Eating Styles Matter
feeding & nourishing babies & toddlers
who don’t follow typical eating progressions
Linda Piette, RD, MS, LDN
JUST TWO MORE BITES
Producer of EATING LESSONS – Babies
www.foodschool.info or www.lindapiette.net
Author of
Vermont Statewide Nutrition Workshop
Waterbury Center
October 31, 2012
© 2012 Eating Styles Matter by Linda Piette
“Eat what you like and let the food
fight it out inside.”
Mark Twain
SCIENTIFIC BREAK THROUGHS
Digestion/ nutrition
Immune Function
Gene Expression
NEW ENVIRONMENT
food touches every part of life
Malnutrition Risks - US
Obesogenic Environment
What disease will 3 out of 4
Americans have by
2020?
PROCESSED FOODS
↑ calorie
↑ salt
Kids like familiar
foods…….
Flavor Exposure
• Starts early
• Breast milk/ formula
flavor impact
• Table foods by 1st
birthday.
• Foods introduced
after age 4 more
likely to be disliked.*
Nov 2002, 5-yr study J American
Dietetic Assoc
Pediatric News- Oct 2002
Incidence of Feeding Problems
• 25% of young children
• 50+% in children with autism
• 80% in children with developmental delays
Growth the most important developmental task of
childhood…..keeping score
Growth charts….
– Standard charts from
www.cdc.gov
– WHO (World Health
Organization) on CDC
website
– Specialized charts for:
• Cerebral Palsy
• Down Syndrome
• Turner/ Williams
Syndromes
– Weight-age
Weekly Weight Gains
Age (months)
1-6
6-12
12-15
15-36
36-48
Weight (ounces)
5-6
3-5
2
1.5
1.2
Height can ↑ 10 in in the 1st year
Source :JUST TWO MORE BITES
Growth
How long does it take to gain a pound ?
Infants:
3 weeks
1-year-old:
2 months
3-year-old:
31/2 months
No eating….no growth
Eating Connections…..
Physical/ Motor
– Motor Skills & Eating (mechanics)
– Body Size & Motor Skills (weight-age)
Readiness
– Digestive
– Neurological
Social/ Cultural
– Family Food Traditions/ Dynamics
– Health Risks
– Economic
Body Size (Weight-Age)
WEIGHT
WEIGHT-AGE
RANGE
(average for age)
8 lbs
Birth
6 – 9.5 lbs
13 lbs
3 months
10 -16 lbs
17 lbs
6 months
14 – 20 lbs
22 lbs
1 year
19 – 26 lbs
27 lbs
2 years
24 -32 lbs
31 lbs
3 years
27 – 36 lbs
Eating Milestones
SOLIDS
• Closes lips around spoon
(6-9 months)
LIQUIDS
• Drinking from a cup by 16
months
• Uses tongue to move
food from side to side
(8-11 months)
• Able to drink 6 oz within
10 minutes or less
• Table foods by 1 year
• Able to drink thin liquids
without gagging
Balancing
• Nutrition goals
(short-term vs long-term)
• Maturity / readiness for food
(digestive, motor & sensory)
Eating Styles
happy, fussy, careful / fragile?
Variations in growth, food variety (flavor & texture), skills & adaptability
Balance short & long-term goals
Nutrition Goals
for babies & toddlers
PRIMARY
SECONDARY
• Growth
• Texture Progression
• Food Variety
• Self-feeding Skills
(Good Nutrition=
Adequate calories +
food variety (texture?)
• Healthy Food Habits
Eating Styles
variations in growth & variety
HAPPY
Good growth
Good food variety
TINY
Poor growth
Good food variety
CAREUL/ RIGID
Good growth
Poor food variety
FRAGILE
Poor growth
Poor food variety
Happy Eaters
Focus on Long-term
Nutrition Goals:
• Trust baby’s ability to
self-regulate calories
• ↓ sugary foods
• Off baby foods early
• Avoid restrictions
• Introduce healthy table
foods early (off baby
foods early)
• Off bottle at 1 year
• ↓ milk to ↑ solids
Fragile Eaters
• Poor Growth
• Poor Food Variety
Not On Schedule…..
Not Ready for Food
Medical Risk
Developmental
Delay
Careful/ Rigid
Eaters
• Good Growth
• ↓ Food Variety
(flavors +/textures)
– Sensitive to flavor, texture/
Temperature
– Brand-specific preferences
• Self-feeding?
Sensory? Behavior?
Careful/Rigid Eaters
Ben
• 1-year-old
• Baby foods –purees
• Frosting only
• Force-feeding
Adam
• Rigid eating (flavor + texture)
• Delayed progression
Tiny Eaters
• Poor Growth
• Good Food Variety
– ↑ Flavors
– Volume…liquids...solids ?
– Texture ?
• Motor delay?
• Food Aversions?
• Behavior ?
Tiny Eaters
Connor
• Reflux
• Delayed texture
progression
• ↓ fluid volume
• Poor Growth (FTT)
George
• 1-year-old
• Eating Table Foods
• Poor Cup Drinking
• Growth Rate Drop
Strategies…..
Balance long and short-term nutrition
goals
- growth or oral motor skills?
-↑ sugar/ fat foods?
-↑ liquids to ↑ calories
Feeding dynamics
- use distractions?
- food as reward/punishment?
- feed while sleeping AVOID
- force feeding ? NEVER
As short-term feeding problems
resolve shift to long-term goals
Monitoring Growth
• Degree of poor growth
• Pattern of growth fall off
• Calorie intake
– Adequacy
– Ratios (solids/ liquids)
Poor Growth
Fragile Eaters
– Medical/ developmental
cause ?
– Specialized growth chart ?
– ↑ calorie need ?
Tiny Eaters
–
–
–
–
–
Oral aversion ?
Motor-delay ?
Timing/ off-schedule intro?
Can’t / won’t eat ?
Family food dynamics ?
Poor Growth MAKE EATING EASIER
………increasing volume
Fragile/ Tiny Eaters
– Liquids
• Eating gear
– Solids
• Gradual progressions
• Modify texture
– Demos & reminders
– Calorie concentration/
supplements
Breast/ Bottle Feeding
Common Problems
• Poor latch
– Adequate support?
• Poor Lip Closure/
– Leakage ?
• Poor Suck/ Swallow/
Breath Coordination
– Rhythmic pattern?
POOR GROWTH….LIQUIDS
?
How much is enough?
• Formula
– Term baby …approx 2 oz
of formula/ pound body wt
(note: ↑muscle tone,
cardiac/pulmonary/
digestive problems
↑ calorie needs)
• Breast….
– 5/6 wet diapers/day
Delay transition to cup?
Breast/ Bottle
Feeding Solutions
Strategies:
– Positioning
– Oral Massage
(promote tongue
grooving & cupping)
– Jaw Support
– Nipple with wide base
– Flow rate ?
Nipples
• Latex/ silicone
– ↑thinness ↑risk of collapse
• Shape
– (wide/ narrow base)
– (orthodontic/
angled/rounded)
• Flow rate (+ pause)
– Slow to med to fast
• Pliability (soft/hard)
– Preemie/Newborn/older
Size (length of shank)
• No flow during pause
– Gerber Silicone Slow
– Gerber silicone Fast
Flow Standard
– Avent Naturally
Feeding Bottle
• Flow during pause
(continuous)
– Gerber Silicone
Medium Flow Standard
– Gerber 3-hole
– Parents Choice
(0+ and 6-mo +)
Special Bottles/ NipplesSolutions
• Haberman-cleft palate
• Pigeon Nipple ½ firm ½
soft (Children’s Medical
Ventures)
• Dr. Brown reduces air
swallowing
Miguelina
Fragile baby
HISTORY
– GI issues
– Delayed/ abnormal oralmotor skills
INTERVENTIONS
• POOR GROWTH
– stabilized with g-tube
– Facial massage
– Positioning/ feeding gear,
etc
– Formula change &
concentration
– Liquids to solids ratio
– G-tube
– Keeping oral alive
Sandy
fragile newborn & toddler
HISTORY
• Cardiac problems
– Weak suck
– ↑ Calorie needs
• Down Syndrome
– ↓ muscle tone
• POOR GROWTH
– Began at birth
– Stabilized after 2nd birthday
INTERVENTION
– OT (massage, nipple change,
texture progression)
– RD (formula concentration,
growth chart, fiber &
medication review)
Cup drinking…new skill
• Which cup?
• Practice with open
cup + thickened
liquid
• Timing
– Transition
– Shaping preferences
• Maximize calories/
oral-motor skills?
George
tiny toddler
HISTORY
• Delayed texture
progression
• Mild torticolis
•
•
•
•
POOR GROWTH
Started at 1-year
After transition to cup
Resolved after
intervention
INTERVENTION
• Thickened milk
• ↑ calorie drink
Cup drinking…
CUP DETAILS
• Height & handles
• Spouts
LIQUIDS
•
•
•
•
•
Formula/ supplement
Texture + flavor
Cost
Shaping habits
Delay transition to cup?
–
–
–
–
Hard/soft
Rate of Fluid Flow
Dot/slit opening
Spill proof
Connor
tiny infant & toddler
• HISTORY
– Reflux
– Delayed texture
progression
– Oral aversion?
• POOR GROWTH
– Through infancy
– Resolved after food group
• INTERVENTION
–
–
–
–
Medication
Thickened formula
Supplements
Food group
Poor FOOD Variety
Fragile Eaters
(poor growth, poor variety)
– Delayed progression with
textures
– Timing & typical
development can ↑
resistance
Careful/ Rigid Eaters
(good growth, poor variety)
• Typical (Flavors +/ texture
• Poor adaptability
• Self-feeding ?
Poor Food Variety MAKE EATING EASIER
…increasing texture
Solids
• Modify texture
• Gradual progressions
– Demos & reminders
Supplements ?
• Ratio of calories from liquids vs
solids
TRANSITIONS
Solids (Purees)→Textures
Calorie Implications
• Liquids - ↑cal (milk or standard formula 20 cal/oz)
• Solids - ↓ cal (fruit/veg 10 cal/oz)
• Exceptions: baby yogurt (30 cal/oz) , heavy cream (51
cal/ TB, oil/ butter (100 cal/TB), avocado, hummus
Eating Milestones
SOLIDS
• Closes lips around spoon
(7-9 months)
LIQUIDS
• Drinking from a cup by 16
months
• Uses tongue to move
food from side to side
(8-11 months)
• Able to drink 6 oz within
10 minutes or less
• Table foods by 1 year
• Able to drink thin liquids
without gagging
Steps to Eating
Oral-Motor Skills
Biting (Jaw)
Chewing
- munching
- rotary
Tongue
- side-to-side
- tongue tip
-food propulsion
Lips
-active for food removal
and closure
Cheeks
-keep food contained
Swallowing
- oral phase
- pharyngeal phase
- esophageal phase
TRANSITION to SOLIDS
Signs of readiness
•
•
•
•
•
•
•
•
•
Sitting up
Closing lip around spoon
Tongue lateralization
Up + down munching
Has doubled birth weight and is
13 lbs.
Her head and back is straight
in supported sitting and she can
reach out for a toy.
Puts hands and toys into mouth
easily and frequently
Shows positive mealtime
communication cues
Shows good oral motor
coordination to accept and
swallow food
Self-Weaning??
• Started in England
• Skip purees/ spoon
feeding
• Start with soft-solids
(ie. Steamed veggies or soft
fruit)
• Typically 8-10 months
Gradual Food Progression
Make steps smaller
Avoid mixed textures
Aim for uniform size….
Food mills
Graters
Give dry crunchy BEFORE
soft/wet solids
Oral Motor Programs
• Facial massage (use
fingers or wash cloth)
•
•
•
•
Nuk brush
Infadent
Vibration
Blowing activities
Ready or not
•
•
•
•
•
….Eating is a Sensory
Experience
Taste
Smell
Sight
Touch
Hearing
Careful & Fragile eaters are
often NOT READY
Poor Variety
MAKE EATING PREDICTABLE
• Prevention
• Repetition
• Routines/ structure
• Modulate sensory experience
• Redefine eating
(expectations)
• Feeding Dynamics
Poor Food Variety
MAKE EATING PREDICTABLE
PREVENTION
• Avoid giving food from
packages
• Pre-meal activity
• Food Jags vs downward
spiral
Poor Food Variety
MAKE EATING PREDICTABLE
REPETITION
• Toddlers “neophobic”
Need to see a food 16-50X
• Build bridges …Gradually
change….flavor
texture
color OR
shape
MAKE EATING PREDICTABLE
for rigid eaters
ROUTINES/ STRUCTURE
• Schedules
• Rituals (stir, stir, lick)
• Songs/ rhymes (1,2,3,
BITE)
Poor Food Variety
MAKE EATING PREDICTABLE
MODULATE SENSORY EXPERIENCE
• Sensory seeker/ avoider ?
– “Big” food flavors
– Dry foods before soft solids
• Distance food contact
– Squish food in baggie
– Cut up straws as holders
– Dry finger foods
• “Comfortable” environment
– (lights, mirrors, noise, etc)
Connor
Sensory seeker
• Over stuffs & pockets food in
cheeks
• Grinds teeth
• Swallows food whole or barely
chewed
• Messy eater; not aware of food
on hands or lips
• Difficulty with manipulating food
with hands or utensils
• Prefers big food flavors
MAKE EATING PREDICTABLE
for rigid eaters
REDEFINE “eating”
(expectations)
tolerating/ looking
smelling
touching
licking
biting
chewing
swallowing
MAKE EATING PREDICTABLE
for rigid eaters
FEEDING DYNAMICS
• Division of responsibility:
Adults (what, when &
where), Child (if & how
much)
Ellen Satter
• Force/ permission
• Dance
• Force
• Distractions (tv, toys,
computers,cars, etc)
• Bribes
Food Fun Group
Based on Kay Toomey SOS
Program
12 weeks – 1.5 hour
sessions
Child group (with 10 foods)
Parent group (discussion &
support)
Picky Eaters vs.
Problem Feeders
Adapted from Kay Toomey “Picky Eaters vs. Problem Feeders”
PICKY EATERS
• Decreased number of
acceptable foods (30 or less)
• Food jags – burn out foods
regained after 2 weeks
• Tolerates new foods on plate
(may touch/taste)
• Eats a variety of food textures
• Family dynamics may intensify
PROBLEM FEEDERS
• Extremely limited range of
acceptable foods (20 or less)
• Brand-specific food
preferences
• Downward spiral – no
regaining of burn out foods
• Cries/falls apart with new
foods
• Feeding skills are often
delayed
Age Related Problem
• 4-6 months = 19%
• 7-8 months = 25%
• 9-11 months = 29%
• 12-14 months = 35%
• 15-18 months = 46%
• 19-24 months = 50%
Carruth, et al. “Prevalence of picky eaters among infants and toddlers and their
caregiver’s decisions about offering a new food,” J of the American Dietetic Assoc.
supp.1 Vol 104 (2004)
Average Weekly Weight Gains
Age (months)
1-6
6-12
12-15
15-36
36-48
Weight (ounces)
5-6
3-5
2
1.5
1.2
Source :JUST TWO MORE BITES by Linda Piette
Help Unhappy Eaters
BALANCE
• Nutrition Goals
(growth & eating
habits)
• Child’s Maturity
(digestive, motor &
sensory)
Shape food attitudes…
Set realistic goals and strategies……..
Consider eating style:
Happy, Careful (rigid), Tiny or Fragile