How to not fight the good (food) fight

In a great piece on NPR this morning, child nutrition specialists talked about picky eating in toddlers and how it’s important that parents let their little ones regulate their eating behaviors as much as possible; kids will usually get what they need if you just let them alone at the dinner table.

The story reminded me of an article I wrote a few years back from Children’s Dream magazine about how hard it was for my wife and me when our then-2-year-old triplets wouldn’t eat. One of the interviews I did for the article was with Children’s beloved pediatrician T. Berry Brazelton, and something he said has always stuck with me: “A battle over food is one a parent is sure to lose.”

Our triplets (l to r), Olivia, Jackson and Sophie, at age 2.

So, here’s the article I wrote back then. Do you have picky eaters at home? Have any advice for those of us who still struggle through the (more than) occasional meal with their toddlers? Share it in the comments section below or on our Thrive Facebook page.

If you’ve ever had your child ignore the dinner you put on the table (and the lunch you put on the table before that and the breakfast that went untouched to start the day), you’ve probably asked yourself, exasperated, “Why won’t this child eat? He needs to eat to survive!”

Indeed (and it’s unlikely this will be the first time you’ve heard this), a person can’t live without the regular intake of food and fluids. But eating is also one of the most social activities we engage in; we gather around the table at holidays, we hold lunch meetings during the workday and we meet for dinners on first dates. So it’s no surprise that it takes some time, practice and even refusal for a child to figure out what, when, how and how much he wants to eat. Yet for many parents—my wife, Sara, and me included—the battle to get kids to eat often makes mealtimes very stressful.

We’re the parents of 2-year-old triplets, and watched with excitement as they learned to roll over, crawl, pull themselves up and finally take those first tentative steps. We didn’t hover. We didn’t critique or correct every movement. We didn’t worry that the kids weren’t taking enough steps, or the right kind of steps. Yet we did, and still do, many of these things when it comes to eating.

For the past year and a half, mealtimes in our house have been equal parts encouragement, frustration, coercion, joy, frustration, emotional outbursts (from all involved), triumph, game-playing, frustration and progress. Oh, and did I mention frustration?

“It’s the number one job of the parent to nurture, so when a child won’t eat, it cuts to the core and makes parents feel helpless,” says Nancy Sullivan, PhD, a Children’s Hospital Boston psychologist who works with families dealing with eating problems.

But Sullivan and other Children’s experts say the best way to handle the frustration caused by eating difficulties is for the parents to take a step back, relax their hold on the parenting reins a bit and—as odd as it may sound—let the child make most of the decisions.

“As long as children are growing appropriately, I encourage parents to give them freedom to eat what they want and as much as they want by age 1,” says renowned Children’s pediatrician T. Berry Brazelton, MD. And while this may sound outrageous to a parent who has been battling to get her child to eat, there are developmental and biological reasons to back up his suggestion.

“As long as children are growing appropriately, I encourage parents to give them freedom to eat what they want and as much as they want by age 1.”

– T. Berry Brazelton, MD

Brazelton’s career, spanning some 65 years and more than 25,000 patients, has focused on what he calls Touchpoints, which are, essentially, times of friction in a child’s development. “Feeding, sleeping and being pleasant always go out the window for a child when he is going through one of these Touchpoints,” says Brazelton. “Every parent gets upset and tries to push to get a child to eat, but it works just the wrong way because feeding is not the problem. The child is learning in another area, so they’re taking energy away from feeding. Pull away and give him back some autonomy, some control over it.”

But if I let my child choose his diet, he won’t eat anything, thinks the concerned parent of a picky toddler. Indeed, parenting chat rooms are filled with stories of kids who will eat nothing but a single Cheerio all day, throw their bottles down repeatedly (while smiling at their parents the whole time, of course) and use pureed vegetables to turn kitchen walls into modern art exhibits.

But Children’s gastroenterologist and nutrition physician Chris Duggan, MD, MPH, says this is not only normal developmental behavior, it’s also completely okay from a caloric perspective. “Children regulate their energy intake,” he says. “The tricky thing is that they do it over the long run. If you look at how much kids eat day to day, there can be huge swings. But if you look at it over a week, their average intake is almost always enough to support growth and development.” Just knowing this, he says, is often enough to reassure worried families that their children won’t waste away.

Given the obesity epidemic among children, Duggan thinks that rather than focusing on how much kids are eating, parents should be far more concerned about what their kids are eating. “The frequency of younger toddlers getting fruits and vegetables is unbelievably low,” he says.

In fact, a study published in the Journal of the American Dietetic Association in 2004 found that 25 percent of 7- to 8-month-olds and 29 percent of 15- to 18-month-olds have zero fruits per day, while 46 percent of 7- to 8-month-olds and 62 percent of 9- to 11-month-olds have a dessert, sweet or sweetened beverage every day.

This doesn’t mean that the country is filled with parents who aren’t trying to get their kids to eat healthfully. As any parent will tell you, the fights are fewer and less furious when you present chicken fingers and French fries instead of baked chicken and sweet potatoes, but Duggan says that taking the path of least resistance in the short term can easily lead to a lifetime of bad eating habits. “Diet variety is one place where parents give up too soon,” he says. “If you say that your 15- or 18-month-old child will never eat certain foods such as fruits and vegetables, then you’re sort of self-predicting this behavior for the long run.”

Developmental milestones, dispersed food intake and overall pickiness notwithstanding, there are times when parents should be worried about their child’s eating habits. According to Duggan and his colleagues in Children’s Growth and Nutrition Program, the line between normal toddler behavior and something that needs clinical attention is crossed when a child fails to grow normally. It’s a condition called failure to thrive, or undernutrition, and is defined by the child not getting onto, or falling off of, his normal growth curve.

In our case, our son, Jackson, has been considered failure to thrive for nearly a year. He and his sisters were born two-and-a-half months prematurely, and all had some gastroesophageal reflux that caused them to spit up. But while Olivia and Sophie outgrew their reflux, Jackson’s intensified, even with the twice-daily doses of an antacid we give him. Still, he mostly held his own in the growth department, keeping pace with the girls until a stomach bug last winter landed him in the hospital for five days.

“Before we knew it, Jackson had fallen off his growth curve, and mealtimes became very intense, with my wife and me obsessing over every un-drunk sip of formula and every uneaten morsel of food.”

Before we knew it, Jackson had fallen off his growth curve, and mealtimes became very intense, with my wife and me obsessing over every un-drunk sip of formula and every uneaten morsel of food. When Jackson threw up, which was often, it seemed like the end of the world. As Duggan and Brazelton can tell you, all of this pressure can only make things worse for the child at the center of the storm.

And it did. Whether physical or psychological, Jackson developed an inability to swallow much of anything. The things he did put into his mouth got mashed to a pulp by his front teeth and moved around for a while. When he tried to swallow, it inevitably triggered his gag reflex, which, in turn, caused him to throw up the bite he’d just eaten—and usually everything else he’d managed to get down at that meal.

So we turned to Children’s Growth and Nutrition team to help us solve the problem. Growth and Nutrition brings together gastroenterologists, general pediatricians, nurse practitioners, nurses, dietitians, social workers and psychologists, among others. Together, they look from various perspectives at eating issues in children of all ages with poor growth, then work to find solutions that will benefit the child while taking into account a family’s individual situation.

In our case, they did a full evaluation to determine if there was an underlying disease (there wasn’t) or a mechanical-swallowing reason for the problem (there isn’t), and gave us a number of methods aimed at helping increase Jackson’s caloric intake. They also worked with our Early Intervention program to have feeding specialists come to our house every week; throughout all of this, people encouraged us to relax, step back and give Jackson some space and some time to figure it out for himself.

At first, nothing seemed to work. Watching Jackson either choose to eat nothing or throw up what he did eat was really difficult, and even though we were getting more calories into him through high-calorie formula and other methods, he was barely putting on any weight. The negative cycle continued until an appointment we had several months ago, when our nutritionist, looking at how far Jackson had fallen off his growth curve, told us that if the trend continued, his long-term physical growth and cognitive development could be permanently impacted. Talk about a punch to the gut.

We immediately started Jackson on a prescription appetite stimulant, which we hoped would encourage him to eat more foods, and more of them, and worked to make the whole situation less stressful for him and for us.

Eventually, slowly, the hard work of not obsessing (how’s that for a contradiction in terms?) started to pay off. Spurred on by the appetite stimulant, Jackson put on a whole pound in six weeks. It may not sound like much, but to us it felt like we had won the lottery. He’s still got a ways to go to get on his growth curve, but he often seems genuinely hungry and excited about eating. And while he and his sisters still regularly decorate our kitchen walls with the vegetable of the day, mealtimes are not as confrontational as they were six months ago.

“Fighting the fight, that’s how parents feel,” says Duggan. “It’s one of the most stressful things parents go through. They say, ‘This child isn’t growing well, we have to get him to gain weight.’ Part of what we help parents do is say, ‘This isn’t a fight, we have to make this as mutually enjoyable of an experience as possible.'”

Or, as Brazelton says, “Giving up the child to their own autonomy is very painful, but it’s what parents have to do. Besides, a battle over food is one a parent is sure to lose.”

Here, from Sid the Science Kid, foods from around the world explain why you should eat them.