My child only eats certain foods.

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A PARENT'S PERSPECTIVE

My son Jordan is 8 years old and going into the fourth grade. Jordan was born full term and healthy. He drank bottles, progressed to baby foods, and then to table foods. My husband and I cannot remember when his "pickiness" started, but we soon began giving him the foods he asked for because it was easier. We wanted him to eat. As time went on (he was about three years old), his list of foods began to get smaller and smaller. He refused to eat anything other than his select choice foods. As a mother, I never wanted him to be hungry, so I traveled everywhere with his peanut butter sandwich on the bread he like--everywhere I went. As the years went on, the list began to deteriorate. Every meal became a battle and feeding him outside of our house became virtually impossible. He would still eat peanut butter sandwiches, but only if it was from my husband or me. He ate pasta but only penne, totally plain pasta, chicken nuggets, but only from Burger King (which is 15 minutes from my house)--just to help give you an idea of what it was like feeding Jordan. He was totally in control, and we couldn't do anything to get him to try and take a bite of anything. We tried bribery, begging, and pleading and, of course, fighting with him. I tried reasoning with him: "If every other kid eats pizza, it must be good." Absolutely nothing worked and years kept going and his list kept getting smaller and smaller. Everyone knew Jordan didn't really eat and everyone had suggestions for us. "Can't you just put a hamburger in front of him and make him eat. Give him to me for a day, and I'll get him to eat." Out of my friends and family no one could really understand what we were going through trying to get Jordan to eat.

Two years ago, I was talking to my neighbor about this feeding problem, and it turned out, her son was so similar to Jordan. This made me so happy to go back and forth with her about what the boys ate. We were in the same boat, and she really understood me. Shortly after our conversation, she found the feeding center and the day treatment program. My neighbor's son was so successful; it was amazing. I called soon after and made an appointment for Jordan to see the feeding team.

Jordan started at the feeding center with regularly scheduled follow-up appointments. At home we were trying the "food game," and if we were consistent, it probably would have worked for Jordan. But Jordan is now one of three boys, and with crazy schedules, we just didn't stick with it. We made no progress and let it go for about a year. Finally, and thank goodness, in January 2007, my husband and I made the decision to enroll Jordan in the 4-week, day treatment program. It was the hardest decision to make; I knew he would have to miss summer camp because we needed to do this over the summer. I knew this would be hard for him because he hated to eat.

It turned out this was the best thing we ever did for our son. Jordan has made the most amazing progress; he is eating pizza, macaroni and cheese, broccoli, all chicken nuggets, peas, meatballs, turkey etc., and actually enjoying it. We are so looking forward to watching him eat at a birthday party or to take him to a restaurant and actually have him order food.

The feeding team we worked with has made all the difference in the world. The loving staff made it so nice and comfortable to come to the feeding center each day. The other families that I have met have helped me get through each day-the tears, and the laughter, and, of course, all of the successes. We never thought we would see Jordan eat. The feeding center exceeded every expectation we had as a family.

THE PROFESSIONAL'S * PERSPECTIVE-HOW FOOD PREFERENCES DEVELOP

For most people, eating is a pleasant experience, not only because of the enjoyment found from the variety of tastes and textures in different foods, but also because eating most often occurs in a social context. Children almost always have likes and dislikes of food, and these preferences change often. If these preferences do not interfere with the consumption of a balanced diet, then there is minimal risk of hindered growth or nutritional inadequacies. In contrast, a number of children do not appear to enjoy eating. Some of these children consume a limited number of foods and some, in fact, do not consume any food. Some researchers in the field define "finicky" eaters as those who refuse to consume a wider variety of foods than is considered normal for a given chronological age. It is estimated that at least 20 to 30 percent of all children will exhibit "finicky" eating patterns between the ages of six months and six years.

The development of food preferences is a complex interaction of biology, culture, and experience. Neophobic behavior, or the avoidance and fear responses toward new foods, has been found to occur across many species of animals, including humans. Biological factors influence a number of food preferences that are common across species, such as liking sweets, salty food, and milk products and disliking sour or bitter foods. It is thought that human beings and other species because of the high percentage of sugar and calories necessary to maintain the body's functioning prefer sweet foods. Salt is also crucial for the body's functioning thereby explaining this disposition. Preferences to milk and milk products are determined by the amount of lactase, an enzyme that breaks down lactose, a sugar, found in milk. Individuals who have the enzyme will show a preference to milk products, while those without the enzyme will not consume milk.

Environmental factors also contribute to one's food preferences. For example, the more a child eats a particular food, the more likely that food will be preferred. Also, if a particular food is paired with other positive events, such as feeling satiated or praise provided by a parent, it is more likely that food will be a preferred food.

Many factors may contribute to the development of food selectivity in children. Children who experience some form of stomach discomfort, such as gastroesophageal reflux, may consume only those foods that are highly preferred and/or those foods that are easier to swallow. The presence of gastroesophageal reflux or a history of constipation may hinder the development of those oral-motor skills necessary to adequately chew and swallow pieces of a variety of foods.

HOW TO INTRODUCE NEW FOODS

Regardless of the child's oral-motor skills, the key to successful introduction of new foods is repeated exposure to the new foods. Results of a study suggest that children with limited diets chose foods that they were repeatedly exposed to during treatment when compared to new foods they were not exposed to during treatment. Because the process of becoming accustomed to new tastes and food takes time, it is important that they are allowed access to their preferred foods and liquids when you begin to expose your child to new foods. The clinical experience of this article's authors indicates that denying children access to their preferred foods is not effective in increasing their consumption of new foods and also may cause the child to lose weight or become dehydrated.

If a child is referred to The Center for Pediatirc Feeding and Swallowing because of their limited diet, our goal is to increase the number of foods consumed to at least four foods in each of the four major food groups (i.e., fruits, vegetables, proteins, and starches). This goal allows most children to obtain adequate nutrition and be able to consume something nutritious during meals conducted at relatives' houses, most restaurants, and birthday parties. We would also like children to be eating what the rest of the family is eating so that the child's parents do not have to continue to be "short-order cooks."

For many children and their families, introducing new foods outside of meals is the most effective and convenient approach. In order for parents to introduce new foods, specific techniques are typically required. Implementing these new techniques may be difficult for many parents to accomplish during meals, given that their other children need supervision and they, themselves, would like to eat in a "semi-relaxed" state.

Exposure to new foods often means many different things to different people. Although many parents believe that exposure means swallowing a piece of food, there are many other lower levels of exposure to new foods. We have found that initially requesting a child to just touch a new food with their finger may still be challenging for the child to accomplish. Once the child is readily able to touch a new food with his/her finger, it will then be easier for the child to accomplish a gradually higher level of exposure with that same food. Many different levels of exposure can be targeted until the child is consuming a new food. Those levels commonly used at our clinic include touching the food to the child's cheek, touching the food to the child's lips, licking the food, placing the food in child's mouth, chewing the food, and swallowing. Sometimes children will be able to skip levels and sometimes additional levels may need to be added. The bottom line is to meet the child where they are and only challenge them a little.

Many times parents promise their children special toys or activities if they swallow a new food (e.g., a trip to the zoo). Even if the child is able to swallow a piece of a new food on that occasion, that one exposure is not enough for the child to eat additional pieces of that food at a future time. For most children under the age of six, praise for completing the level of exposure asked and immediate access to a preferred activity for 15 to 20 seconds is more effective than promising the child a larger, and more expensive, toy or activity later on that day or week.

CONCLUSION

Many young children display some sort of picky eating. Although most children's diets will eventually consist of an adequate number of foods, some children's diets may not change without intervention. Children with limited diets typically have difficulty consuming new foods because they have some stomach discomfort, have limited oral-motor skills, or have limited positive experiences with food other than their preferred foods. Before introducing new foods to children with limited diets, it is important to rule out any stomach discomfort and make sure they have adequate oral-motor skills for the texture of food you are attempting to present. Some children may need to be exposed to a wider variety of foods at a puree consistency before exposing them to higher textured foods. It has been found that asking a child to first complete a lower level of exposure with a new food, such as touching the food to their cheek, before asking the child to swallow the food is often beneficial. Motivation in the form of immediate access to a preferred toy or activity for 15 to 20 seconds has also been found to be beneficial in increasing a child's exposure to new foods. Once a child has swallowed a new food multiple times (10 times according to some researchers) that food can more easily be incorporated into the child's diet.

Melissa Feldstein is the proud parent of Jordan.

Red Flags for Food Selectivity

* Child does not eat any food from any of the four food groups

* Child decreases his/her food variety

* Child only eats specific "brands" of foods

* Child avoids parties and sleepovers because of their limited diets

* Child has difficulty trying new foods

* Child eats less than 3-4 foods in each food group

By Merrill Berkowitz, PhD, BCBA; Mary Louise Kerwin, PhD, BCBA; and Melissa Feldstein

Merrill Berkowitz, PhD, BCBA is the behavior analyst for The Center for Pediatric Feeding and Swallowing at St. Joseph's Children's Hospital. Dr. Berkowitz earned his doctorate in school psychology at Syracuse University and a Master's degree in clinical psychology at Loyola College in Maryland.

Mary Louise Kerwin, PhD, BCBA is a professor of psychology at Rowan University in Glassboro, NJ. A board certified behavior analyst and a licensed psychologist, she earned her PhD in Development and Counseling Psychology from the University of Notre Dame. She co-founded and co-directed Pediatric Feeding and Swallowing programs at Children's Seashore House and The Children's Hospital of Philadelphia. Dr. Kerwin is a research consultant at the Center for Pediatric Feeding and Swallowing at St. Joseph's Children's Hospital.