SELECTED ARTICLE
Author
Tatyana Elleseff MA CCC-SLP 
Article Title
How to improve the feeding abilities of young adopted picky eaters 
Posted Date
6/30/2009 
 

It is an unfortunate fact that so many parents of adopted children are too familiar with the problem of food selectivity. Food selectivity, better known as “picky eating” is common in many formerly institutionalized children. It often develops due to numerous physical and sensory constraints associated with institutialization (e.g. an orphanage may feed their wards a highly limited diet lacking a variety of tastes and textures). It is important to make a clear distinction between children who are picky eaters due to serious impairment (e.g., autism, neurological disorders, swallowing difficulties, etc) and children who were fed highly limited diets before their adoption took place. In the case of neurological impairment, picky eating will most likely not abate without intensive feeding intervention (typically performed by speech language pathologists who specialize in feeding and swallowing). However, in the case of picky eating due to institutionalization there are a few strategies that parents can try to work on improving their adopted child’s food selectivity.

These strategies are intended to help parents figure out whether their child is just unused to new tastes and textures or whether it’s a more serious issue that merits professional consultation with a relevant provider (see above). Picky eating can take so many forms. It may take form of a highly limited diet with exclusion of entire food groups (grains, vegetables etc) or it may involve the exclusion of foods with certain textures or tastes (e.g., crunchy, smooth, sour, bitter). So why should we be concerned with picky eating habits? Children will grow out of that on their own, right?

Well, it’s really not that simple. Limited nutritional intake for prolonged periods of time can stunt growth, cause acute/chronic illness and even limit the child’s social interactions. “But what can we do?” ask frustrated parents. “We try to give them different foods but they don’t even want to look at them, much less eat them”... The truth is that a simple (usually pleasurable) act of feeding designed to bond the child with his/her caretaker from the earliest age, can turn into a nightmare for both child and parent when food selectivity comes into play. It may also be further exacerbated by the following erroneous beliefs that some parents hold regarding feeding:

    1. Children will eat the food presented to them because there is nothing else to eat
    2. You can verbally cajole or bribe children into eating the foods that they need to eat

However, if the child’s food selectivity is extremely severe, chances are that he will choose to go hungry rather than eat foods that he considers repellent. In extreme circumstances, we may have a situation where a frustrated parent is trying to feed the child via any means possible (bribing, cajoling, threatening, force feeding), and the child is desperate to escape the same activity by any means possible (e.g., screaming, crying, spitting, vomiting). The key here is to: “GO SLOW!” For example, never introduce a brand new dish to a child if you know it will elicit a strong reaction. Introduce new foods in little bits and pieces very gradually.

It may also help placing bits of new foods and mixing them into existing foods the child is currently eating (e.g. placing bits of fruit [that the child refuses to eat on its own] into the child’s oatmeal). You will also have a much better chance in getting the child to try the new food if it has a similar look and texture of the food that they are already eating. For example, if the child only likes to eat “buckwheat kasha”, present the child with a similar “kasha” (e.g., oatmeal) to see if he is willing to try a small amount of the dish. It is equally important for a parent or a sibling to demonstrate how “yummy” the new food is so that your child is more receptive to intake.

One very important consideration that often comes into play with picky eaters is “sensory integration deficits”. Very briefly, sensory integration has to do with the child’s overall ability to self-regulate. Deficits in sensory integration may involve the child being hyper or hyposensitive to their immediate environment (e.g. inability to focus, impulsivity, high arousal or withdrawing from input, high tolerance of pain etc). They can also manifest in poor postural control (e.g. clumsy, constantly in motion) or in regards to feeding they may cause sensory defensiveness (hyper vigilance and intense avoidance of certain food textures and tastes). Mild sensorimotor difficulties can be frequently observed in young adopted children during mealtimes. They can manifest in a variety of following ways: low tone of cheeks and lips (muscle feels mushy, soft, and lose), deficient chewing movements, poor tongue control during eating and drinking, poor discrimination and awareness of food in mouth [food stuffing, having bits of food in mouth for hours after a meal], open mouth posture and visible drooling during mealtimes, as well as poor attention (e.g., running around the table while eating) during feeding which may often result in episodes of coughing, mild choking, and drooling/loss of food from mouth.

Keeping the above in mind, the major goal of feeding is to decrease sensory defensiveness and increase the child’s acceptance of new foods via a hierarchy of sensory textures and tastes. As stated above the first step to a varied diet is to start building upon the foods that the child already accepts. Consequently it is important for parents to create an inventory of foods that their child is willing to tolerate and foods that they refuse to eat.

    1. Make a list of the foods and drinks the child will accept and organize by sensory properties (e.g. crunchy, soft, etc)
    2. Make a list of other foods (that your child does not accept yet) in the same categories
During that time it is also helpful to rule out certain conditions that may make certain foods unpalatable to children. For example, food allergies and gastroesopageal reflux may not evidence as dramatically with some children as they evidence with others. Therefore, it is very important to rule them out before the initiation of new food trials. So how do we begin? For starters, structure all meals and snacks. The routine is intended to reduce mealtime anxiety and improve the child’s appetite. In order for the latter to occur it is very important to eliminate nibbling of non-scheduled snacks or filling juices between meals. It is also important to serve food in one specific designated area (e.g. dining room or kitchen) as opposed to any room in the house (e.g., bedroom, living room). Finally, try to limit meal presentation to 30 minutes. This is important for two reasons:
    1. Meals that take more than 30 minutes begin to increase the child’s fatigue and often cause loss of calories due to increased effort involved in food consumption
    2. Mealtime should not become “a never ending buffet” from which a child may partake whenever it strikes their fancy.
After the implementation of structure during meals, begin the introduction of new foods in tiny amounts to the child’s existing diet. Here you may work based on the following premise:
    1. Introduce foods with similar taste, color, and texture
    2. Once the child is somewhat accepting of new foods, gradually fade old foods so that the child is primarily eating the new foods (e.g., start with a few kernels of corn in mashed potatoes and as you continue working gradually replace all mashed potatoes with corn)
    3. Use a reward system for trying new foods (keep a plate of preferred food next to the plate with small amounts of new food; reward the child with preferred food after he has taken a small bite of the new food)
    4. If a child refuses to taste the new food compromise and negotiate for the child to touch (with lips/mouth) the new food without swallowing it (earn double rewards for swallowing food instead of just holding it in mouth and then spitting out)
    5. Always feed a child from dishes and cups and never from the original containers (e.g., juice boxes)
    6. Make sure that you go though a variety of utensils and dishes so the child does not become “stuck” on a set of feeding utensils (only wants to eat from specific set)
    7. Sand timers may be helpful for setting specific short term meal time limits for younger children
    8. Encourage your child to observe you prepare and serve food
    9. USE PRAISE FOR EVERY LITTLE EFFORT YOUR CHILD EXHIBITS IN REGARDS TO NEW FOOD TRIALS
Some important DONTS:
    1. Don’t ask a child what he wants or you will become a short-order cook (the goal is for the child to eat what the parents eat and not for the parent to eat what the child eats or make several meals per each mealtime)
    2. Don’t fight about food or have power struggles
    3. Don’t let the children watch TV during mealtimes or snacks
    4. Don’t let children play with food as it is messy, costly and is generally a waste of time (to date there’s no evidence that playing with food leads to food consumption as opposed to touching (to lips), smelling, and tasting food)

Chewing Development in children

Jaw movement Age Appears Phasic bite release 5-9 months Munching pattern 9-12 months Diagonal rotary chewing pattern 15 months + Sustained bite (Chewing with lips closed. May still lose food or saliva) 18-24months Chews with closed lips (no loss of food/saliva) 24 months +

Food consumption guidelines for adopted infants and toddlers by age

Foods Types Eaten Age Appears: Liquids bottle 1 month Liquids bottle & introduction of baby cereals/purees (rice cereal, oatmeal) fruits and vegetables (very ripe, mashed banana, apple sauce, pureed pear, acorn or butternut squash, sweet potato) 4-8 months Liquids, pureed foods, ground foods, and mashed table foods (grains, fruits, vegetables, meats such as turkey and chicken etc) 8-12 months Liquids and coarsely chopped table foods 12-18 months Liquids and all table foods 18 months + While it is unusual to end an article with a disclaimer, it is important to mention again that this article was not written to discuss the feeding strategies for adopted children diagnosed with autism or any other serious neurological or genetic based disorders. It is also not intended for parents who are concerned with the swallowing abilities of their young adopted children.

For above concerns, parents are strongly encouraged to schedule face to face consultations with speech language therapists in their area. To find more information on this topic or to find a speech language pathologist in your area, visit the ASHA website and click on the 'Public' tab located at the top of the screen. Best of luck and happy feeding!

References:

Feeding and Swallowing Disorders, American Speech-Language-Hearing Association, www.asha.org Feeding and Nutrition for the Child with Special Needs, by Marsha Dunn Klein and Tracey A. Delaney, Therapy Skill Builders, 1994

Feeding and Swallowing Disorders in Infancy: Assessment and Management, by Lynn S. Wolf and Robin P. Glass, Therapy Skill Builders, 1992 Morris, Suzanne Evans and Marsha Dunn Klein; Pre-Feeding Skills, Second Edition; Therapy Skill Builders; 2000

Select Online Resources (pertaining to feeding milestones):

http://www.childrensmemorial.org/documents/TypicalDevelFeeding.pdf

http://www.cedwvu.org/programs/feeding/development.doc

http://www.latrobe.edu.au/hcs/projects/paed_feeding/Biting-Chewing.htm

 
References
Tatyana Elleseff MA CCC-SLP is a bilingual speech language pathologist with a private practice in Somerset, NJ and multiple hospital and agency affiliations in Central New Jersey. She is a New York University graduate with Bilingual Certification from Columbia University. Additionally she holds dual licensure from the states of New York and New Jersey as well as a Certificate of Clinical Competence from ASHA (American Speech Language and Hearing Association). She specializes in providing a variety of comprehensive speech and language services to bilingual pediatric clients including internationally adopted children from various countries around the world. For more information about her services or to schedule a consultation call 917-916-7487 or visit her website: www.smartspeechtherapy.com 
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