The Baby Steps Nutrition Podcast

I was delighted to be invited to participate in the fabulous Baby Steps Nutrition Podcast out of San Francisco, USA last week. It gave me the opportunity to discuss in depth some of the ways we can identify eating issues and also better ways to work with children who struggle to eat well.

Argavan Nilforoush is a pediatric dietician who like me is passionate about supporting parents. The Baby Steps Nutrition Podcast invites a variety of experts onto the show to talk about issues families face when raising children.

Picky eating is a topic that frequently comes up, so I was delighted to be able to chat about it with Argavan and particularly answer questions that took us deep into some great topics.

I have typed up my notes from the podcast for those of you who, like me, prefer to read rather than listen. At the bottom of the notes, I have attached a link to the podcast, so you are able to listen if you prefer.

I have also included some additional information that we did not have time for on the recording 😊 And for those of you who don’t know me well, it’s a good opportunity to get to know me a little better.

How did you come to be a Picky Eating Advisor?

I’ve always been passionate about food for children. I come from a nutrition background and spent years working in schools and community groups with a particular focus on cooking.

But what I realised was that every second parent was telling me “look, I know what to feed my children, I just don’t know how to get them to eat it”. So, I looked for someone to refer them to and that turned out to be a whole lot harder than I was expecting.

Picky eating is quite a slippery concept. There is no one definition even within the scientific or academic literature that states “this is exactly what picky eating is”.

Similarly, when it comes to treating PE, it’s quite a challenge as it’s physical, it’s social, it’s psychological. When I look at the world’s experts they come from a range of backgrounds – psychologist, doctor, occupational therapist, speech language therapist.

There is no one path that qualifies one as an expert.
And of course, like many conditions, which expert you see will determine how they approach the problem. An OT may focus more on the sensory components, for example, whereas an SLT would be looking at oral motor function and a gastroenterologist, how the stomach empties.

I quickly realised that referring the parents I was working with to someone who focused on picky eating was not straightforward. In many cases it was also prohibitively expensive. A good psychologist is $ 200+ per hour.

Being very much a problem solution sort of person and having always been entrepreneurial, I set out to be a resource for parents. I could be that person who would provide solutions for their child’s picky eating.

That became a huge undertaking with now 10 years of ongoing study in a range of different areas from courses specifically focused on resolving picky eating to those all about sensory sensitivities to studying psychology at university.

However, at the beginning of all of this I had one of those life-changing moments. I had the opportunity and the privilege to work with a 9 y.o. boy with autism who was frightened to even touch foods that were outside of his comfort zone.

His mother was desperate as she kept being told “of course he’s fussy, he has autism” by the professionals she was seeing for his additional challenges.

She couldn’t see why that prevented him from getting support for the eating particularly as a bad diet can contribute to poor sleep and behaviour, not to mention being less than ideal for growth and development.

I was excited to be able to work with him and used cooking to teach him to be more comfortable around foods and then add them to the diet. 

This lovely boy went from chicken nuggets to chicken curry. He was the first of many students. I then spent about 2 years cooking with children with extreme PE and also additional challenges like ASD, ADHD and sensory sensitivities and teaching them to eat more comfortably and widely.

However, that wasn’t my long-term path. I am very much a believer in parent empowerment. Parents are almost always the ones best placed to work with their children. No one knows a child as well, spends as much time or is as invested as a parent.

But what parents need are both the tools and the confidence that they can do this. That they can resolve their child’s eating challenges. And I truly believe that in most cases that’s the case. In fact, I’m planning a PhD on that very topic starting in 6 months.

Spending all that time watching how SE approach food, talking to them, and figuring out what supports them to become more comfortable around food was an amazing experience.

But instead of working individually with children which is time consuming, logistically difficult, and relatively expensive I wondered if I could teach parents what I had learned, and it turns out I could.
So, I now work with individual parents, Kindergartens and have a range of video programs and a couple of books.

As I am so passionate about what I do I am also still doing a lot of additional learning as there really is so much that both creates and maintains that genuine inability to eat new foods.

As eating is complex, can you describe the difference between PE and Extreme PE?

Again, there is nothing that is the gold standard for saying “yes, this child has extreme eating issues and this one does not” because picky eating is not specifically defined. It also operates along a spectrum with “I prefer nuggets to broccoli” at one end and “I eat a handful of very specific foods at the other end”.

Even within that spectrum there may be variation too as certain things may be possible for a child and other things impossible. Therefore, they may sit near one end of the spectrum for some capabilities and at the opposite end for others.

Generally, to define eating challenges, there are a series of benchmarks and/or red flags that are used. They vary between experts, but this is a reasonable representation of those:

An averagely picky eater:
– Eats 25+ foods
– Does not have an extreme reaction to new foods
– Will sometimes try something new
– Eats from all the main food groups – protein/carbs/fruit and vegetables

Extreme picky eating:
– Eats less than 15 foods
– Has an extreme reaction to new foods
– Rarely tries something new
– Does not eat from all the main food groups – protein/carbs/fruit and vegetables.

But remember this is a spectrum so a child may be a mix of the two. For example, they may eat a fairly wide range of foods, but have a really extreme reaction to something new. Or they may eat from all the food groups but have less than 15 foods in the diet.

Can you give some insights into the emotional and psychological aspects that can impact a child’s feeding behaviour.

This is a huge topic but let’s look at some of the factors.

General temperament – if you have child who is generally anxious then this often plays into the food.

Young children can control 3 things. Eating, sleeping and toileting so often they do. And when I say control, I’d like to clarify that this is probably not a ‘control’ thing per se – as in, let me win this battle with mum or dad – but a lot more sub conscious.

Children may get a good reaction to tipping the plate of food onto the floor, but in general control over food is not so calculated.

If you are generally anxious about new things, rigid in your approach or don’t like change then all of this can play heavily into the food sphere.

And when we step back, it’s so logical. If you are uncomfortable with heights, you don’t climb a tower. It’s the same with food. If you aren’t super comfortable with foods, it’s far easier to say no than to say yes.

Why risk that piece of chicken breast when I know I like nuggets and they are safe and comforting to eat?

And of course, the more often a child does this the more it becomes habit.

After a while they will say no without even considering. In many ways this is also self-replicating on a number of levels:

1. If it’s safer to say no then say yes.

2. If you always say no, then you don’t even consider a yes, it’s not on the radar.

3. The safety mechanism in the brain rewards you for staying safe by saying no.

4. And in fact, that stay safe part of the brain the amygdala now is on hyper alert and sends out a don’t go there message at the slightest hint of ‘could be less than perfect’.

You can see how this all plays out over time!

There are also the potential wider social and psychological elements that play into this:

Labeling someone a fussy eater can become a self-fulfilling prophesy – just like labeling someone ‘the naughty child’. Calling someone a picky eater is like saying “you’re a pretty bad eater”.

That is not a great way to give someone confidence that they are able to eat more widely and well.

There is not growth mindset encouraging them with positive expectations as we would as a parent if we were talking about reading or swimming.

The label of a picky eater may also give a child a ‘get out of goal free card’. I no longer need to try because I’m a fussy eater.

Bad experiences – there are many reasons why a child may have had a bad experience around food. For example, undiagnosed allergies or intolerances that lead to pain or discomfort when eating.

Ditto silent reflux or some other medical reason for feeling uncomfortable.

Similarly, sensory sensitivities often go hand in hand with picky eating. Perhaps certain textures, tastes or smells are discomfiting.

Most adults can point to an alcoholic drink or a food they’ve eaten at one time and felt unwell afterwards. From that point onwards, it’s hard to contemplate going there again.

That’s a good way to think about how unpleasant the thought of certain foods is for some children. Which is not to say that there aren’t ways to overcome some of this, but it does bring in some strong psychological barriers for accepting certain foods.

How do you navigate the delicate balance between respecting a child’s autonomy and ensuring they receive the necessary nutrition?

That’s a great question. And I could give a very simple answer along the lines of you decide the what, the where, and the how much in regard to food and your child decides what to eat from what’s on offer.

And in general, that’s a great basis for supporting children to become competent eaters and the basic principle is foundational. However, I also feel that eating is complex, children are complex, and families are complex. So, for eating competent children this is probably enough to support them to eat well.

However, for children with additional diagnoses, sensory challenges, or extreme anxieties for example, it may not be enough.

I also work with many families where eating has, for whatever reason, got way off track and passive learning is just not enough to turn that bus around, particularly in the short term.

However, I do have many ways that I recommend that walk that balance between nutritional intake and agency for a child:

1. Take charge. We need to be in charge – often when eating goes awry, the child starts making decisions. When we decide what to serve, the times it’s served at, and the amounts served then that helps to put us back in charge.

2. Child’s food. Serving a food our child can eat at every meal – no one comes to the table happily if there is nothing they enjoy. The more relaxed we are, the more likely we are to eat, so having that initial comfort level is important.

3. Blasé about eating. If food has been served that everyone can share in, then stepping back from the eating and letting things play out as they will. Pressuring anyone to eat often backfires. In fact, even encouraging someone to eat, puts us in the middle of the feeding relationship and in general I would suggest we remove ourselves from that equation.

To build competence a child must learn how to eat for themselves and trust their own decisions.

However, there are always exceptions to rules. And so, if for example, your child doesn’t interpret interoceptive cues well and so doesn’t recognise hunger, then that would be something that would need to be worked on.

4. Set tight boundaries. In order for children to learn how to eat well they do need to be taught. I find the best way to do that is to set tight boundaries, but within that give choice and autonomy.

5. Rotating not repeating food. Even within a narrow diet, eating as many different foods as possible helps to ensure there is the maximum spread of nutrients. As the parent it’s our responsibility to coordinate that.

6. Create opportunity. Consistently provide a child with the opportunity to eat new foods and taste different versions of accepted foods.

7. Giving choices. Within parameters, however. “Did you want peas or carrots with the chicken tonight?” rather than “what do you want to eat?”.

These are some good actionable steps for parents who do want to maximise nutrients without impinging on autonomy.

Toddlerhood is a common stage to exhibit PE. What are signs caregivers should look for to indicate professional evaluation by a feeding specialist may be warranted?

There are multiple ways to evaluate feeding and a good way to think about it is globally. I often do this with a list of red flags. If your child is ticking multiple of these red flags consistently then it’s definitely worth checking it out. If it’s one, occasionally, then it’s probably more likely to just be a toddler thing!

Before we get into those I did want to just do a skills overview. This is not an exhaustive list but gives you some things to think about:

– If your child isn’t able to chew or swallow properly.

– Consistently chokes – which is not being able to breathe rather than gagging which is unpleasant but not dangerous. So, it’s the choking we’re looking for as a problem.

– Can’t keep food in the mouth properly, it sort of drops out.

– Consistently regurgitates or vomits foods.

– Can’t breathe and eat at the same time.

– Doesn’t eat age-appropriate foods – so for example is still only eating purees.

Then these are all signs that help is advisable.

The general feeding red flags for all children are as follows. Bear in mind though for toddlers it’s developmentally normal to be exerting their independence and testing boundaries so if they are in charge of feeding you are likely to see some of these signs.

My advice is to make sure you have a good feeding routine in place for a month first and then re-evaluate. If these still apply then it may indicate issue:
1. A  child is not able to try any new foods.

2. A child has not added a new food for a long period and/or are dropping previously accepted foods.

3. A child eats less than 20 foods.

4. A child has an extreme reaction to unfamiliar foods.

5. Mealtimes are stressful and disrupted and your child eats differently to the rest of the family. (And obviously here we do need to have perspective as busy toddlers often don’t make the best mealtime companions).

6. A child has a very rigid approach to food eg. foods must be prepared/served in a specific way, only one brand is accepted etc.

7. You believe they would starve rather than eat something outside of the comfort zone.

8. Social situations are difficult/uncomfortable.

9. A child avoids whole food or texture groups. eg. fruit/ anything soft.

10. A child is losing weight or has stagnant growth.
Generally, as a parent you know from observing your child and others of the same age when your child seems to be marching to a completely different drum.

If this is the case then it’s worth looking for support.
I find that parents usually have a really good gauge on their own child and instinctively know when something is wrong.

What have been your AHA moments working with children who struggle to approach food?

– That many children, particularly as they age, deep down really do want to eat differently, they just can’t bring themselves to do so. These children are great to work with as once they have the confidence to take steps forwards they often make great progress.

– That a preference for plain pasta and toast doesn’t mean that children don’t like flavour. Often the plain pasta eaters actually also love strong tastes like garlic or BBQ sauce or blue cheese.

– That the more I know the more I discover.

Discuss the thesis you are working on at the moment.

My thesis: Exploring positive experiences with GP’s when help seeking for a child’s picky eating.
Until recently there has been relatively little research into picky eating in general. Now more and more studies are being done but many focus on the negative aspects, for example, how little help is available or how parents struggle to have their concerns validated by their GP.

Rather than look at what was going wrong, I wanted to see whether there were good experiences and if so:

1) did that lead to better outcomes for families and 2) how can we replicate good interactions so more parents can experience that when visiting their doctor.

What’s the old lawyer adage, don’t ask questions you don’t know the answer to? Well, interestingly, despite having spoken to 100’s of parents I have discovered things that I wasn’t expecting. Which in the context of research can be really interesting and positive. For example, many of the caregivers rave about their GP’s and that is due to a commonality of factors:
– The GP listens.
– The GP takes what the parent says seriously.
– There is no judgement.
– The GP looks for solutions.

None of which is surprising. However, what was surprising was that many of the children are no better off even though the GP was great. In fact, some of them are perhaps paradoxically worse off because the GP was understanding and helpful!

I’m going to explain this. For example, a parent feels the GP is great as they take the pressure off a parent to ensure their child eats a range of fruit and vegetables and frames this as a) food is food – so it doesn’t matter what they eat, calories are the most important or b) it’s a phase and they will grow out of it or c) there’s not really anything you can do to change your child’s eating so don’t worry.

Unfortunately, what happens is that the parent stops feeling worried and guilty – which is good – but at the same time doesn’t actively seek expert feeding advice (GP’s are not trained in child feeding). So, the feeding issues are never addressed properly and years later many of the parents still have a child who is not able to eat a range of food, and often is left with a nutrient light diet.

There are also parents I studied whose children were perhaps not as extremely picky who benefited from similar advice from the GP. The advice to calm down and not worry so much, changed their feeding practices and instead of applying pressure and being overly anxious, they were able to find balance and in the long run that actually helped their child.

Which means we’re back to discussing how feeding is complex and generic solutions may not be ideal. What’s right for one family may be detrimental for another.

I’d like to finish this answer off with one of my favourite quotes though. This is Dr James A Phalen speaking on the American Academy of Pediatrician’s website. He is referring to a new feeding diagnosis called PFD – Pediatric Feeding Disorder which is for the more extreme end of PE. Dr Phalen, summarises how PE is commonly viewed by doctors, and why that should not be the case:

“Pediatrician’s may believe that because a child is growing well, that a child does not have PFD, however, good growth does not indicate appropriate feeding. Similarly, PE is often overlooked. Pediatrician’s must ask the right questions to detect PFD”.

Dr Phalen speaks to the dilemma many parents face when visiting a GP and having their concerns dismissed as their child is ‘ticking height and weight charts’. Eating is far more complex than just calories ingested.

How do you see the field of child feeding therapy evolving in the future, and what advancements are you excited about. What about a multidisciplinary approach?

PFD – Pediatric Feeding Disorder is for me a game changer. Previously, ARFID (Avoidant Restrictive Food Intake Order) was the only recognised diagnosis, and that is an eating disorder and classified under mental disorders. PFD is a feeding disorder which I feel is more appropriate for most of the families I work with.

The diagnosis was put together by a team of experts from all areas that may impact on feeding from gastroenterologists to psychologists to dieticians.

They identified 4 main domains that impact on feeding – medical, skills based, nutrition and psychological. And within each of those categories is almost a check list of things to look for.

This diagnosis entered into the International Classification of Diseases (ICD) 1st Oct 2021 so it’s still fairly new but can be accessed by health care professionals.

Although I love this diagnosis and the multidisciplinary input, I am also hesitant about unnecessarily medicalising PE, particularly for young children. Yes, if there is a problem swallowing, that needs to be fixed, for example. But I’d be less excited about taking a 4-year-old with eating challenges and putting them in a medical facility and saying, “there is a problem with this child so how can we fix them?”.

I believe a check for skills/medical issues can be done once picky eating is identified. From there, supporting parents to work with their child is often a cost-effective, gentle, sensible, and logistically sound way to resolve challenges.

Ideally, we should have more education around feeding challenges and more community support.

Which is why podcasts like this one are invaluable so thank you so much for taking time out of your busy week to put today interviews like this that help to disseminate important information.

What is a key piece of advice or takeaway for listeners – parents and professionals?

I feel, the most important thing about supporting someone to eat well is building a comfort level with the foods we would like them to eat. I think of feeding like reading.
So, in the same way that many parents read to their child every night when they are younger even though they do not read a word back for 4-5 years, it can be great to think of that carrot or piece of chicken or apple in the same way.

Carrot, carrot, carrot.

And when we read to our child it is with love and patience. We are relaxed and we often like to have fun. Ditto the food. Can we make meals loving and relaxed. Can we bring in fun? And overall can we also be patient.

If I had to pick 2 of the biggest interconnected mistakes parents make, it’s not being consistent enough for long enough when teaching our child to eat something new.

To link to the recording: https://podcasts.apple.com/us/podcast/baby-steps-nutrition-podcast/id1580301084?i=1000625477634

Judith, MA Cantab (Cambridge University), Post Grad Dip Psychology (Massey University), is an AOTA accredited picky eating advisor and internationally certified nutritional therapist. She works with 100+ families every year resolving fussy eating and returning pleasure and joy to the meal table.

She is also mum to two boys and the author of Creating Confident Eaters and Winner Winner I Eat Dinner. Her dream is that every child is able to approach food from a place of safety and joy, not fear.

Learn more about Judith here: https://theconfidenteater.com/about/

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