have included this feeding problem in this book because I have seen some families with one child having infantile anorexia and being short and underweight, and the second child being tall and overweight. This speaks to the strong genetic predisposition for these feeding disorders. However, when the parents introduced the feeding guidelines for the family and the children learned to regulate their eating internally, the underweight children ate more and gained weight, whereas the overweight children ate less, stopped gaining weight, and some even lost weight.

This leads me to the final chapter to get everybody on board. Eating should be a family affair, and the prevention and treatment of these feeding difficulties can only be successful if the parents work together and get everybody on board who helps feed their children. I always remind parents that what is good for their children is good for the parents as well. Regular meals will benefit everybody, and family meals will bring the family together.

How to Use This Book

Parents who want to help their children to develop healthy eating habits in those important first three years of life should read the first three chapters of the book to navigate through this early developmental period. In these early years, the foundation of a child’s eating habits are laid, and often poor eating habits (such as random snacking; eating while watching television or movies; and frequently having candy, dessert, and junk foods) become established. Once children become used to eating this way, their eating is no longer internally regulated by their physiological needs, but becomes controlled by these habits and their emotional needs. This is often the beginning of dysregulated eating and makes children vulnerable to become overweight or develop eating disorders during later childhood, adolescence, or adulthood.

If parents already experience feeding difficulties with their child, I suggest that they look at the table of contents to see what chapter addresses their major concerns. If their child rarely shows signs of hunger and is otherwise active and playful, they should read the chapter on infantile anorexia. If on the other hand, the child is selective and consistently refuses certain foods, they should read the chapter on selective eaters and sensory food aversions. If their child were to have both problems—that she refuses to eat certain foods and eats only small amounts, even when given her favorite foods—the parents should read both chapters and chapter seven on children who have more than one feeding disorder at the same time.

If the child appears fearful of eating after he experienced gagging, choking, vomiting, or was subjected to medical procedures, such as insertion of feeding or breathing tubes, they should go to chapter 6, which deals with the posttraumatic feeding disorder. On the other hand, if the child eats too much, chapter 8 deals with that problem.

After having read the specific chapter that addresses their child’s problem, I advise all parents to read chapters 2 and 3, which will help them to establish healthy eating habits for their children. As I have mentioned earlier, the guidelines for feeding and limit setting are important for all children, but they are critical for children who eat too little or eat too much in order for them to learn to regulate their eating according to feelings of hunger and satiety.

This book is not meant to replace seeking professional help for the child’s feeding difficulties from the family’s pediatrician or other specialists. It does not address feeding difficulties that may be associated with the child’s medical or neurological problems, and it is not meant to give parents dietary advice. I have written this book to help parents prevent feeding and eating disorders of their children and to help especially those parents who cannot access professional help for the behavioral problems of their children that are related to feeding.

Chapter 1

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