Picky Eating & Continence Challenges, Part 2

Picky eating is a challenge for many parents. It can feel twice as tricky when you’re trying to improve your child’s digestion and elimination through diet. This video by Vermont Continence Project nutrition consultant, Kelli Borgman, RD, and OT consultant, Chayah Lichtig, OTR, offers practical everyday suggestions for broadening your child’s diet and improving the mealtime experience for your family.

Please watch Picky Eating and Continence Challenges, Part 1  before watching this video.

A full transcript of the video appears below.

Hello, my name is Kelli Borgman. I’m a dietitian consultant with the Vermont Continence Project. Our topic today in this video will address how to help the picky eater to develop a diet that supports healthier elimination. I’m going to begin talking about the parent child feeding relationship and Chayah Lichtig will take over the the second part to talk about mealtimes, supports and communication.

When it comes to figuring out how to support your picky or extremely picky eater, I encourage parents and caregivers to slow things down a bit and take a closer look at the different areas of the parent child feeding relationship that might need to shift or change. This can happen in two different ways, either offering more support when it’s needed or requested by your child, and giving space for autonomy to increase confidence in order to expand skill and variety. When your child is ready.

But of course this is easier said than done. In real life. How do we as parents know moment to moment, meal to meal, when to step back and when to intervene? On many busy days, it may not feel like we have a choice in the matter, or we just don’t have time or capacity to set up an ideal situation. And just to be clear, things don’t need to be ideal every day for them to make progress. But in general, there’s got to be some ground rules to start from, especially when stress or refusals are happening or there’s worry about nutrients or growth.

This is where a division of responsibility comes into play. It’s a starting place to start thinking about how to have healthy boundaries with your child around food and eating. The Division of Responsibility is a model of feeding developed by a person named Ellyn Satter, who’s a dietitian and family therapist. The model basically breaks down the balance of what the child is responsible for at meal times versus the adult. It talks about the adult being in charge of the what, when and where of feeding, and the child is responsible for deciding if they want to eat and if so, how much. The model offers distinct roles which allows each individual to do their own job. The parent does not have to get involved with pressure, bribing or other creative ways they can think of to try and make their child eat.

When your child decides how much food is the right amount for them at that moment in time, they can build confidence and communication with their own bodies. This positively affects their long term relationship to food and taking care of their bodies. It’s the child’s job to tune into what their body is telling them.

There is a very important “and” to briefly mentioned in addition to considering the division of responsibility, when kids have current medical concerns or a history of intensive or frequent medical intervention or there are signs of neurodivergence or sensory processing differences, adaptations or more supports may be needed beyond this model and in words, the parent may need to rebalance their expectations around what they want their child to eat versus their what they’re actually eating, and take a different approach to routines and boundaries when it comes to the what, where and when. For example, neurodivergent kids often need to see more of their comfort foods on their plate than other kids to feel safe and relaxed when eating. Sometimes when eating has been challenging, kids tune out their hunger signals and try to avoid eating or want to be distracted or get up from the table. So supports that might work for that child may be taking special care to be sure the mealtime space is suitable suited for them. They have a comfortable and supportive seating situation. Visual and sound input is considered, for example, sometimes changing the lighting or adding music or eating in a quiet, quieter place can be helpful. Or the child is offered a high calorie drink like milk or a nutritional shake at the end of mealtime. If they need support to get the nutrients their bodies need to play, grow and learn, then absolutely accommodations and supports to the basic division of responsibility should be considered.

So just to review in a little more detail what the foundational roles are per the division of responsibility for each person. The child’s role is to eat what they are able to when they’re able to, to eat the amount they need, to learn to eat the foods their family generally eats, to grow at a predictable pace, and to learn behaviors and communication that gets their needs met at mealtimes.  or helps in that. So being clear, positive, polite are some of the basics.

The parent or caregiver role is to buy and prepare the food, offer meals and snacks at regular intervals to create pleasant mealtime, expectations and routines (So what we expect to everyone to do and how we talk about it), to be considerate means acknowledging and taking into account your child’s needs and feelings without going overboard and giving too much attention, which is more like catering, and avoiding controlling their body size basically means avoiding portion control or overriding their decision about if or how much they choose to eat.

And of course, kids in certain scenarios, growth scenarios like tube feeding or low growth need different accommodations. Just wanted to mention that.

To go into a little more detail about meals and snacks at regular intervals, the benefit of having a meal routine and a flexible routine is that it can really support the body’s regulation of hunger and fullness. There’s an entrainment and a natural, predictable ebb and flow throughout the day that can get established. It reduces the guesswork, since on challenging days with toileting or other issues, there may be barriers to communication between your child in their body or between your child and yourself. A flexible routine can also increase calorie intake and ensure they’re getting regular breaks from play and learning to really focus energy and eating.

Taking a look at when your child is naturally hungry is a good place to start. Noticing that the whole 24 hour cycle with elimination patterns in relation to when they eat and drink will also guide you on developing this routine. If a flexible routine is challenging for your family, using technology and visuals like app reminders and timers, meal planning apps and visual aids like schedules or menu boards may be helpful.

Offering balanced meals is key, so having a meal or snack plan that includes a starch or carbohydrate and some protein or fat will help with fullness and allow your child to take breaks from eating and avoid grazing and excessive drinking, which can make continence challenges worse.

Our overall goal as parents and caregivers is to help our child be more calm and emotionally prepared for the mealtime experience. Remember that mealtime is about much more than just calories. Instead of waiting for the moment that your child sits down and gives to your child in food and mealtime related activities, some of those might include choosing food together, even going to the grocery store together, preparing food together, setting the table, passing and serving food, watching others eat, talking about food, and participating in mealtime cleanup. You may notice that your child can participate in all of those activities without having done any eating themselves.

Most people benefit from knowing what to expect and knowing what’s expected of them. We suggest that adults create and follow some agreements about how mealtime and eating go. Most of these are useful whether your child is a picky eater or not. Some examples are start with an empty plate. An empty plate gives your child the opportunity to choose what and how much of each food they want. Optimally, people serve themselves, and this sometimes does need support, especially for younger kids. Model and teach passing. Passing food is a wonderful, low pressure way to get closer to a food when you may not be sure whether you want to eat it or even try it. Also, if you’re serving your child because they can’t serve themselves for some reason, keep the portions small. An over-full plate can be overwhelming, while a less full plate is an opportunity to finish your portion and ask for some more.

Remember the Division of Responsibility and how the parent gets to choose what food is offered? Well, we suggest including something your picky eater likes and will eat every time. This doesn’t mean catering to your child by offering exactly what they want each time, but making sure that they are welcome at the meal time. Parents and other family members should eat that food, too. We’re showing that we’re all willing to try a variety of foods. Finally, your child’s role in the Division of Responsibility needs to be honored. At any time, they are allowed to refuse any food that is offered to them.

The ways that parents talk about foods can really affect the way children see those foods, too, and how they see the relationship to those foods are really common. One that we see is that a child tries a food and doesn’t choose to have another bite. The parent says, “Oh, you didn’t like that”. Remember that there are lots of reasons your child may not might not go for that second bite. As Kelli described, they may not have been exposed to that food yet. And the flavors or textures may be unfamiliar. They might be full and yes, they might not really enjoy it.

Here are some alternative phrases you can try instead of “You don’t like it”. “That had an unexpected taste. Huh?” Or, “you’re not interested in eating more of that right now.” Or “one taste was enough for now, huh?”

If you think they might spit it or throw it, you can tell them where they can put it. For example, “you can put that on the corner of my plate”. Or “I like how you tried that food”.

Don’t forget that there are lots of things about and not about food that you can talk about during a meal. If you want to talk about a food, you could talk about it sensory characteristics. Is it warm? Is it mushy? Is it cold? Is it hard? Is it crunchy? You can share experiences about food like, “well, this apple is crunchy, but I ate an apple pie last week and that was soft and mushy”. You can ask questions about the food. “Hmm. Did you notice that some of the bites were kind of chewy and other bites were kind of mushy?” Or you can just share your own observations about the food.

And then there are so many other things you can talk about at the meal as well. Things like what was your favorite animal or game or what did you do outside today when you were at school? Games like Two Truths and a Lie or Thorn Rose, but are also a great way to catch up with your child about their day.

Ultimately, you’re still probably wondering how to expand the foods your child is trying and even eating on a regular basis. Just like with toilet teaching. Start with a little investigation. What are the characteristics of the food that your child likes right now? See if you can get specific. Does your child like sweet foods? Sour, spicy, very flavorful or bland? So they seem to go for warm or cool foods, or right in the middle, like room temperature.? If your child has very specific foods they eat, there may even be a specific shape that there may be a round cracker they eat regularly, but a square one with the same flavor is a no go.

Finally, texture is a really common category that people limit in their diet. Everyone knows someone who only mushy food or doesn’t like chewy meat or thick drinks. Our dietitian Kelli, describes food textures in detail in the video Constipation, management, food. So be sure to check that out.

Let’s give an example. Many children like cheese she uses salty and savory and soft cheeses are a soft cube texture, and they’re usually cool or maybe room temp, and they’re generally a yellow or white color. When working to expand variety, especially with the goal of improving nutrition. Think about going to a preferred foods neighbors. Neighbor foods aren’t exactly the same as preferred foods, but they don’t live all the way across town. For example, if your child likes Fruit Roll-Ups, maybe they would be interested in trying some dried mango. If your child likes cheese, why don’t you try something like a salty roasted potato, maybe dipped in a cheese sauce?

Also, don’t be afraid to play with flavor. Not every child who’s a picky eater dislikes flavor. For example, some picky eaters might really like something like Doritos. And you can widen your diet by diving into those flavors. For example, Doritos and chips and salsa are definitely neighbors, and nachos definitely live on the same street as Doritos, chips and salsa, even if they’re not next door neighbors. You can also try combinations of preferred foods like your child might like a crunchy pretzel, and they might also like a queso dip. And if you can combine them, you’re on your way to increasing your child’s flexibility with the foods they might be willing to try.

You also want to think about making micro changes over time. This means don’t change too many of the characteristics of a food that your child likes or don’t get a food that is too many differences away from foods that they prefer right now. We’re looking for just enough change that your child is willing to try it and hopefully accept it into their diet.

Picky eating can be a big challenge for parents and for families. We hope that the suggestions that we’ve made in these videos have been helpful for your picky eater. But if you’re finding that your child may be more described by the extreme picky eating category or your family is experiencing a lot of conflict and distress around food and meal time, we’d suggest finding some more targeted support for your child and for your family. One support we definitely suggest is a dietitian with a background in pediatrics. Also looking for an O.T. or a speech language pathologist with a background in feeding a mental health professional. With a background in feeding and attachment can be really helpful for working on the relationship between you and your child around mealtime. And finally, many regional hospitals do have intensive feeding teams who may be able to help you on your journey if some of those more local options are not enough or are not available.

Thank you for taking the time to watch this. The information contained in this video is for informational purposes only. It is not a substitute for professional health or medical advice, diagnosis or treatment. Always seek the advice of your physician or other qualified health care provider.