Picky Eaters & Pet Medication – PediaCast 369
- Dr Lauren Garbacz visits the PediaCast Studio as we talk about picky eaters and other common feeding problems. When is picky eating a concern? How should parents engage their picky eater? And where can families seek additional help? Also covered this week: the danger of pet medication in the home. We hope you can join us!
- Danger of Pet Medication
- Picky Eaters
- Feeding Problems
- Dr Lauren Garbacz
Interdisciplinary Feeding Clinic
Nationwide Children’s Hospital
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello everyone, and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike. I'm coming to you from the campus of America's largest children's hospital, Nationwide Children's. We're in Columbus, Ohio.
It's Episode 369 for February 22nd, 2017. We're calling this one "Picky Eaters and Pet Medication". I want to welcome everyone to the program.
So this is one of those episodes that I think will end up taking on a life of its own. And the reason I say that is because pediatricians face questions about picky eaters really nearly every day in the course of our office practice. Now, to be sure, overeating, high fat diets, childhood obesity — common problems and ones that sometimes get more attention in the news, in magazine articles, newspapers, blog posts. We hear about overeating and childhood obesity all the time.
I don't think we hear quite as much about picky eaters in the press and yet pediatricians get asked about picky eating all the time, especially during the toddler years.
Now, we've covered picky eating a couple of times in the past on PediaCast. In fact, as recently as Episode 326, we talked about how common this problem is, with one research study reporting that about 18% of all children of every age will be considered a moderately picky eater and another 3% is seriously, so severely selective in their eating.
So, 3% would be considered sort of extreme, very severely picky eaters. So, if you add those two groups together, just over one in five kids are moderately to severely selective in their eating habits.
So it turns out there's a lot of children and teenagers who are affected, which is why the topic comes up so frequently during the visit to the doctor's office.
We also talked about picky eaters back in Episode 257 when we answered a listener question about her teenager with very selective eating habits. So, again, this is not a problem limited to young children, middle school, and high school. Even college kids can be picky eaters. In fact, there are lot of adults who are picky eaters as well.
And then, that Episode 257, we talked about some of the warning signs of picky eating. So, when should you really be concerned and seek medical help for your child's picky eating. And if not medical help, maybe psychological or mental health help.
So we're going to cover picky eating again this week but this time we're going to go into more detail compared to those previous episodes as we devote most of our show to picky eaters and common feeding problems.
And we plan to take a comprehensive approach, so that the information will be here for parents to find for a long time to come. That's what I meant by this episode taking on a life of its own. Sometimes you just have one of those topics that continuous to be a thorn in the side of parents. And they ask the Google machine to help them out, they find our show.
By the way, if you're one of those moms or dads who found us by Google-ing picky eaters, welcome. We do have 10 years of additional shows in the archives, so be sure to check out our other topics at PediaCast.org. You'll find all of our shows there, as well as in iTunes, Google Play, iHeart Radio and most podcasting apps for a variety of platforms. Or just Google any topic and drop PediaCast alongside your search term, that's another easy way to find the show that might answer your question.
Of course, if you can't find the topic you're interested in learning more about in the past episodes of the program, that would be a fantastic time to check on our Contact page over at PediaCast.org and suggest your topic or ask your question there. We'll try to incorporate those ideas and questions in upcoming editions of the program.
All right, back to our topic at hand, the last couple of times we covered picky eaters, I presented the information and answered our listener questions on my own. This time, I brought along some extra expert power to help me out. Dr. Lauren Garbacz is joining us.
She's a pediatric psychologist who specializes in helping kids and families deal with picky eating and other feeding problems. She'll share her expertise with us with some practical advice for dealing with that problem in your homes. So, stay tune for that.
First, though, I do have a public service announcement for you. Almost two-thirds of US households own a pet. And many of them have children that either live in or visit the home. As pet owners know, it's common for those furry friends to need medication from time to time, either to treat a health condition or to prevent things like fleas, ticks, and heartworm.
Many parents however may not be aware of the risks of these medications. A new study from the Center for Injury Research and Policy at Nationwide Children's Hospital and the Central Ohio Poison Center looked at phone calls to the Poison Center for children exposed to medications intended for pets from January 1999 through December 2013.
So what did they find? Well, according to the report which was recently published in the journal Pediatrics, the Poison Center received an average of 95 calls each year about youth — 19 years of age or younger — having been exposed to medications intended for pets. That's about two phone calls each week here in Central Ohio which suggest the numbers are much higher if you consider the entire nation.
Most of the calls where for children age five years and younger who ate or swallowed pet medications after finding it through exploratory behavior such as taking the medicines off the counter or finding it in a bag. Another common accidental or unintentional exposure occurred while a parent was trying to give medication to a pet.
The majority of exposures occurred at home and, fortunately, we're not expected to result in long term or long lasting health effects, although 3% of the calls did represent a serious concern. Most of the encounters, in fact, 88% where from medications intended for dogs.
While the majority of incidents involve young children, the study found this can also be a problem among teenagers but for different reasons. More than half of the calls for that age group were the result of a teen mistakenly taking pet medication instead of medicine intended for humans. Storing pet medication in a different place than human medicine could help prevent some of this confusion.
Kristi Roberts, the study's author and research project coordinator, says, "When you have kids and pets in the home, sometimes things get a little busy. Thinking about how your pet's medicines could be a risk for your family might not even cross your mind. The good news is that by taking a few simple steps like storing medication for pets and human in different places and keeping all medications up and away and out of sight, and only giving medicine to pets when children are not in the room, by following those guidelines, you can help keep everyone in the family a little safer."
Henry Spiller, director of the Central Ohio Poison Center adds, "Veterinarians can also help prevent these unintended exposures by recommending safety guidelines and by dispensing pet medication in child-resistant containers."
So, we eluded to some of these guidelines. Let's get a little bit more specific and detailed for you. First, make sure that you do keep all medications safely stored until it's time for the next dose. Don't leave med on the counter or in the bag. Put them away.
And when you put those medications away make sure they are up and away and out of sight. Store pet medication where children cannot see or reach them and in a locked cabinet is best. That's true for all medication.
Also, store pet medicine away from human medicine. It's easy to grab the wrong container and mix up pets pills and liquids with human pills and liquids. Help prevent these mistake by storing medications for humans and pets in different locations.
Also, keep all medication including medicine for pets in their original child-resistant containers with the labels attached.
Check for a clean bowl. Many veterinarians recommend mixing pet medicine with food, so your dog or cat will eat it. If you need to do this, make sure children are in a separate room before giving your pet the medicine food mix. And make sure your pet has finished all the food and hasn't spit it out or vomited it somewhere in the room before children are allowed back in.
For medications that are applied to your pet's skin or fur, put it on when children are in another room and allow the fur to completely dry and put the medicine away before allowing the children back in contact with your pet.
And finally, know how to call the poison helpline, save the National Poison Helpline number, 1-800-222-1222, in your cell phone. And also post it in the visible spot in your home. That number by the way is the same regardless of where you live in the United States. If you call 1-800-222-1222, you'll be linked up to the poison center that services in your area.
And call right away if you think your child has been unintentionally exposed to any chemical or medication, whether intentional or unintentional. And that does include pet medicine. And don't wait for symptoms to develop. Just call right away if there's been an exposure.
Again, that number for the poison center closest to you in the United States is 1-800-222-1222.
All right, before we move on, I also want to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.
Let's take a quick break, then we'll get Dr. Lauren Garbacz settled into the studio. And we will be back to talk about picky eaters and other feeding problems. That's coming up, right after this.
Dr. Mike Patrick: All right, we are back. Dr. Lauren Garbacz is a pediatric psychologist at Nationwide Children's Hospital and an assistant professor of Pediatrics at the Ohio State University College of Medicine. As a member of our Interdisciplinary Feeding Clinic team, Dr. Garbacz evaluates and treats a wide variety of feeding problems including picky eaters and a few others which we're going to talk about. It's the topic that interests many parents along with the plenty of grandmothers and well-meaning aunts.
So, let's get right to it and talk about picky eaters and other feeding problems and kids with Dr. Lauren Garbacz. Thanks so much for being here today.
Dr. Lauren Garbacz: Thank you for having me.
Dr. Mike Patrick: Appreciate you stopping by.
So for the young child, what does normal eating look like? I think before we talk about feeding problems and picky eaters, what's normal?
Dr. Lauren Garbacz: We don't know a lot about exactly what normal eating looks like. It really varies so much by the child. It's really going to depend on their age level.
We have a few studies that I've looked at, how parents describe their kids eating. One study in kids who were ages four to seven, more than half of parents talked about their kids having an aversion to new foods. And this is going to be much higher in toddlers and younger pre-schoolers. That's really developmentally typical for that age.
So, with normal eating, we really want kids to be eating a variety of foods. We want them to be willing to try some new foods, to explore different tastes and textures. And when we see a lot of stress that's impairing any social functioning where a lot of stress within the family, then that can become problematic but otherwise some pickiness is really typical for most kids.
Dr. Mike Patrick: And in terms of the family, some families are going to have a little bit more of a limited diet than others would. And other families eat a big, large variety of foods. So I suspect too there's some subjectivity in what constitutes picky eater depending on what family they live in.
Dr. Lauren Garbacz: Absolutely. And that's what makes it difficult to define this and when it's problematic. It is subjective. We need to take all of those individual child and family factors into account when we're working with the families so that we can find something that works for that particular family.
Dr. Mike Patrick: And then as a pediatrician, one other observation, I think, that's really important to me right upfront is the fact that as kids progress from infancy into toddlerhood, if you look at the shape of their growth chart, growth slows down. They don't keep growing like they did when they were infants or we'd all be giants.
And so, one of the ways that slowdown in growth is accomplished is by maybe not eating quite as much as parents would think. So when they get to that normal toddler slowdown of eating, sometimes parents get concerned about that. Do you run across that situation?
Dr. Lauren Garbacz: Absolutely. When we first meet with families, we do a lot of normalizing and kind of talking them down when they're really concerned about certain things that maybe normative.
Pediatricians have typically already done that for them and do a wonderful job of that before they even come to us. But oftentimes, we need to help families understand that kids tend to kind of wax and wane in their appetite throughout the day oftentimes. So we're not so concerned with one particularly meal going badly, for example, because they might sort of make up for the next meal. So helping parents sort of look at trends overtime and not so particular about one meal or one particular food that they're not eating.
Dr. Mike Patrick: Absolutely. One other issue with toddlers that we see often is that they have a tendency to be more grazers. In our society, we talk about three meals a day — breakfast, lunch, dinner — but that doesn't always fit in with the toddlers' plan, does it?
Dr. Lauren Garbacz: No, toddlers often have their own plan.
Dr. Lauren Garbacz: So, we certainly want kids at that early age to start learning how to build their hunger between meals. We don't want them to learn to get satiated with small snacks throughout the day. But we also need to understand that toddlers, part of their developmental task at that time is to learn how to be their own person. And so, we're going to see a lot of pushback in eating as one thing that they can control.
Dr. Mike Patrick: And again, that's going to be different from one family to another depending on expectations and whether that causes distress stress within the family.
Dr. Lauren Garbacz: Absolutely.
Dr. Mike Patrick: We talked about some pickiness is normal. When would you say that kid's a picky eater?
Dr. Lauren Garbacz: Again, we don't have good cut-offs or anything. It is often subjective. As kids gets older, they should be eating obviously a wider variety of foods. If we see a kindergartener or school age child who's maybe only eating four of five different foods regularly, that can become concerning.
Most importantly, we want parents to be checking with their pediatricians to determine if there are any problems with their growth. If they're not gaining weight or height the way that they should. Sometimes, pediatricians will refer to a nutritionist if it seems like they're really some nutrients that maybe lacking in their diet due to a limited variety. That's really the first place to start.
And then, if there are behavioral components, we'll often get a referral in psychology to help with that.
Dr. Mike Patrick: Sure. When would you say that this is really a problem? There's that, well, this kid's a little picky and now we're going to say, "Oh, this is a picky eater." But when would you say okay, we need to intervene?
Dr. Lauren Garbacz: Our best diagnostic criteria that we use at this point are whether, like I mentioned, if there are problems with weight gain or growth, if we're seeing some nutritional deficiency.
And, sometimes, that will end up leading to needing to rely on oral nutritional supplements like Pediasure or Ensure, Boost. If kids are over-relying on those, we typically need to intervene to help them gain more variety back into their diet.
Especially within psychology, we're really looking for sort of really marked interference and functioning for kids, whether it's stress within the family, whether it's social functioning. I've seen kids who don't go to day camp or overnight camp because they're not able to eat enough variety of food. Or they don't want to eat outside their house. So that would be an impairment in social functioning.
Dr. Mike Patrick: We're talking about their health and that would be both their physical health and their mental health. If you have a kid who maybe a little bit of a picky eater but there's still collection of foods that they eat — it's not you can't count them on one hand — and they're growing well, and they're healthy, and there's not really stress about this in the house, and their quality of life is not disrupted, then that's a kid you'd still just kind of watch and reassure the family?
Dr. Lauren Garbacz: Absolutely. The biggest reason to start to address something is those physical concerns and stress that's really getting in the way. If you're thinking about all day, "How am I going to feed my kid? How are they going to eat enough food?" that's really interfering with all of the other things you need to be worrying about with your child. That would be a time that you might seek some support.
Dr. Mike Patrick: Sure. How can parents tell if their kid is really getting enough to eat? We're talking about pickiness but then there's also volume. And I know a lot of pediatricians hear parents say, "He didn't eat enough," or "She doesn't eat enough." How can a parent be reassured that no, they're really are getting enough to eat?
Dr. Lauren Garbacz: We really do use weight and growth as our main indicators. So if pediatricians are seeing kids solidly make progress on the growth chart, they're not losing weight, they're not falling off the growth chart, we know they're getting what they need at a basic level.
Again, if there's concerns for different micronutrients that they maybe missing, nutritionists can really help with that. They have some great strategies for how to be creative in adding different foods in different ways to kids' diets. Multivitamins…
Dr. Mike Patrick: They sneak it in, right?
Dr. Lauren Garbacz: They do. Although some kids will really know that that's sneaked in. So it will works for some kids, not all. They are really good at helping to increase fat in a diet. So if you can add oil or butter to something that's helpful if kids need to gain weight. Sometimes, they'll recommend a multivitamin if there's some nutrients that are missing.
Dr. Mike Patrick: Sure. We mentioned that as long as your growth is okay. But you do have to take into account what the family growth pattern looks like, correct?
Dr. Lauren Garbacz: Absolutely.
Dr. Mike Patrick: So you see some folks, they're concerned that their child's so small. But then, you look at mom and dad and they're pretty small, too. And so, then you can also look at the kid's growth chart and to say not only where are they on the growth chart — if they're small or they're large — but also are they following sort of the general shape of the chart.
So you have a kid who maybe down at the fifth percentile but if he's always been at the fifth percentile, and mom and dad are kind of small, that's less of a concern. But if a year ago, they were 50th percentile and now they're fifth percentile, then that would be something to worry about.
Dr. Lauren Garbacz: That's right. And that's why we're working in an interdisciplinary way, because we need to consider all of these factors together to help parents feel assured that their child's doing okay.
Dr. Mike Patrick: So it's really a big picture sort of thing. And that's where if you have a concern, talk to your pediatrician and they can give you that big picture. But then, if it looks like, yeah, there really is an issue here, then we'll send John to the help that he need. And we'll talk more about your clinic and what you do there.
So that's really with the quantity of food, how do you know especially in picky eaters that they're getting enough nutrition? That they're getting the right mixed of foods, because there's a lot of kids who just won't eat any vegetables at all and yet they appear healthy. How can that be?
Dr. Lauren Garbacz: Again, that's really talking about micronutrients and our dietitians can really help us out with that quite a bit. I would definitely recommend seeking consultation with the nutritionist. There's a lot that can be learned just in one session sitting down with them.
Kids typically are picky for vegetables. They enjoy the fatty foods, the ones that taste good, the salty, the sweet foods that we're all drawn too. So trying to get them to eat outside of that, especially for some kids, can be challenging.
If we help kids approach new foods like vegetables they may not like as much slowly — so we let them kind of explore, we let them touch it first, maybe just put it to their lips, take a lick before they need to take a bite, before we pile on a huge amount on their plate — that may help them start to kind of get used to a food and approach it without a lot of pressure before being asked to eat a big quantity.
Dr. Mike Patrick: That really makes sense, just to explore and without the pressure. I think for a lot of parents, myself included when my kids were little, there really is that push to be like, "No, you need to eat this." But you're going to have the opposite reaction than what you want oftentimes, right?
Dr. Lauren Garbacz: For sure.
Dr. Lauren Garbacz: Feeding is difficult because parents feel a lot of pressure. They feel responsibility to make sure that their child's eating enough. And so, oftentimes, that leads to difficult kind of cycle and dynamic of pushing food, kids pushing back. And that's when we start to see things sort of evolved. Sort of backing off, realizing — especially if their weight is okay — that kids generally the course of the day or the course of the week get what they need.
Dr. Mike Patrick: You talked about supplements like Pediasure and Boost and micronutrients. And you were talking different, whether it's carbohydrates or fats or proteins or individual vitamins as well. In this country, vitamin deficiencies are pretty rare things because our foods are just so fortified, it doesn't really take much food to get those. We need them in such small quantities.
So, if there's a specific concern and there are signs of a vitamin deficiency and someone sees a nutritionist, and they have recommendation for supplementation of the vitamin or other nutrients, that's well and good. But the kids who parents would just say, "You know, I don't think we're at the point that we need to see someone, but my kid's really picky." Just in general, do you think vitamins are good idea for those kids? Or is that not necessary unless there really is symptoms of a deficiency?
Dr. Lauren Garbacz: Well, my nutritionist colleagues will always say a vitamin is not going to be harmful. Those all nutrients that if you get too many of them, it's not going to hurt you. So, if it helps parents feel better and helps them feel like it may be filling in for anything that they may be missing, then it's a great idea.
You can get a complete vitamin. You can crushed it up in food if kids won't take it.
Dr. Mike Patrick: There are some vitamins that if you were to get too many of them, especially the fat soluble vitamins, that there could be an issue. But taking pediatric, a child-sized vitamin every day is certainly not going to do that. You're just going to run into that trouble if you're doing this 100,000 units of vitamin D the kind of situation every day. But just as long as you're doing a daily vitamin that's meant for kids, you're probably going to be fine with that.
Dr. Lauren Garbacz: That's safe.
Dr. Mike Patrick: Yeah. We might make expensive urine but you know, that'd be about it.
Dr. Mike Patrick: And then, in terms of supplements, again if a kid is growing along their expected growth curve, as you take their past growth into account and you take their family history into account, not all small kids need supplements.
Dr. Lauren Garbacz: That's very true. So that's again where you want to take the lead from your physician, from a nutritionist. Nutritionist will often gather a food log and get a snapshot of what kids are eating. And most of the time, kids don't need those supplements. So it's really if there's a significant concern for weight and they're really not getting from the food that they're eating enough calories each day.
Dr. Mike Patrick: And for parents who are concerned though, talk to your doctor. We say a lot of kids who are small don't need these things but there are other kids who do. And so, you really want some advise and professional opinion on whether your kid, which of those two groups your kid fits into.
And that really brings to my next question. When should parents bring up picky eating with their child's doctor?
Dr. Lauren Garbacz: It's always a good idea to bring it up. At the very least, you'll end up with some reassurance and you'll kind of be able to talk about what's within the range of typical. You'll start a precedent by talking with your doctor about that. So that if it becomes an ongoing concern or chronic issue, you'll have that history of having talked about it.
And if it really is causing a lot of stress, I would be open with your doctor about that. Lots of times, if something's typical but pediatricians aren't aware of the stress it's causing or if there's any kind of impairment it's causing for kids in their social or family functioning, they may not refer you on because it's not physically a problem. So, you do need to be open with your pediatrician about how it's affecting you and your family.
Dr. Mike Patrick: I think that's a good point. There's so many competing interests especially during a well checkup. As a pediatrician, you want to talk about this and you want to talk about that. And the AAP recommends that you bring this up and that.
But what's most important is what is affecting a family at that time. And so, if that has to preempt some of those other things that we talked about, then that is what needs to happen because it's important to that family at that time.
So I would just encourage parents it's okay to tell your pediatrician, "I appreciate you asking me about these things but I really want to talk about my kid's picky eating." That's okay to do that if that's what's really bothering you at that point, correct?
Dr. Lauren Garbacz: Absolutely.
Dr. Mike Patrick: What are some of the causes of kids being picky eater?
Dr. Lauren Garbacz: Again, that's something that we don't know a lot about at this time. We really need a lot more research in this area. But we do know that kids with certain medical histories in particular are more at risk for having some aversions to new foods or certain texture.
So kids with gastro intestinal issues in their past or currently. Something like reflux or eating chronic constipation can cause some aversion in kids. And then, even once those conditions are treated, that can become a habit and kids continue on that path. We need to intervene sometimes and help them feel that other foods outside of their comfort zone are okay, safe, and will not make them feel bad.
Dr. Mike Patrick: Right. So sometimes, if they had symptoms from a particular issue such as reflux or constipation and then they ate a particular food, but they just had the symptoms of their disease, they can start to associate their symptoms with that food. And then not want to eat it even though the food may not have cause the symptoms to begin with.
Dr. Lauren Garbacz: That's exactly it.
Dr. Mike Patrick: And then, of course, we all have different tastes. In our family, my father never like tomatoes. I'm not a particular fan. My son doesn't like tomatoes. So, there is some genetic component to pickiness based on taste.
Dr. Lauren Garbacz: Certainly. I hear that a lot from families that, "Oh, I was picky as a child. My husband was picky as a child." Whether it's sort of model then learn sometimes or whether it's just something that we can't test and identify at this point but maybe there is a genetic component that is there oftentimes, not always, with kids, we all have foods that we don't like. And it's okay for kids to learn. There are some foods that I don't like and it's okay. I don't have to eat them.
Oftentimes, what we need to help kids understand is that I like to think of foods in three categories — preferred foods, less preferred foods and then challenge foods, foods that you really have to get yourself to eat. And to get enough nutrition, we need all of those foods in our diet. Sometimes kids really want to stick to the preferred foods and that's it.
Dr. Mike Patrick: I bet brussel sprouts are in that lower for a lot of kids, right?
Dr. Lauren Garbacz: For most people, yes. For most kids, especially.
Dr. Mike Patrick: And then, some kids can have preferences based on textures as well. Speak to that.
Dr. Lauren Garbacz: Especially, like you were talking about if there's sort of a learned association with certain textures, kids may avoid those. If they have any oral motor weaknesses as they're developing, especially when they're moving into solid foods as toddlers, that can often cause an aversion.
Kids will maybe have a hard time chewing a piece of meat, chew it, and spit it out. And that's just how they will continue to eat that meat. They'll get the flavor, and then they don't really know what to do with the rest or they're not comfortable with that sensations. So they need some gradual exposure to learning how to tolerate that particular texture.
Dr. Mike Patrick: And then, you'd mentioned earlier this can become a control issue as well. How do you know when it's not so much that they don't like the taste or they don't like the texture, but they just don't want to eat a particular food because it's something they have control over?
Dr. Lauren Garbacz: Those things often come together. So if a child doesn't like a texture, they will do everything they can to avoid it. So it can become a behavioral issue to manage as well. But sometimes there's not really a real reason that kids are avoiding a certain kind of food.
We do know what happens a lot more often, that kids have a really strong reactions if they tend to be a more timid kind of child. Somebody who tends to like to be in their comfort zone and avoid new things, they may have a little bit of a stronger reaction when presented with something new.
Or kids who tend to be impulsive or just have some behavior issues in general, they tend to have more difficult-to-manage behaviors at meal time. And so, we typically need some kind of behavioral intervention or behavioral plan to help motivate them to do what they need to do at meals.
Dr. Mike Patrick: Yes. And that's where families, it can be really helpful to get some extra professional help from a psychologist or feeding clinic to really help manage those kind of behavioral issues especially when interfering with quality of the family life.
Dr. Lauren Garbacz: Yeah. Typically meals are stressful when those kinds of situations are going on. We definitely want to intervene and help make that time a little bit easier and more enjoyable for everybody at the table.
Dr. Mike Patrick: Is there a way to prevent a child from becoming a picky eater to begin with? A lot of families would say, "Boy, if I had to, I'd do it over." What would I do right from the beginning that would help my kid not be a picky eater?
Dr. Lauren Garbacz: Well, it's hard to say if any one thing would actually prevent it. But I would say the biggest thing to think about would be that issue we talked about before, putting pressure on somebody to eat. Lots of times when we put pressure, it causes us to want to back off and avoid it. If we can kind of make eating a no-pressure, enjoyable situation, that can help a lot.
Also, I think, setting a good example of meal structures early on in your child's life. We know kids tend to do better when they sit down for as many meals a day as possible. We're often on a go these days. That can contribute to not learning good eating habits and not learning how to build up hunger.
And we tend to snack a little bit more these days and all of that grazing like we talked about in between meals might cause kids to learn to satiate their hunger with just a little bit of food and not learn how to kind of build up that hunger from meals. So just teaching good habits early on is always helpful.
Dr. Mike Patrick: If we're not pushing new foods on our kids, what's the best way to really try to introduce something without being pushy? How do you find that middle ground?
Dr. Lauren Garbacz: Well, you know my motto is "Always starts small." So, if we want to introduce a child to a piece of broccoli, we might put one on our plate and one on their plate. And we might just sort of, we want to be really animated with the young child and make it a positive experience. Interact in a positive way and make it playful while they have that piece of broccoli in front of them. So they start to associate with kind of a good time with my parent.
And then, like I said, they might be able to just kind of touch it, lick it, taste it. And then, you can try having them take a really little bite. Really starting small and not trying to throw too much at them at once.
Dr. Mike Patrick: And what point is it you're really pushing too much? I mean, because sometimes, you have a kid who only eats a handful of foods and you really do want them to try some new things. And nothing is working. How far do you push it?
Dr. Lauren Garbacz: Well, oftentimes, kids need motivation. If they're not motivated to eat that food, you're going to end up in a battle. I think you can set appropriate limits with your child and say, before the meal, let them know this is how much of a challenge food I want you to eat. And then, they know exactly what that goal is. And they're going to be more likely to meet it.
Other kids may need a reward or something at the end of the meal that they can look forward to. Or they may be able to kind of alternate bites of the food they like with the food they don't like as much. Oftentimes, we see kids eat the food that they like first on their plate. And then, they're not as hungry for that other food that doesn't taste as good anyway.
Dr. Mike Patrick: When you talk about rewards, you probably don't want it to be — and again, I'm not a psychologist, so if I say something silly here, please absolutely correct me — but it would seem to me that you wouldn't want the reward to be something the rest of the families going to get anyway.
In other words, if you don't eat your piece, then you're not going to get dessert but everyone else is going to eat dessert while you watch, that really seems more of a punishment than a reward. And you can really do more damage with that kind of thing, right? Yes, maybe, no?
Dr. Lauren Garbacz: Punishment just doesn't work as well. Yeah, I would say we usually try to stir away from using food as a reward anyway. It can get confusing for kids. Certainly, restricting dessert if they don't eat all of their food is sort of a natural consequence. But, yeah, you don't want to make a big thing about it, you don't want to make it punishing because then that's just going to start to associate meal time with negative things.
But you still want to have a reward that a child can either earn or not earn if they eat their dinner. So it might be something like if your child is really going through phase where they're having trouble eating, you might set up a plan where you get to use your screen, you get to use your table or your phone or TV after dinner if you eat your food. If you don't, then you need to go play something in your bedroom and you don't have access to those screens for the evening. And most kids really want access to those screens these days.
Dr. Mike Patrick: Do sticker charts still work? Or is that too low tech these days?
Dr. Lauren Garbacz: Sticker charts absolutely can work. It's just important…
Dr. Mike Patrick: My kids are rolling their eyes at me.
Dr. Lauren Garbacz: It's important that something is tied to those stickers. Probably just giving a sticker in and of itself is not going to be rewarding enough, at least not after the first one or two times you do it. But if you have something they really want, like their game on their phone, tied to those stickers, if you earn five stickers for eating your dinner well five nights, then that becomes a more powerful tool.
Dr. Mike Patrick: Yeah. And if you do that, they only need to get a couple of stickers. So you want them to have some success with seeing that these rewards as to how the system works. And then, maybe the two stickers. And then, okay now, you're going to earn three stickers to do it. Then, you're going to earn four stickers, that kind of thing.
Dr. Lauren Garbacz: You increase the challenge a little bit as they get good at it.
Dr. Mike Patrick: Besides picky eating, as a psychologist that sees kids with feeding problems, what are some of the other common issues that you see that kids have trouble with regard the food other than just being picky?
Dr. Lauren Garbacz: Sometimes parents come in and they want to work on volume at meals. Maybe this is a child who has had trouble maintaining their weight through oral intake. And so, they're on some supplement. Or they, for other reasons, have tube feedings that they do and they want to start to increase the oral intake and pull back on the tube feedings. We'll work on increasing volumes at meals in that way.
Dr. Mike Patrick: What about hoarding food, hiding food, sneaking food? Do you see much of that?
Dr. Lauren Garbacz: We do. A lot of times, kids will really seek out those preferred foods that maybe really restricted — candy, things like that. Sometimes, they will eat that without their parents knowing. So we need to start to make it more rewarding for them to get those foods at appropriate times when they ask than it is to hide and sneak. So we often have to do some behavioral planning with parents around that.
Dr. Mike Patrick: And what are some specific advice that you give to folks with that kind of problem?
Dr. Lauren Garbacz: We need to reward kids for being honest. That's the biggest thing. At first, you just want them coming to tell you that they want candy. They may not be able to have it in that moment but you still give them a lot of praise for coming to you and asking instead of taking it.
If you found a stash of wrapper or you know where they keep things, you could do a sweep of their room. And if there are no candy wrappers around, you give them praise for that. So finding ways to praise them for the things that you want them to do is going to be the best thing.
Dr. Mike Patrick: And then kind of get closer and closer to the desired outcome as you positively reinforce their behaviors.
Dr. Lauren Garbacz: Absolutely. A lot of times if kids feel too restricted in what they're allowed to eat, that will lend them to start to sneak things. We also want to help parents find ways to set limits while also not making it feel so restrictive for kids.
Dr. Mike Patrick: Another common issue that I've come across in my career is the kid who may have a choking incident. I mean not a life-threatening choking incident but one where they really felt like they we're going to die when they were choking. And then, they kind of start to have some swallowing problems that aren't necessarily caused from a medical issue but really just stemmed from that experience because that's when these things start. How do you get kids to sort of jump over their hurdle of feeling like they're choking all the time when something like that happens?
Dr. Lauren Garbacz: That can also occur if a child has a vomiting episode. We see sort of this, they were great eaters before and then we see an abrupt change after an event like that. We really treat it in the same way that we work with picky eaters — gradual, slow steps.
So we would typically start with foods kids really like. And we're willing to accept any success at that. If they're only willing to eat marshmallows for a little while, we just let them eat marshmallows and praise them for that. Then we start to add a little bit more and, like you said before, we want to find ways to give them success and we build on that.
Dr. Mike Patrick: That can be really frustrating for families and parents. Sometimes, I think parents just need someone to say, "I understand this is frustrating. We're going to walk along side you but we may not find any answer or solution overnight."
Dr. Lauren Garbacz: Yeah. And it can be terrifying for families, too, if kids are going days on end without really eating much. Typically, they'll check in with pediatricians which is the best thing to do at that point. And sometimes, we'll start kids on Pediasure or a mealtime supplement. We try to get them off that as quick as possible but we also want parents to feel reassurance so that they're not feeling like they need to push too much, too fast.
Dr. Mike Patrick: And there are also some very real medical conditions that could be associated with a change in their behaviors or habits. It really is important to, even though we may say, "Okay, we're going to reassure you but you do want to maybe make sure there's not something medically going on."
Dr. Lauren Garbacz: Oftentimes, if we see a real chronic pattern aversion, we want to rule out any gastrointestinal issues. Maybe there's been some damage to the esophagus from untreated reflux. Or maybe there's some other kind of gastro, GI issue that is causing kids some discomfort while they're eating. We need to get that treated before we're really going to make some good progress.
Dr. Mike Patrick: And younger kids with feeding problems obviously would need to be seen right away. Especially in infancy and young toddlerhood, anatomical issues can come up. Kid sometimes will have an undiagnosed small cleft palate that could be a problem.
They can have a little fistula or a connection between the trachea and the esophagus that can cause food to go actually down the wrong pipe. So just things that should be checked out by a doctor when you're having a concern to make sure that there's not a medical reason for these things.
Foreign bodies in the esophagus, sometimes we'll see kids who aren't eating as well as they did and they act like they're choking just in the emergency department. And we get an X-ray and what do you know? There's an object, a coin or something in the esophagus.
Not to suggest that's what the issue with your child's eating problem, but things to think about and certainly to seek help from your pediatrician.
What about older kids, like middle school and high school kids? You've got a picky eater and you think, okay, they're going to outgrow these. And they get to high school and still aren't eating any vegetables. Is that something that you commonly run into?
Dr. Lauren Garbacz: Yeah. I'll often work with..
Dr. Mike Patrick: What about my 20-year-old?
Dr. Lauren Garbacz: All right. They're actually faster to work with sometimes than younger kids because you can reason with them a little bit better. You can pull in some of those cognitive strategies. We address it largely the same way. It's really through exposure that people become more accustomed to tolerate in something that they weren't before.
Dr. Mike Patrick: And I do find that it is at least with my kids, as they're getting older and they're more likely to try something, and it's kind of an Aha moment like, "Oh, you know what? That actually tastes pretty good." And then, suddenly they're eating that food again, where for years, they hadn't.
Dr. Lauren Garbacz: Yeah, it's that whole adage that something is oftentimes worst in your mind — leading up to it, that anticipation — than it is once you actually do it. So kids will typically avoid, avoid, avoid that vegetable and then may take a bite of it and say, "Oh, I actually like that." That happens a lot.
Dr. Mike Patrick: It's just getting them to try.
Dr. Lauren Garbacz: Exactly.
Dr. Mike Patrick: But then, have those control issues. "Okay, now, I've tried it. I like it. But I can't pretend like I like it."
Dr. Lauren Garbacz: Right. Right.
Dr. Mike Patrick: You see that.
So we're talking about middle school and high school kids. At what point should parents be concerned about an eating disorder? So talking about things like anorexia, bulimia.
Dr. Lauren Garbacz: It can be tough to tease apart sometimes, even for professionals. But the hallmark difference to an eating disorder and a child who's a selective eater is really with eating disorders, kids have some kind of distorted body image. And their main reason for not eating in something like anorexia nervosa is because they want to be thin or they want to lose weight.
Kids who are picky. That's not necessarily their goal. They just maybe don't have a really strong hunger drive and don't enjoy eating that much or they just want to avoid certain foods.
Dr. Mike Patrick: For folks who are interested in hearing more about eating disorders and anorexia nervosa, bulimia nervosa, we did do an episode on that where we really went into depth on eating disorders. That was PediaCast Episode 249. And I'll put a link to it in the Show Notes for this episode, 369, over at PediaCast.org so folks can find it easily.
But that's kind of a different issue and still an important one for many families, so I just want you to get that information if you need it.
So tell us a little bit about the Interdisciplinary Feeding Clinic here at Nationwide Children's.
Dr. Lauren Garbacz: So our feeding clinic here, as it implies the name, is interdisciplinary, with nurse practitioner or physician who sees kids. We have a dietitian. We have speech language or occupational therapy where here at Nationwide Children's, we refer to those as feeding therapists as disciplines. And then, we have a psychologist.
So we all see the patients together for an evaluation in our feeding clinic and then make a determination about who they need to follow up with after that visit.
Dr. Mike Patrick: Yeah, that's really a great one stop for all of the different components of many feeding problems, being able to see the psychologist, the nutrition folks.
And then, speech therapy and occupational therapy, why would they need to be involved in feeding issues?
Dr. Lauren Garbacz: So we want to make sure that kids are being assessed for any oral motor difficulties that may be contributing. We want to make sure they're safe to eat certain types of food. And we want to determine whether they need any kind of ongoing support and developing oral motor skills.
Dr. Mike Patrick: So if a family had concern with their child's feeding or really picky eater, very selective and there is an issue with growth or family life, how do they get in touch with the feeding clinic? Is this something they can just call and make an appointment for themselves or they need a referral from their primary care doctor.
Dr. Lauren Garbacz: Here at Nationwide Children's, they do need a referral from a provider. So if it's within our system, that's easy for any provider to send that referral over. Outside the system, they'll need to fax in their referral. For our clinic, we do require that parents complete a questionnaire. So once they're referred, they will have somebody contact them, provide the questionnaire and once parents fill that out and send it back, then they'll be scheduled for their appointment.
Dr. Mike Patrick: Great. And we'll put a link to the Interdisciplinary Feeding Clinic here at Nationwide Children's in the Show Notes as well, so folks can look that up and get more information and figure out how to get in touch with you if they need your services. And again, we'll put that in the Show Notes for this episode, 369, over at PediaCast.org.
All right, well, Dr. Lauren Garbacz, she is a pediatric psychologist with the Interdisciplinary Feeding Clinic here at Nationwide Children's. Thank you so much for joining us today.
Dr. Lauren Garbacz: Thank you.
Dr. Mike Patrick: All right, we are back with just enough time to say thanks to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.
And, of course, thanks to our special guest this week, Dr. Lauren Garbacz, pediatric psychologist with the Interdisciplinary Feeding Clinic at Nationwide Children's Hospital. Really appreciate your helping us understand and deal with our picky eaters.
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Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.
you next time on PediaCast.