My child won't eat... what should I do?

I hear from worried parents often that their kids won't eat. There are many reasons for this. Usually as long as a child is hydrated, gaining weight appropriately, and getting a variety of nutrients, I am not worried.

Some reasons kids don't eat:

• They're really getting enough food, parents just have unrealistic expectations. This is very common. Portion sizes are smaller than many parents think. They vary with age and size of a child as well as his activity level. If your child is growing well and has plenty of energy throughout the day, why should he eat more? Kids tend to eat small meals frequently and even on holidays they don't overeat like the adults tend to do. When offering snacks, think of them as mini meals to help balance out the nutrients of the day. Don't let them snack all day long though or they'll never really be hungry. Schedule meals and snacks and allow water in between. We have an obesity epidemic in this country, so if you're comparing your child to another child, chances are that your thin child is healthy and normal, but the other one is one of the 30% who is overweight. Or maybe not. It doesn't matter. Just be sure your child is getting a proper variety of nutrients, he should determine how much to eat. Talk to his doctor about his growth at regularly scheduled well visits (more often if you're concerned) to be sure it's appropriate.
• They're sick and it's temporary. When kids are sick they lose their appetites. This is normal. It usually returns with a vengeance when they're feeling better. They need to drink to stay hydrated and can eat what they feel up to it, but don't force it. See their doctor if you're worried.
• It's a new food and they just aren't sure yet. I encourage that kids over 3 years old take one bite of a food. Kids often hear me say, "taste a bite without a fight." The bite needs to be enough that they taste it. If they like it they can keep eating. If they don't want more, resist trying to convince them to eat more. Allowing them to take ownership of the decision of what to eat empowers them. Kids like power, right. Give it to them while modeling healthy eating behaviors yourself. They learn from what you do, not what you say -- and not from what they're forced to do. When preparing a new dish, include familiar foods they like to balance out the meal so they can enjoy at least something on the plate.
• They're picky eaters. Aren't they all? Most kids go through phases where they love a food then they suddenly dislike it. They might dislike a certain texture or a whole food group. While there are kids with real problems eating, most picky eaters can be encouraged to eat a healthy variety of foods as described above. Some children really suffer from being overly restrictive. Children with autism, sensory problems, food allergies, and other issues are not included in this "typical" picky eater category. A great series of blogs on picky eaters (typical and more concerning) is found on Raise Healthy Eaters. 
• They're more interested in something else. Make meals an event in itself. Sit together and talk. Turn off the television. Put away your phone. Have everyone focus on the meal, which includes the food and the conversation. Try to keep the conversation pleasant and not about the food. Take the pressure off eating!

In general, parents should choose what foods kids are offered so that there's a balance of nutrients, but kids determine how much they eat. If they're hungry, they'll eat. If they're not hungry, they shouldn't eat. Learning to eat when not hungry is something that causes many of us to struggle with weight. Most kids are able to limit intake to needs. Don't force them to change that great quality!

For more, see my other blogs on the subject:

• Nutrition for the Picky Eater
• Taste a Bite Without a Fight
• Food Strike!
• Kid's Weight Is Weighing On My Mind

Private discussions with the pediatrician

photo source: Shutterstock

Every once in awhile a parent will tell the nurse that they want the child out of the room to discuss an issue with with the doctor privately. This is usually something they perceive as a negative thing for the child to hear, such as the child being overweight or having behavior problems.

While I understand the parent's intentions, I find this to be disruptive and counter productive. As much as I try to find an excuse to have a child leave, it is usually obvious that the nurse keeps them out longer than needed.

If we have the child leave the room, he knows something is up. We are talking about him. But not sharing with him. What could possibly be so bad that we won't talk to him about it? (How do you feel when you suspect people are talking about you?)

Then there's the issue of any patient needs to know what the issue is so we can address it. My guess is most of these kids already know what the concerns are. They need help working on them. If they are overweight, we need to talk about what they eat, how they exercise, and how they sleep. If it's behavior problems, they need to give insight into how they feel and what leads to the behaviors. They need to be a part of the plan to fix the problems. If they aren't on board, they won't change their habits. I can talk about weight (or behavior, or drugs, or whatever the concern is) sensitively and in an age appropriate manner with the child. The kids at school are likely talking about it in a not-so-sensitive manner, so it's best to not make it worse by secretly discussing it.

If a parent really wants to let a physician know specific points without the child present, find a way to do that outside of a visit with the child.

Send in a letter or secure electronic message with your concerns before the appointment. Be sure it's at least a few days before the appointment so the doctor has a chance to review it!

Schedule a consult appointment for just parents to come in without the child.

Call in advance to tell the phone nurse your concerns so she can pass it on to the physician.

Don't bring siblings to an appointment where you want to discuss a private matter about another child.

All of these means allow the physician (or other provider) to know your concerns without blatantly kicking a child out to talk about something privately.

 

When To See Your PCP?

We have many kids who come in for what I consider "band aid" medicine. We only see them when they have a problem. They never come in when well so we can know more about them: what they enjoy doing, what good (and bad) habits they have, if they are growing properly... you get the idea.

I understand that it is time and money to visit the doctor's office, but it is time and money well spent.  Sometimes it isn't obvious that this is an investment that benefits in the long run, but preventative care has been shown to be worthwhile!  I typically feel that I give inferior care to kids I rarely see because I only see them when they are sick, and can only focus on the current problem, not the overall health. You can't use a band aid to fix a broken bone or high cholesterol.  Without proper evaluation, you don't even know you have some health problems.  Even our cars get better care: people do routine maintenance checks on their car every 3-5 thousand miles, they don't just call the service station when it won't start.

Many problems have few or no signs or symptoms until they become severe. Anemia, elevated lead levels, high blood pressure, growth problems, and behavior concerns are some that we typically only see when critical if kids don't come in for recommended visits or do recommended testing.  Some parents fail to bring kids to the lab or other facility for recommended evaluations. This can delay diagnosis and puts kids at risk.

There are kids who visit urgent cares often, yet never come in for routine care.  It may be years between visits with the primary care provider (PCP).  "PCP" is used broadly here, since the primary care isn't done.  I understand that sometimes it is because kids wake in the middle of the night and the parent wants a quick fix, parents don't want to take off work so go on weekends, or the drugstore with a clinic is on the way home, but this isn't good care on many levels.

I don't always trust an outsider's assessment of certain physical signs.  Studies show parents are much happier with a diagnosis of "ear infection" and a prescription than an accurate assessment of a viral respiratory infection and instructions on home remedies.  Many ear infections are over diagnosed, leading to inappropriate antibiotic use, despite better parental satisfaction.  It benefits a practitioner who will be evaluated with patient/parent surveys to provide a prescription rather than an accurate assessment and instructions.  It also takes less time to write a quick script than to discuss the diagnosis, when to follow up if worsening, what to do to help symptoms, etc. Less work and more satisfaction, sounds good, but...

I don't know if the provider has enough experience with infants/young children to recognize what is really going on. I'm sure some of the people working urgent cares are really good at what they do, but many have little experience when they start working without supervision. They have no one to ask for a second opinion, so even after years of working they haven't developed the same skills as a practitioner working with more experienced providers who are able to help when needed.  Bad habits can be reinforced because they simply have no way to learn better skills.

Quick treatment of some infections that really do need treatment leads to poor immune memory, increasing the reinfection rate.  Strep throat recurrences have been shown to happen more when kids start treatment with less than 2 days of symptoms. There is benefit to waiting!  Strep should be treated within a week to prevent complications, but allowing the body a couple days to fight it off first builds the immune system!  It is okay to wait until office hours for many (if not most) problems. 

Difficulty breathing, dehydration, altered mental status, many injuries, and other things do require emergent care. If your parent alert system is telling you your child needs to be seen, then an ER visit is appropriate.

Keeping a good timeline of infections helps the PCP know when it is time for more intervention, such as ear tubes or prevention medications. If quick fixes are always at another location, we might not recognize the frequency. Even when parents bring kids in with a history of frequent infections we can't make appropriate recommendations because we might not trust the diagnoses.  Parents might not ever be told that their child has asthma that needs a prevention medication, so they simply keep using the quick relief inhaler, which puts the child at risk for serious complications.  Asthmatics who have regularly scheduled asthma visits when they feel well have fewer wheezing episodes requiring emergent visits and admissions.  Improve management of frequent or chronic illnesses by visiting with the primary care provider for illnesses and when your child feels well to optimize medication use, make appropriate referrals, improve safety, and spend overall less time and money.

Recommended routine maintenance is spelled out clearly in a book that comes with every car, yet a maintenance book doesn't come with kids. Yearly exams for those over 3 years (more for infants and toddlers) are recommended at a minimum.  Routine care also means regular visits to check on chronic conditions, such as asthma or obesity.

Preventative Care Guidelines are developed by people smarter than me by reviewing statistics including risk/benefit ratios, cost analysis, and more.  These aren't perfect and are regularly reviewed and often change. Some recommendations are simply not followed because insurance companies don't cover the cost. Pediatricians and many others are fighting for better coverage.  Examples of things recommended at various visits (depending on age):

• height/weight measurements

• blood pressure screenings

• lab screenings (anemia, lead, cholesterol)

• vision and hearing screenings

• development assessments

• mental health screens

• more...    

I'd like to think that I can make a difference with healthy lifestyles by providing regular routine care. Sleep habits, screen time, exercise, safety, and more are discussed at various well visits. This might uncover issues that need additional visits to be properly addressed, but early recognition helps improve outcomes.

I know my own kids take what others at the office (other doctors, the midlevels, even the nurses) say about safety, nutrition, and sleep more seriously than when I say it. (Never mind that I have qualifications to discuss and advise on this topic, I am just Mom to my kids!)  I also recognize that I see my kids daily, but don't know their growth parameters, blood pressure, heart sounds, etc from day to day living.  I bring my own children in for routine well care and follow up of health issues so that they can be the healthiest they can be.  It has become routine for me to schedule their summer physicals every Spring Break.  This routine helps because:

• it gives plenty of time to find a time/date that fits our busy family calendar and the provider's schedule. 
• it is a routine, which helps me remember... yes, I forget to make appointments just like everyone else! (Others use birth dates to remember, but I prefer summer visits for many reasons.)

It is not uncommon to uncover a problem during a well visit that needs to be addressed more completely but wasn't recognized ... even by smart, educated, attentive parents.  Please join me in healthy parenting and schedule routine checks for your kids!  Do the tests, treatments, and follow up recommended by your provider or speak up during your visit if you don't plan on doing them, which allows for open discussion about why they should or should not be done.

Use band aides when appropriate, but treat overall health with routine visits!

New Year's Reflection

I was fortunate to be able to spend New Years with my extended family in the St Louis area.  Conversation led to my mother remembering old family videos in the basement. After a little digging around, my brother found the never before seen footage!

We had a blast watching videos of past holidays and vacations.

Some things were fun to compare. My daughter is better at ballet than I was at her age.

Other things were simply laughable.  Although I was impressed at my grandmother looking fit and trim in short shorts, most clothing choices of the 70s should never be repeated.  What will they think of our current clothes in 30 years?

One thing that struck me sadly was the average weight of people at all ages in the 70s seemed to be less than the average weight of people the same age today.  I'm not saying my friends and family have gained weight ~ I would get into trouble for that!  It was simply noticeable that people of today are heavier when comparing large groups.

I've read the statistics before...

Self Reported Weight up Nearly 20 Pounds Since 1990
Mean Body Weight, Height, and Body Mass Index, US 1960-2002

... but it was interesting to see large groups of people from my past vacations and comparing to what I see daily when out and about.  It made it real.

If the US is such a great nation, how have our individuals as a group gained weight in this unhealthy manner?

Is it the convenience of pre-packaged foods, many of which are processed and/or high in fat?   More women work now than previously. Does this contribute to less home-cooking and more fast foods?

Is it that the meal size increasing?  Large sodas of my childhood are now the smallest size available.  Who needs 64 ounces of acidic bubbly sugar?  We eat larger servings both at home and at restaurants. 

Are we less active than we used to be?  I can easily see how today's kids are tempted with tv, video games, and other sedentary activities.  As a child, I only had one tv channel, and most often it had adult programming. (There were no recordings available!) I had many other things to do both in the house and outside.  We didn't have many structured activities, so we just made it up as we went along.  And we had a blast!   What about adults? Are they less active? Do we work more hours than our parents?  Do we spend more free time in front of the tv/computer than our parent's generation? What did they do for fun?  Was it out of a chair?

Do we sleep enough? With many tasks to do and distractions, such as tv programming and internet available all night, do people stay up too late to get a good night's rest?  More and more research supports that sleep is needed for concentration, endurance, immune functions, as well as weight control and more.  How often do we feel tired?

I suspect that there are many reasons for our generalized weight gain, which means that there are many potential fixes, and not one alone will help.  I have tried to limit processed foods at home, but they are convenient and easy, so I sometimes splurge.  We try to eat as a family at home most nights, though activities sometimes interfere.  Portion control is relatively easy for my kids: they eat minimally by nature.  My husband and I need to check ourselves.  My kids are much better at exercise than I am, mostly because they have time and they love to move!  I don't want to forego sleep to fit in exercise. No one gave me time for Christmas... but I'm working on finding some free time!

What do you find helps keep your family healthy?

  

Kid's Weight is Weighing in my Mind

Reports of increasing obesity levels have been circulating for years on the news.  I see kids in my office regularly who are in the overweight or obese category and we all struggle how to treat this growing problem.  Excess weight in childhood is linked to many health issues such as high cholesterol, diabetes, metabolic syndrome, and it can trigger earlier puberty- leading to overall shorter adult height.  Not to mention the psychological and social implications of bullying, depression, eating disorders, and more.

Why is weight so much more of a problem now than it was years ago? As a child I did not have a perfect diet, yet I was not overweight because we spent most waking moments outside if we weren't in school. My mother packed a dessert in every lunch box.  We ate red meat most days.  We usually had white bread and butter on the table at dinner.  We drank 2% milk and I ate ice cream every night.  But we walked to school-- without a parent by the time I was in 1st grade (gasp!)  There were only a couple tv channels, and Saturday morning was the only time we could watch tv.  We were able to ride bikes, go to a wooded area, play on a nearby playground, dig in the dirt, you name it - we found something to make it fun!  Today's kids are shut up in the house after school watching one of many tv channels or playing video games. Even those who are shuttled to activities get overall less exercise because it is structured differently.  They ride in the car to practice or class, then sit and wait for things to start. They might sit or stand while others are getting instruction. Simply put: they don't get to do things at their own pace with their own creativity for as long as they want.

What to do???  On one hand kids need to learn to make healthy choices to maintain a healthy body weight for height, but on the other hand you don't want to focus so much on weight that they develop eating disorders.  I think this is possible if we focus on the word healthy, not weight.   Starting at school age I ask kids at every well visit if they think they are too heavy, too skinny, too short, or too tall.  If they have a concern, I follow up with something along the line of, "How would you change that?" I am often surprised by the answers, but I can use this very important information to guide how I approach their weight, height, and BMI.  We talk about where they are on the graph, and healthy ways to either stay in a good place or how to get to a better BMI.  I focus on 3 things we all need to be healthy (not healthy weight, but healthy):

1. Healthy eating
2. Exercise (with proper safety equipment- but that's another topic!)
3. Sleep (again, another topic entirely!)

Food is a part of our daily needs, but much more than that. It is a huge part of our lifestyle. We have special meals for celebrations but on a day to day basis it tends to be more repetitive. We all get into ruts of what our kids will eat, so that is what we prepare. The typical kid likes pizza, nuggets, fries, PB&J, burgers, mac and cheese, and a few other select meals.  If we are lucky our kids like one or two vegetables and some fruits.  We might even be able to sneak a whole grain bread in the mix.  If our family is busy we eat on the run-- often prepared foods that are low in nutrition, high in fat and calories, and things our kids think taste good (ie things we won't hear whining about).  We want our kids to be happy, and we don't want to hear they are hungry 30 minutes after the meal is over because they didn't like what was served and chose not to eat, so we tend to cave in and give them what they want.  We as parents need to learn to stop trying to make our kids happy for the moment, but healthy for a life time.

There is often a discrepancy between the child's BMI (body mass index) and the parent's perception of healthy.  The perception of calorie needs and actual calorie needs can be very mismatched.  I have seen a number of parents who worry that their toddler or child won't eat, so they encourage eating in a variety of ways:

• turn on the tv and feed the child while the child is distracted
• reward eating with dessert
• refuse to let the child leave the table until the plate is empty
• allow excessive milk "since at least it's healthy"
• allow snacking throughout the day
• legitimize that a "healthy" snack of goldfish is better than cookies

Any of these are problematic on several levels.  Kids don't learn to respond to their own hunger cues if they are forced to eat.  If offered a choice between a favorite low-nutrition/high fat food and a healthy meal that includes a vegetable, lean protein, whole grain, and low fat milk, which do you think any self-respecting kid would choose?  If they are only offered the healthy meal or no food at all, most kids will eventually eat because they are hungry. No kid will starve to death after 1-2 days of not eating.  They can, however, over time slowly kill themselves with unhealthy habits.  

So what does your child need to eat? Think of the calories used in your child's life and how many they really need.  Calorie needs are based on age, weight, activity level, growing patterns, and more.  

One of my personal pet peeves is the practice of giving treats during and after athletic games. It is not uncommon for kids to get a treat at half time and after every game. Most teams have a schedule of which parent will bring treats for after the game.  Do parents realize how damaging this can be?  

• A 50 pound child playing 15 minutes of basketball burns 39 calories.  Think about how many minutes your child actually plays in a game. Most do not play a full hour, which would burn 158 calories in that 50 pound child.
• A 50 pound child burns 23 calories playing 15 minutes of t-ball, softball, or baseball.  They burn 90 calories in an hour.
• A non-competitive 50 pound soccer player burns 34 calories in 15 min/135 per hour. A competitive player burns 51 calories in 15 min/ 203 in an hour.
• Find your own child's calories burned (must be at least 50 pounds) at CalorieLab.

Now consider those famous treats at games.  Many teams have a half time snack AND an after game treat.  Calories found on brand company websites or NutritionData:

• Typical flavored drinks or juice range 50-90 calories per 6 ounce serving. 
• Potato chips (1 ounce) 158 calories (A common bag size is 2 oz... which is 316 calories and has 1/3 of the child's DAILY recommended fat intake!)
• Fruit roll up (28g) 104 calories
• 1 medium chocolate chip cookie: 48 calories
• Orange slices (1 cup): 85 calories
• Grapes (1 cup): 62 calories
• Apple slices (1 cup): 65 calories

So...Let's say the kids get orange slices (a lot of calories but also good vitamin C, low in fat, and high in fiber) at half time, then a fruit drink and cookie after the game. That totals about 200 calories.  The typical 50 pound soccer player burned 135 calories in a one hour game. They took in more calories than they used.  And I chose the cookie, which has fewer calories than other options (we're not talking nutrition here) and only let them have one...

What's wrong with WATER?  And eating real food after the game.  As a family. Around the table.  That snack is likely to decrease appetite for the next meal, and it isn't needed.  And if they're hungry, they're more likely to eat the healthy foods on their plate.

There are many resources on the web to learn about healthy foods for both kids and parents. Rethink the way you look at how your family eats.


Simple suggestions:

• Offer a fruit and vegetable at every meal. Fill the plate with various colors!
• Picky kids? Hide the vegetable in sauces, offer dips of yogurt or cheese, let kids eat in fun new ways - like with a toothpick. Don't forget to lead by example and eat your veggies!
• Buy whole grains. 
• Choose lean proteins.
• Eat together as a family as often as possible.
• Turn off the tv during meals.
• Encourage the "taste a bite without a fight" rule for kids over 3 years. But don't force more than one bite.
• Don't buy foods and drinks with a lot of empty calories. Save them for special treats. If they aren't in the home, they can't be eaten!
• Drink water instead of juice, flavored drinks, or sodas.
• Choose low fat milk (1% or skim) after 4 years of age. (Whole milk from 1-2 years is okay for the normal weight toddler. 2% milk is okay for the normal weight 2-4 year old.  It is now acceptable for most kids to take in lesser milk fat than previously recommended.) 
• Limit portions on the plate to fist sized. Keep the serving platters off the table.
• Don't skip meals!
• Eat small healthy snacks between meals. Think of fruit, vegetable slices, cheese, and nuts for snacks.
• Don't forget to move every day and get enough sleep!