Sunday, January 20, 2013

Eating from the Trash, Pediatric Nutrition Drinks & More - Q&A w/Dr. Rowell on Adoption/Feeding Issues - Part II

Dr. Katja Rowell, MD
Part I of our Q&A with Dr. Katja Rowell, MD, can be found here. If you haven't read it, it's not to be missed! It deals with food hoarding and integrating older foster/adopted childrens' food preferences into your family.

Dr. Rowell, author of the new book Love Me, Feed Me: The Adoptive Parent's Guide to Ending the Worry About Weight, Picky Eating, Power Struggles and More (aff) was kind enough to give two copies of her book away to my readers (see this post - giveaway now closed!) and has answered another two reader questions for the second part of our Q&A on adoptive and foster care feeding issues. You can find much more on both of the topics addressed here in the book.

Reader Question #3: I have an adopted son (2 years old) who receives food therapy services due to some sensory issues he will not chew food and we still cannot get him to eat. His doctor and nutritionist has prescribed him Bright Begginings Pediatric Drink to make sure that he is getting proper nutrtiion. My question is this I hate giving him three of these a day because he does not eat, what types of food would be good to introduce to him that do not over stimulate him so that he will start eating "normal" foods?

Whether it was something the child was born with (like a cleft palate, or a painful condition such as reflux), or neglectful or traumatic feeding, foster and adopted children are more likely to present with feeding challenges. How we address and meet those challenges is critical. I find that the most selective children also tend to be smaller, and that worry about size fuels the counterproductive feeding practice of only serving supplements or a few favored foods. Oftentimes I also see children who are very bright, independent, or sensitive to pressure or encouragement. If your child tries to draw, for example, and you try to help him, does he let you, or does he get upset and want to do it himself? (These are general observations of traits I often see with selective eaters.)

Too often, when parents ask for help from their doctors (most of whom receive NO training in feeding and weight issues) the solution is a supplement. The solution is in “what” you are feeding your son, and the “how” question is often ignored. As the World Health Organization wrote, “Inappropriate feeding practices are often a greater determinant of inadequate intakes than the availability of foods in the households.” So, before I get to your “what foods to introduce” question, allow me to talk briefly about the “how” of feeding.

Research tells us that the more we push children to eat, usually the worse the child eats and grows. The pressure is met with resistance, and our efforts often backfire.
  • Feed based on what your child can do. If you have a three year-old who eats more like an older infant, feed him based on what he can do. Slowly increase texture and tastes as you can.
  • Ask your speech therapist for suggestions for safe foods, and ideas to progress with texture.
  • Institute structure. Too often parents are told to push the child to eat all day, which deprives the child of the opportunity to develop an appetite. Serve him balanced meals and snacks every 2-3 hours, with only water in between.
  • Initially try serving the supplement only with snacks. Talk to a pediatric RD (registered dietitian) familiar with Ellyn Satter's Division of Responsibility if he truly is compromised with nutrition and growth. (My book has a list of questions to ask RDs and therapists.)
  • How are you trying to “get” him to eat? Games, stickers, TV, begging? Often, pressure backfires.
  • Work on the Division of Responsibility in feeding. You present the foods, he decides how much and if to eat from what you present. (See my answer to Reader Question #2 in Part I of my Q&A on this blog for ideas on planning meals for a selective eater. Something he eats, even if it’s yogurt or applesauce needs to be included at every meal and snack. This is not “starve him out.”)
  • If meals have been unpleasant, or a battle with lots of tears and stress, you need to rehab the mealtime atmosphere and attitudes. Stress kills appetite.
  • If your therapy tasks result in push-back, they are probably not helping your son learn to eat. Trust your gut. As one mother said, “Bad therapy is worse than no therapy.” Some children find even the encouragement recommended in therapy is a turn-off.
  • Try to eat with your child as often as possible. Ignore how much of what he is eating as much as possible.
  • Offer, don’t push.
  • Realize that he may eat less initially as you transition to the Trust Model of feeding.
In terms of what to offer, children generally want to grow up and learn to eat the foods the family eats. If you can modify the foods you enjoy, that would be ideal. Does he like soft, salty, sweet? Are there sauces he particularly likes? Sit with him and eat your meal. If you are making squash for dinner, can you add a little butter and some brown sugar and fork mash it for him? Hang in there. Know that this is a marathon and not a sprint, and that I’ve seen ten-year-old “feeding clinic failures” branch out and do just fine with their eating.

Look for the sensory symbol throughout my book for tips for feeding children with sensory issues.

Reader Question #4: How do you help a child heal and stop eating out of the trash?

It sounds like your child has had some trauma around food, likely some major food insecurity, or restriction, or real hunger. Perhaps to survive he had to literally obtain food from the trash. Perhaps he has been shamed for his hunger, or his size. I like how you phrase your question about helping him heal. Healing a history of food insecurity takes time. Let’s look at how you can help your child begin to heal.

First, has your child had a full physical exam to rule out any nutritional concerns, like anemia or iron deficiency, or lead levels? (Some nutritional deficiencies can lead to PICA, or the eating of non-food items.) How old is he? Are there events that trigger the episodes, like visits with siblings, or stress at school? Here are a few general thoughts that might help heal his anxiety.
  • Try not to shame him about eating from the trash. Remain calm, neutral and supportive. If he survived by eating from the trash or taking care of himself, let him know how brave that was, and what a survivor he is. If he fed younger siblings, compliment him on what a good job he did, but that he doesn’t have to do that anymore.
  • Reassure him verbally, but mostly with your actions, that you are now taking care of and thinking about his needs so he doesn’t have to so much. (See my answer to Reader Question #1 in Part I of my Q&A on this blog for more on food anxiety and hoarding in kids with trauma).
  • Have you tried to ask him what is happening around these episodes? Was he hungry, are there foods he might like you to serve, did he have some feelings he was working on? If you are working with a therapist, this is something you can talk about together to help gain insight, or consider specific therapies. (Avoidance, dieting, shame or restriction would not be considered therapies, in my opinion.)
  • Is there a certain type of food he is eating from the trash? If he is eating “forbidden” foods, like half-used frosting containers, or candy, the goal would be to include those foods, and turn them into “formerly” forbidden foods. That means ask him for his favorites, and plan to serve them with meals and snacks. He can have a portion as his dessert, and once or twice a week, he gets to have those FFFs as his “treat” snack, where he can eat as much as he wants. Serve with milk (dairy, or your alternative), sit with him and enjoy it. He may eat a lot at first, and it will scare you, but as the shame, secrecy and access improves, over time, he should be able to learn to manage and enjoy those foods.
  • Examine how you talk about food, or fatness. If a child hears about “junk” food or “bad” foods, or even “red-light” foods, they often think, “that food is ‘bad’ and if I eat it, ‘I’m bad.’” This elicits shame, which often fuels the secrecy and bingeing. Poverty, food insecurity and higher BMI (body mass index) are related. I’ve had questions from foster parents worried about a fat child, who are advised to put the child on a diet to try to get the child to lose weight. This will not help him heal, and is more likely to lead to higher weight and increased food anxietyand obsession over time.
  • Perhaps a food stash may help your child feel secure. A granola bar, a packet of trail mix… Ask him to try to save it for meals and snack times with you, but it is there if he needs it. See my first Q&A post for more on my thoughts about food stashes.
The critical step to healing his relationship to food is being absolutely reliable about feeding your child, every two to three hours for younger children, and every 3-4 hours for older children. As one mom told me, “I find the more we let the anxiety and control around food go, the more he lets go of the obsession surrounding food (what a concept).” Hang in there and keep asking those questions!


  1. Thanks for posting! FYI, I have a webinar coming up on this topic on January 28th with Q and A,

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