Kids needing feeding clinic intervention are the pickiest of the picky. Their super picky appetites have frustrated their parents to no end. They tend to have more dental problems, get sick more often, and can have more developmental delays or behavior problems. They don’t eat well, have a very short list of acceptable foods, and don’t grow well as a result.
Why are they doing this? The feeding clinic approach doesn’t ask why, but operates from a cognitive approach – that is, it’s assumed kids are doing this by some choice on their part. Feeding clinics are part behavioral intervention, part social group (peer pressure is leveraged to help kids try more foods), and part occupational therapy. They try strategies to get little ones eating more, by pressuring them to push through texture aversions, gagging, squirreling food in their cheeks, spitting food out, or rigid beliefs about foods.
I’ve met a lot of feeding clinic flunkies – kids who stumped teams of psychologists, speech and language pathologists, GI doctors, and occupational therapists. What went wrong?
In some cases a swallowing issue is found, and an occupational therapist as well as a speech and language pathologist can help this. Otherwise, it’s often assumed that there is no physical rationale for the child’s eating pattern, that it is purely psychological.
But that’s rarely the whole story, in all the kids I’ve met with feeding problems this deep. I often end up finding a physiological backstory. And when that is defined, it can be fixed; when that is fixed, appetites can improve. Eating becomes a non-issue, stress for the entire household drops several notches, and the child can begin eating and growing normally again.
What physiological gaffes can create a picky eater monster? Here are the usual suspects:
1 – Reflux medication. These lower appetite over time, and make everything harder to absorb from the gut. My opinion? These medications are rightfully earning a bad reputation. They are over-prescribed for infants and children. They are associated with lesser bone density (and fractures in older adults), and lower digestive capacity in general. They make it harder for many nutrients to be absorbed, notably, minerals like calcium and iron, and vitamin B12. Reflux medicines also let fungal infections (Candida or yeast) flourish at the expense of healthy gut microflora. I have seen at least one case of stunting due to long term use of reflux medicine. Leaving a baby on this medication during crucial developmental years means optimal levels of nutrients will not reach brain, bones, and body tissues.
Reflux medications leave food sitting longer in the stomach, because they reduce digestion. Food will remain poorly digested. The result can be constipation or loose stools, bloating, gas, more reflux, and – never feeling very hungry. Strategies to wean off reflux medicines – and how to avoid them in the first place – are discussed in detail in Special Needs Kids Go Pharm-Free. Be sure to tell your doctor if you would like to wean this out of your child’s regimen.
2 – Intestinal candidiasis. This is a Candida (yeast) infection in the intestine or GI tract. While Candida microbes are a usual resident of a human gut, they can take over and grow too much. This makes kids more picky for sugary, starchy, smooth foods. A yeast-heavy GI tract also tends to have a pH that weakens digestion. The result is a little like too much reflux medication: Bloating, gas, constipation or loose stool, and picky appetite. Treating the yeast infection with the right medication, diet, herbal tools, or probiotics can move your child to eating healthfully and heartily. In my practice, I use stool and urine tests to detect how much yeast is growing in the gut, and to see what might herbs or medicines might best clear it out.
3 – Food sensitivities. Food allergy is not so hard to see: Usually there are hives, rashes, eczema, stomach pain, tingling at lips, tongue or throat, or vomiting. But food sensitivities can have few obvious symptoms, other than weak picky appetite. I test for these in my practice with a blood test called ELISA IgG to specific foods. We find problem foods, and figure out how to rotate them. This can help your child feel less discomfort when eating, and can help reduce the texture aversion part of the story.
4 – Mineral deficiencies. Picky eaters usually have poor mineral status in their blood and tissues. Iron, zinc, and other minerals all influence appetite. These can be checked with blood tests, but there are also easy to check clinical signs for mineral deficiency states too. See Special Needs Kids Eat Right for a table on detecting mineral imbalances without drawing blood. Restoring good minerals can lift a picky appetite.
If you have an epically picky eater, take heart – there are many nutrition strategies that may crack this nut for you. See either of my books for details.
A friend of mine is a care provider for a disabled adult. She told me a little about this man, who is in his forties, and what kind of care he needs. He is infantile due to a head injury as a boy. She happened to mention, “he has pica” – so, all sorts of non-food things have to be kept out of his reach lest he eat them or chew them. Well, he can’t chew, she explained. He doesn’t have teeth, so all his food is pureed. No teeth at all.
Why no teeth, I asked. Did they all rot? Did he lack access to dental care at some point? Does he have poor immune function? My friend wasn’t sure because the teeth were gone when she began working with this man, but she implied his teeth were removed because of his pica “behavior”.
Somewhere along the way, apparently, it was decided that the best solution to this behavior was to remove all this man’s teeth.
I hope this isn’t true. I’m hoping there is a reasonable explanation for why this individual no longer has teeth – besides ignorance on the part of a physician or dental surgeon somewhere – but my friend confirms that this disabled man’s primary care doctor has told them that pica is purely a behavior.
Not exactly. Pica is a well-known clinical sign of iron deficiency anemia. It also indicates other mineral imbalances or deficiencies – like zinc or magnesium deficiency, or copper or lead toxicity. Mouthing or chewing objects is expected for teething babies, or during the developmental phase when oral exploration is key. Beyond that, persistently eating things that aren’t food – erasers, dirt, sand, rocks, clay, metal objects, plastic, wood, ice – should be regarded as a flag for iron deficiency anemia, zinc deficiency, or mineral imbalances for magnesium, copper, lead, cadmium, or manganese.
Could it be in this day and age that such a fundamental tenet of nutrition was overlooked? Or even more crazy, that it might have cost a developmentally disabled adult who can’t speak for himself every tooth in his head? Was this man’s suffering avoidable?
Possibly. His head injury may have left him with pica that is purely behavioral or developmental in origin. But, it’s simple to screen for mineral imbalances by checking clinical signs and lab tests. My friend tells me she has no idea if anyone ever did this for this man. It can be straightforward to correct pica with the right nutrition measures. When this is done, pica “behavior” can resolve or improve – as can other behaviors that attend mineral deficits or toxicities, like aggression, attention deficits, criminality, or even schizophrenia.
Pica can mean that minerals necessary for learning, growth, behavior modulation, and development are not fully on board, or that they have been displaced by toxic minerals instead. It’s common in people with developmental disabilities, including autism – not a coincidence, in my opinion. Neurotoxic effects of excessive lead, cadmium, copper, or mercury are well known; costs of deficiency for essential minerals in utero or early in life are old news too. Stunting, learning delays, behavior problems, attention deficits, and lower IQ have all been linked to pica and/or mineral imbalances. Pica can also predispose people to greater lead exposure, for two reasons: They may ingest objects containing lead; and, the lower one’s iron status is, the easier it is to absorb more lead, with any exposure.
Before it’s assumed that eating weird stuff is just a behavior – especially in a developmentally or learning disabled person – a doctor should do a full iron study. Blood work should assess ferritin, serum iron, total iron binding capacity (TIBC), hemoglobin, and hematocrit. Your doctor might look at red blood cell shape, size, and number to fully rule out anemia or pre-anemia. Reference ranges for iron parameters are wide. Children should fall solidly in the middle of the ranges for ferritin and serum iron. Teetering at either edge of the range, high or low should prompt more investigation. Marginal iron markers often go hand in hand with inattention, insomnia, picky appetites, or behavior and learning deficits. It is also wise to check serum copper, serum zinc, and ceruloplasmin (a copper transport protein in the blood), to rule out toxic levels of copper. Copper circulating unbound in serum can become neurotoxic, while ceruloplasmin will safely transport this mineral for us. Adequate zinc status can keep copper levels in check.
People with iron deficiency anemia often have pica for pebbles, ice, sand, dirt, clay or metal objects. Those with poor zinc status often uncontrollably chew fabric, clothing, erasers, wood, or pencils, or clench and grind teeth, in sleep or when awake.
One caveat: If iron supplementation is warranted per your provider’s advice, make sure your child is not ill, with a fever, or has active infections, including gut candida infections. Microbes love iron, and will thrive when it is supplemented – which can make your child feel some GI discomfort at the least, or worsen a fever, trigger pain, and worsen behavior outbursts. Iron is also poisonous at the wrong dose, so only use supplements with professional guidance.
To learn more on how kids present when they need iron, zinc, or other minerals, or when they may have toxic mineral loads, see Special Needs Kids Eat Right. Correcting mineral balance is an easy nutrition fix that is worth the effort. Check status of all essential minerals and rule toxic mineral exposures, to really know if pica has a physiological underpinning. Toxic minerals don’t remain in whole blood for long, so a knowledgeable practitioner may want to check packed red blood cell elements to more accurately assess presence of toxic metals. Optimizing minerals means optimizing many pathways in the brain for learning, processing, and emotional regulation – something that will benefit any person with a developmental disability – without pulling all their teeth!
This may be the one question I’m asked most often: How can I change my child’s appetite? Picky appetites in kids are common, but not necessarily normal or healthy. If your child has been eating fewer than ten foods for more than a year, something is amiss. Your child is probably not getting all the nutrients needed for optimal growth, learning, mood, and functioning. While a whole industry has evolved around foods just for that limited kid palate, consider what is done in other countries with healthier populations: There is no kid food. There’s just food.
That was the US, not all that long ago. Other than breakfast cereals, which were just getting steam as marketing vehicles for kids when I was growing up, we just ate food. Nobody blinked. It wasn’t because my mom was a particularly fearsome presence at the dinner table, demanding compliance. We liked the food. So we ate it, pretty much.
But times have changed. I know of many kids who are legendary-picky – kids who eat only noodles or pasta with butter, and chocolate milk, day after day, year after year. Or just coffee cake, and milk – literally. Some kids venture into as many as four foods – pizza, mac and cheese, grilled cheese, and noodles with butter (which is really just two foods, wheat and dairy). I sigh a little each time I’m in a restaurant with a gorgeous farm to table menu, but pass by a table with the bowl of pasta, Parmesan, and butter for the eight year old, while everyone else enjoys the cornucopia we are so fortunate to have in the US.
There are myriad cookbooks full of tricks to slip vegetables and fruits into foods your child does like to eat. While you work on those, think about a longer term goal of seeing your child naturally gravitate to a variety of foods. Add these simple steps to trigger some innate curiosity in your child’s appetite. Allow at least two months for these tools to fully engage. It takes time for nutrients to be absorbed into spaces and places where they’ve been lacking for a long while, and get back on line doing their usual jobs.
Step 1 – Probiotics! You’ve no doubt heard about these friendly, helpful bacteria. Microflora, healthy gut bugs, probiotics – call them what you will – but make sure your child is hosting the right bacteria in his gut to support a healthy appetite. Eating a little yogurt every day – especially the squeezable fruity flavored kind – is not enough to do the trick. High daily doses of probiotics are needed to bust a picky appetite. These help digest food, produce nutrients we need, run interference on inflammation, maintain optimal pH for good digestion, and keep pathogenic bacteria, viruses, and mold species (yeast or Candida) under control. These gut microbes eat what we eat, and they eat first. They either leave behind toxins, or good stuff, depending on whether the intestine is harboring healthy or unhealthy microflora.
They also drive appetites. What I’ve observed for years in practice is just emerging in medical literature: Kids who have lost these good “bugs” tend to have either weak, picky appetites with reflux, or appetites that are ravenous but only for starchy foods or sweets. This is often a gut with Candida species (yeasts or molds) in control. Antibiotics kill bacteria but not yeasts or molds, so with each antibiotic dose, yeast microbes will flourish anew in the gut. As they crowd out the good bugs, they change gut pH over time so that digestion weakens, and can trigger reflux, constipation, or malabsorption. Yeast desperately needs simple carbs (as anyone who has baked with it will know), and this makes for fiercely rigid appetites in children whose guts are overly yeasty. Children may or may not show any other signs of yeast overgrowth besides that rigid appetite, so this often goes untreated. Confirmatory signs are large or painful-to-pass stools, constipation, ringworm patches, relentless red itchy diaper rash or rash at groin, urine or stool incontinence, bloating, a history of thrush in infancy… and, a penchant for bread, bread, sweets, pasta, bread, pizza, bagels, and bread.
What to do: Buy a high potency, high quality probiotic and have your child use it daily for at least three months. Look for a potency guarantee; a potency of 20 billion colony forming units (CFUs) per dose or more; mixed strains of Lactobacillus and Bifido species; and, no fillers. Many probiotics contain ingredients like inulin, which are added as food for the probiotic cultures – this is optional. Others have dairy ingredients, which are best avoided. There are many probiotic products out there – some of the best are only available on line or through health care providers. For more information about purchasing and administering these, see Special Needs Kids Go Pharm Free.
Sidebar: Kids whose guts are not colonized early in life with healthy microflora have more asthma, allergies, and problems with growth, feeding, and stooling. Besides taking antibiotics, kids can also lose these healthy microflora colonies if they were born via C-section delivery, if mom was given antibiotics while breastfeeding, or if they needed time in the NICU after birth.
Step 2 – Replenish zinc. This mineral has a big impact on appetite and power to improve a reluctant eater’s habits. Like most minerals, it is usually lacking in picky eaters’ food intakes. Most kids’ multivitamins don’t have enough zinc to overcome a poor eating pattern. Kids who have oral tactile sensitivity, who balk at varying food textures, who fall apart and stop eating if they encounter a novel texture, taste, or color in their food are often candidates for zinc replenishment. It’s a make-or-break nutrient for growth and onset of puberty too – so if your child seems later than expected in starting that pubertal boost, and has an appetite limited to starchy foods and milk, then there may be too little zinc in the mix. Besides a faint or mercurial appetite, other flags for low zinc are frequent infection, poor wound healing, skin that cracks near nails, white dots on nails, hypersensitivity to smells (and eventually, loss of sense of smell), or low taste acuity.
Zinc can be found aplenty in nuts, pork, dark meat poultry, cauliflower, eggs, some fruits and vegetables, and even pumpkin seeds. If this variety isn’t cpart of your child’s menu, add a chewable zinc lozenge or tablet (there are many on the market) that gives 15-20 mg zinc per lozenge; use it daily with food for 6-8 weeks, then check progress for appetite or other signs that describe low zinc. Your doctor can always check zinc status with a blood test too. 15-20 mg of zinc is a bit higher than the government’s dietary reference intake for healthy kids with good diets, but is workable because zinc has substantially lower toxicity than minerals like iron, and we’re talking about restoring a depleted status. I’ve dosed zinc to as high as 50 mg/day safely for children in my practice, but this is a path to take with professional guidance. Too much zinc can drive iron status downward, so don’t go overboard.
If a daily lozenge is a battle: Metagenics Zinc Drink (15 mg per teaspoon) is a tasteless colorless liquid that vanishes in juice, water, or any liquid. Available at many on line supplement sites or through health care providers. Other liquid preparations abound; many of these add magnesium and calcium too. Use these only at the lowest effective dose. Questions? Send me an e mail through my contact form at NutritionCare.net, or check with your doctor.
Step 3: Restore iron. This crucial nutrient is overlooked for kids, more than you might think. Iron deficiency anemia is not uncommon in American children; many more may have marginal iron status, a condition that precedes outright anemia that your pediatrician can discern with a blood test for ferritin, a protein that stores iron. Though pediatric reference ranges for ferritin drop as low as 10 (depending on the lab doing the test), a ferritin level below 30 usually coincides in my experience with some compromise in learning, attention, behavior, sleep – and appetite. Kids with weak iron status or anemia may put non-food items in their mouths often, to chew on or even try to eat: Ice, snow, dirt, dirty snow, sand, pebbles, wood, fabric, plastic toys, pencils, paper, or other objects are typical choices for a child in poor iron status. Other signals for poor iron status are pallor, irritability, insomnia, dark circles at eyes, outright lethargy and breathlessness with little exertion, or recurring infections. If this describes your child, tell your pediatrician so your child can be screened for iron status. The most informative testing includes ferritin, serum iron, hemoglobin and hematocrit, total iron binding capacity (“TIBC”) and perhaps a blood cell count (CBC).
Examples of some iron rich foods are lentils, kidney beans, chick peas (garbanzo beans) red meats, liver, sesame seeds or sesame butter (tahini), eggs, or dried prunes. Wheat breads and cereals (not the gluten-free versions) are often fortified, but I have encountered children with weak iron status who were eating these fortified items daily. Picky kids usually shun the other iron rich foods, or eat them too infrequently for them to keep up iron stores.
Restoring good iron status is easy to do with gentle, low doses of supplements or herbs (licorice, nettles, dandelion, thyme). Iron in good stead can help your child’s appetite broaden, and may trigger other benefits. If your child isn’t using an iron supplement, you can add one – but don’t give doses above 5-7 mg of iron daily, without your doctor’s guidance. You can also check if your child’s multivitamin has any iron in it. If it has only 5 mg per dose or less, your child may need more. Check with your doctor. Given to excess, iron is toxic and even fatally poisonous so don’t use iron supplements without guidance.
What to do: Two easy tools to supplement iron when necessary are VegLife chewable iron tablets (18 mg per tablet) for older children who weigh more or for children with very low ferritin, and Floradix Iron Plus Herbs liquid (10 mg in 2 teaspoons) for younger kids who need a daily reliable iron source. These are low dose and well tolerated by children in my experience. The Floradix liquid vanishes well in dark berry juices. I prefer food based forms or gentle supplemental forms like ferrous bis glycinate. Ferrous sulfate (the form usually prescribed by doctors for anemia) seems to trigger more stomach pain, constipation, and nausea than food-based forms or ferrous bis-glycinate.
Give these three steps three months to work for your child. Changes will be gradual, so consider a pre and post log book on what your child is eating. Check in with your doctor if you’re not certain for dosing supplements. If your child’s appetite hasn’t budged after these steps, I’d like to know about it!