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Nick DeBlasio, MD and Mizuho Spangler, DO

Toddlers often become picky eaters which can be a source of major stress for parents. Nick Deblasio MD general pediatrician discusses how to manage and modify behavior by parental standards.

 Pearls:
  • At one year of age formula should be discontinued and whole cow’s milk and water should be the only fluids offered. Breast feeding may be continued ad lib at any age.

  • Consistency is extremely important in management of picky eaters. Healthy foods should be offered over and over and parents should not give in and provide unhealthy foods that the toddler is demanding.

  • Good eating habits start in the toddler years and toddlers should be sat down for 3 meals and 2 snacks a day without food provided at other times.

  • Often feeding issues start at one year of age with the transition to whole cow’s milk, the discontinuation of bottles, and as children are developing more independence. It is important to continue formula or breast milk until one year of age as cow’s milk does not have accessible iron and early introduction can lead to iron deficiency.

  • Deblasio recommends that at one year families transition “cold turkey” from bottle to sippy cup and from formula to whole cow’s milk. The goal is for them to take a maximum of 20-24 oz of whole milk with all other fluids being water.

  • What if they refuse to drink from a cup? There is plenty of water in the foods so they should become dehydrated. Developmentally typical children will be able to drink from a cup even if they would prefer the comfort of the bottle.

  • What about other sources of dairy/calcium? This is ok to go without milk for a few weeks. If families are worried they can give yogurt or cheese.

  • What about juice? As families start whole cow’s milk the temptation is to give fruit juice. Juice is essentially sugar water and represents an important problem in toddlers diet. Even home made juice is not a good option. Keeping kids off of juice is a challenge for pediatricians, as juice is traditionally thought of as  a healthy food and WIC provides it to families  which sends a mixed message. Again toddlers should only be taking milk and water.

  • What do you recommend for “grazers?” “Grazers” tend to eat all day and do not feel full or hungry.Good eating habits start in the toddler years and grazing can lead to weight problems later as appropriate hunger and satiety cues are not established.

    • Families should offer 3 meals and 2 snacks a day. Offer typical healthy foods with fruits and veggies at each meal or snack. Kids should sit at table for 20 minutes at each meal or snack. After 20 minutes, the food should be taken away. No food should be offered between snacks or meals even when requested. Children should not be forced to finish meals.

    • Family  members  should role-model good eating behavior by eating fruits and vegetables, sitting through the meal and talking to the child. There should not be other things going on like TV, tablet, or cellphone use.

  • What do you do with picky eaters and families who have “tried everything?” Often they have not tried long enough or are being inconsistent.

    • Check the fluid intake. Often picky eaters are drinking too much.

    • Check what the families are offering. Families should offer no junk food at any point. Inconsistency and trying for too short of a period can lead to failure. When toddlers know they can hold out and get the chicken nuggets they will. If only healthy foods are offered toddlers will eventually get hungry and eat them.

    • Instruct families to be  persistent with offering healthy foods.  It may take 20 time before a child will be willing to eat it. They should also offer a variety of healthy foods.

  • What do you think of sneaking vegetables into other foods? Deblasio does not have a strong opinion on this. He supports the statement that you need to continue to offer the healthy food in its normal form along with any foods that have been modified to contain more vegetables.

  • How do you negotiate when a child will not eat one specific food? Try to find another healthy food.  Bring them to the store and let them pick a vegetable and they may be more willing to eat one that they selected.

  • How should we encourage parents through this process? Parents worry about children losing weight and not eating enough. Using the growth curve to assure the family that the child is doing well this can help take away some of the anxiety. Tell parents be consistent and not think about this meal by meal but look at the week overall. You can also reassure parents that picky eating may also improve when the children see their peers eating healthy foods.

What do you think of supplements like Ensure and Pediasure? These should be used for patients with failure to thrive and not for picky eaters. This is a problem when families use this for picky eaters as they are not needed and high calorie leading to obesity. Vitamins are also not needed for picky eaters.