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!

Food Hoarding & Integrating Kids' Diet Preferences - Q&A w/ Dr. Rowell on Adoption/Foster Feeding Issues- Part I

I am so grateful to Dr. Katja Rowell, MD, for not only giving two copies of her new book Love Me, Feed Me: The Adoptive Parent's Guide to Ending the Worry About Weight, Picky Eating, Power Struggles and More (aff) away to my readers (see this post - giveaway now closed!) but also for volunteering her time to answer my readers' questions. During the giveaway readers were given the opportunity to ask questions about adoption- and fostering-centered feeding issues and in this post Dr. Rowell (aka The Feeding Doctor) answers two of them. In a second installment, Dr. Rowell will answer a few more. You can find much more on both of the topics addressed here in the book.

This information is educational. It is not meant to replace careful evaluation and treatment by medical, nutritional or mental health professionals.

Reader Question #1 (from Gabby): Do you recommend foster parents leave food accessible, such as bowls of fruit on the counters/basket of snacks on the shelf at kids' level; or just provide healthy meals and snacks on a set schedule? In training we've heard conflicting strategies up to, and including, giving the child their own container to keep wherever they please and allowing them to "hoard sensibly" while helping them clean out the container weekly... What is your best suggestion for dealing with foster children with food issues?

The best way to lessen hoarding behaviors is to lessen anxiety about food.

Too often, the food stash is presented as the solution to hoarding and food anxiety. It seems to have been presented to you as an either/or scenario: food stash, or healthy food on a schedule? I think the answer is both, or no stash, and that it may change with time. One of my main goals is to empower you, to help you know there is no perfect solution or anything that says you have to get it “right” from day one. That’s not how parenting works. We figure it out with each of our kids…

What I am firm about is that if you offer a food stash, it is not an “out” for providing regular meals and snacks. (Note I did not say “healthy” as I believe that to learn to handle and enjoy all foods, meals and snacks need to include “healthy” and not-so-“healthy” options.) My main concern with the stash, or allowing the child to help himself to the pantry, is that it misses the opportunity to complete bonding cycles and deepen the attachment with your child. For the older child who had to be self-reliant with feeding, showing that you will take care of him is important, and feeding is a concrete way of doing so. Feeding is about trust and nurturing, whether your child is 15 months or 15 years old.

Allowing the child to help himself to food at will can also undermine self-regulation, or knowing how much to eat, which is a skill your child may need to relearn.

Here are two scenarios from my book Love Me, Feed Me: The Adoptive Parent's Guide to Ending the Worry About Weight, Picky Eating, Power Struggles and More:

“Consider Marcus, who did not want to let go of his biscuit. He certainly can be allowed to hang on to the biscuit for a while, and maybe even have one in a baggie in his pocket. Follow his lead. If he throws a tantrum about having it taken away, allow him to carry it with him. But the parent also has to be absolutely reliable about regularly providing food. You may need to offer food more frequently at first, perhaps every hour or so.

In a different case, three-year-old Arielle, adopted at 11 months, was on calorie restriction and was experiencing intense food anxiety and preoccupation. Mom tried to let her carry food in an attempt to address her anxiety, but Arielle gobbled it up and begged for more. In this scenario, Arielle’s actions were not the “hoarding” behaviors seen when a child first arrives from a place of food insecurity, but were actually symptoms of a feeding relationship disruption due to her food restriction (see Chapter 5). Letting her have her own stash of food to carry around didn’t work for this family in this situation.

Feeding your child directly shows your child that you will take care of her and builds trust. Completing that cycle of need and meeting her needs, over and over again, is the basis for attachment.”

A few other thoughts:

• Offer frequent reassurances such as, “There will always be enough food.”
• Show him the pantry during the day, perhaps even as you end a meal, “See, there is always enough food here.”
• Plan on pleasant family meals—if you’re battling over broccoli or a therapy task, that’s not helping him feel more secure.
• Structure is critical. If you go to the park, don’t forget to bring a balanced and filling snack.
• Offer food every 2-4 hours depending on your child’s age. Include fat, protein and carbs.
• Institute the Division of Responsibility. At meals and snacks, he gets to eat as much or as little as he wants from what you provide. Even if he eats a lot initially, this will reassure him.

What it boils down to is this: with reliable, pleasant, and satisfying meals and snacks, hewill learn over time that he doesn’t have to worry about when or how much he will get to eat. You get to worry or think about the food, so he doesn’t have to.

Reader Question #2 (from Ben): How do you respectfully integrate your own family's eating habits and preferences with a child's? For instance we eat a lot of vegetarian only meals, and not a lot of processed foods. How would we honor a child's past experiences while also, hopefully, demonstrating our own?

This question is so thoughtful. Rather than ask, “How can I get her to eat my way?” I think you are asking how can I help her feel honored, safe and nurtured while helping her learn to eat a variety of foods as part of our family. By using the word integrate, you sense that it will take time and is a process. How we frame these questions matters.

I recommend handling this how you might handle an entrenched selective eater. Familiar foods feel safe. Early on especially, it is best to focus on “heart needs” as one client put it, rather than worrying too much about nutrition. All too often, adoptive and foster parents find themselves so caught up in nutrition and weight worries that they push and pressure children to eat only “healthy” foods. Alas, this can lead to conflict and power struggles, and doesn’t help the child learn to eat a greater variety of foods. Often, in fact, it makes matters worse. (Particularly with older or traumatized children, or children with sensory issues.)

• If you are fostering an older child, consider asking her what her favorite foods are. Also ask if there are foods she likes in general or if there are foods she doesn’t like “right now.” (You never know, she may have been forced to eat foods she has gagged or vomited, or held down and forced to eat.) Hopefully her list of favorite and accepted foods will include a few foods that you are comfortable serving: bread, tortillas, rice, pasta, crackers, corn, canned mandarin oranges, baked beans…
• Provide her favorite sauce or condiment. Keep a Ketchup bottle at the table, or mustard, or hot sauce that she can use as she sees fit. She may put ketchup on everything for a while, and that’s okay. (Research shows that condiments help children branch out.)
• If she likes crunchy foods, consider offering new foods that are also crunchy. If she tends to like more smooth textures, consider offering puddings or applesauce.
• Offer meals and snacks every 2-3 hours for younger children, and 3-4 for older children, maybe more frequently when a child first arrives if they are food insecure.
• Sit and eat together, whenever possible, without TV or other distractions.
• Reassure her that there will always be enough food, and that she doesn’t have to eat anything she doesn’t want to.
• You can consider asking her to try a new food, and see how she reacts. Some children will try it, others will rage or protest if required to take a “no thank-you bite.” Take her lead.
• Always have at least one thing from her accepted list on the table. She needs to feel that she can come to the table and feel that her hunger will be fed.
• Consider leaving herbs on the side for now. If you make a Curry, put the cilantro in a little bowl on the side and serve it with rice. If your child isn’t fond of spicy food, prepare foods more mild than usual, and add hot-sauce to your own at the table.
• Perhaps serve corn bread or one of her favorite sides with your lentil dish.
• Invite her to help you meal-plan if she is old enough. Perhaps you can say, “We’re having lentils for dinner. Would you like cornbread or rice with that?” Resist the urge to argue, pressure or fight, even if she refuses the food she chose.

When children feel anxious (adults too for that matter) or there are battles at the table, it makes it close to impossible to learn to eat. Stress can kill the appetite or make some children (food insecure or restricted) eat more, so a pleasant table is important. Try to focus not on who is eating how much of what, but on each other. Ask about whom she sat next to at lunch, or how her favorite are class is going. Talk to other family-members too.

Other ways to help children feel safe and “in control” at the table:

• Set out paper napkins and let her know that she may politely spit out any food she doesn’t want to swallow. Children are much more likely to try a new food if they can spit it out.
• Don’t worry about enforcing manners right away. Lead by example.
• Serve foods family-style (so she can serve herself)

Try not to worry if all she eats is bread and milk for a little while. Make up for balance where you can. Fruit leathers or dried fruit, 100% fruit juices or nectars, smoothies at breakfast, popcorn for fiber, maybe a good chewable multivitamin. And hang in there. As sixteen year-old Yiseth said, “Think of it from the kid’s point of view. What is the kid thinking? It shouldn’t be ‘how can I get her to try this,’ but ‘how can I help my child do this at her own pace.’

Over time, and it may take a lot of time if your child has been neglected or abused around foods or if she has sensory issues, she will feel safer with these tips and will be more likely to enjoy your family’s foods.

A lovely resource that helped me “see it from the kid’s point of view” is the book Three Little Words: A Memoir by Ashley Rhodes-Courter, who describes her ten years in foster care. She explores her neglect and even abuse around food, and how at thirteen, she bristled at the nutrition lectures and pressure from her loving and concerned adoptive parents.

FREE Tele-Seminar on Tapping (Emotional Freedom Technique) For "Trauma Mamas"

You know you're a "trauma mama" when you're just desperate enough to suspend your skepticism and try new therapies that before parenting traumatized children you would have considered too "out there" to give a second thought to. One of the things that falls into that category for me is tapping, also known as the Emotional Freedom Technique (EFT). I have always been skeptical of trying new therapies that aren't heavily evidence-based, however the stresses of parenting and trying to help heal children with an alphabet soup of diagnoses (ADHD, bipolar, ODD, attachment disorder, FASD, etc) leads a lot of adoptive and foster parents to open their minds to trying alternative treatments.

This week I'm going to stretch myself and step out of my comfort zone to participate in a FREE tele-seminar by EFT guru Brad Yates that's specifically for "Super Moms" - Otherwise known as you and I. Another "trauma mama" blogger convinced Brad Yates to do this free EFT phone-in seminar for parents like us whose kids have experienced abuse and neglect (or even "just" the trauma of being adopted at birth which is, yes, a trauma in and of itself). Dads and moms of kids with special needs are welcome.

Emotional Freedom Technique, or "tapping," has no negative side effects. It's incredibly safe and gentle, because it only involves tapping gently on acupressure points while stating affirmations. It's really almost that simple. So, at worst, it won't help. At best, it can be transformative. At Parenting in SPACE I heard many families talking about the wonderful help its given them as parents and also the gifts it's given their challenging children. EFT is believed to reduce the emotional impact of stressful incidents, so it's especially appropriate for parents who are living in chaotic households due to their childrens' special needs, or to children or adults who've experienced any kind of trauma.

Brad Yates is the author of several books including The Wizard's Wish: Or, How He Made the Yuckies Go Away - A Story About the Magic in You. This book is a story for children about using EFT to reduce stress and negative emotions.

If you'd like to read about how "tapping" or the Emotional Freedom Technique (EFT) has helped other foster and adoptive families (including skeptical ones), check out Christine Moers' post My Crush on Brad Yates and Lindsay's post Snake Oil, Kitty Litter in Capsules, and Such Witchery.

Click here for information on calling in for this free session. I'll be there!

FREE Arm & Hammer Simply Saline Neti Pot for Nasal / Sinus Irrigation

As cold and sniffles season sets in, we were happy to learn there's a wonderfully useful and generous freebie available from Arm & Hammer / Simply Saline. You can get a rebate of the full purchase price (up to $14.99) on a neti pot. Just download this form and send it with your original cash register receipt before 7/31/2013. You will get up to $14.99 back by mail as a rebate.

If you haven't yet discovered them, neti pots are simply magical. Check out this article from WebMD called "Neti Pots - Do They Work?"  They use saline and gravity to gently and safely cleanse, without force, the entire nasal passages. They are a godsend for people with sinus infections, chronic sinusitis, rhinitis, allergies, colds and dry noses. They not only loosen and remove mucus but they also wash out pollens and other irritants that are sitting around in the nose waiting to make us sicker. They are safe for children as long as they're old enough to voluntarily blow their nose after using it. Our 10 year old recently let us neti his nose for the first time when he was sick and he loved it. Using a neti pot for the first time is a strange experience (the water goes in one nostril and out the other!) but once you get the hang of it it's easy, comfortable and even kind of fun.

This neti pot freebie comes with some packets of saline mixture that you simply mix up with water in the neti pot. There are instructions online for using just sea salt or a sea salt / baking soda mixture to make your own saline, but we tend to buy the NeilMed's Sinus Rinse Pre-Mixed Packets because the convenience factor makes us more likely to actually use the neti pot regularly.

From a budget-related perspective, neti pots are a fantastic investment (or in this case, a fantastic freebie) because they result in fewer sinus infections and fewer allergies. They can also reduce postnasal drip, thereby reducing chest congestion and sore throats. Ultimately they may result in less antibiotic use and fewer doctor's visits... if that's not budget-friendly, I don't know what is!