Podcast Episode 210: Picky Eating & Responsive Feeding – Dr. Elizabeth Zmuda

Apr 21, 2022

Disclosure: This episode is sponsored by American Dairy Association Mideast and American Dairy Association Indiana and we thank them for their support of the podcast. Representing America’s dairy farm families, they provide science-based resources, offering solutions for families, health professionals and educators to trust and confidently choose and recommend nutritious dairy foods. America’s dairy farmers are committed to feeding all people through sustainable farming practices and providing the best care of their animals.

Dr. Zmuda is an ambassador for the National Dairy Council.

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Child Nutrition, Picky Eating and Responsive Feeding

All parents want what is best for their child and that includes growing up strong, healthy, and enjoying a wide variety of foods. However, children may go through a period of “picky eating” which can start at any age, but it is most common in toddlers. The introduction of new tastes, textures, smells and temperatures can be frightening to a child. It’s important to provide parents with strategies and reassurance that picky eating is part of normal development. It’s also important for health professionals to assess if picky eating is influencing weight changes, nutrient deficiencies or ARFID (Avoidant Restrictive Food Intake Disorder) which is an extreme form of picky eating that impacts normal development.

When you’re feeding your child, think about feeding with the 5 senses. Instead of focusing on if the child likes the food or not, focus on the color, the smell, how it feels to chew it. Talking about food in a more objective way is fun and helps you focus on the skill development without being so worried.” – Dr. Elizabeth Zmuda

Tune in to this podcast to learn about:

  • The definition of picky eating
  • How eating is learning, exploring and building skills
  • Responsive feeding and feeding with the 5 senses
  • How parents bring their own stories and histories to the dinner table
  • Just because a child spits out a food doesn’t necessarily mean they don’t like it
  • How these same strategies help to prevent obesity and eating disorders
  • The difference between picky eating and ARFID (Avoidant Restrictive Food Intake Disorder)
  • How to introduce new foods and include nutrient rich foods
  • How nutrient rich dairy foods can be helpful as a familiar food for picky eaters
  • If sneaking in nutrition by hiding vegetables in other foods is effective
  • If plant-based milk alternatives are an acceptable substitute for cow’s milk
  • New recommendations for birth – 23 months including yogurt and cheese as options for infants starting as early as 6 months of age
  • Strategies for parents and health professionals to address picky eating behaviors and develop healthy eating patterns in toddlers
  • Resources for parents and health professionals on child nutrition, picky eating, responsive feeding, dietary guidelines, recipes, tips and more

Picky eating is part of normal child development – it’s incredibly common for children to become selective around ages 2-5 years old.” – Dr. Elizabeth Zmuda

Dr. Elizabeth Zmuda, DO

Dr. Elizabeth Zmuda DO, is a Fellow of the American Board of Pediatrics and the American Osteopathic Board of Pediatricians and the Director of Medical Education OhioHealth Doctors Hospital in Columbus, Ohio. She received her medical degree from Ohio University College of Osteopathic Medicine and completed her residency at Nationwide Children’s Hospital in Columbus, Ohio

Dr. Zmuda serves on the Ohio Home and School Health and Parenting at Mealtime and Playtime committees through the Ohio Academy of Pediatrics. She is also currently writing the chapter on Nutrition in School, Preschool, and Childcare for the American Academy of Pediatrics Pediatric Nutrition Handbook. She is passionate about nutrition, physical activity, and strong emotional skills as critical components in academic performance and overall well-being in children. The mother of 4 children, she loves her job and believes that her kids make her a better pediatrician and her experience and knowledge gained from her work makes her a better mom.

Kids are ‘learning to eat’ much like they learn other skills, so the expectation that they will be perfect right away is unrealistic. We need to approach feeding the same way we approach learning to crawl, walk, swing or ride a bike. Patience, love and positive reinforcement go a long way to creating successful happy children in all regards.” – Dr. Elizabeth Zmuda

About the American Dairy Association Mideast and American Dairy Association Indiana

The American Dairy Association Mideast proudly represents Ohio and West Virginia’s dairy farm families who work hard to care for their cows and land so they can nourish our communities with fresh, safe, and nutritious dairy foods. We are an affiliate of the National Dairy Council, whose 100+ years of experience is dedicated to fostering healthy people, healthy communities, and a healthy planet now and for future generations. As a local affiliatewe provide practical information and education resources about dairy’s contribution to health through science-based information, foster a commitment to sustainable nutrition, and empower youth wellness through Fuel Up To Play 60.

American Dairy Association Indiana, Inc. (ADAI) is a not-for-profit promotion, communication, and nutrition education organization funded by and serving Indiana dairy farm families. We provide service to consumers, health professionals, teachers, food service professionals, and the media.

A simple guide for parents to remember that can help relieve some of the stress about nutrition is to offer milk with meals and water in between. They don’t have to remember anything else and the great part is that having milk three times a day gives the child some flexibility in their other food choices because there is so much nutrition in the milk. The child can work on developing skills to accept other foods that will provide some of the similar nutrients later on.” – Dr. Elizabeth Zmuda

Resources:

National Dairy Council

American Academy of Pediatrics

Ohio Academy of Pediatrics

United States Department of Agriculture (USDA)

Academy of Nutrition and Dietetics

Share Our Strength

Additional

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Episode Transcript

[00:00:00] Melissa: Hello. And welcome back to the sound bites podcast. Today’s episode is about picky eaters, especially those toddlers ages, two to five. It’s really easy for parents to become concerned about whether they’re feeding their child the best they can. And worry about their child’s weight, whether it’s underweight or overweight.

And if they’re getting the nutrition they need for growth and development. So what happens when your child does not want to eat what you offer or they like a certain food one day and the next day they don’t. We’re going to talk about all of that. And more today. My guest today is Dr. Elizabeth Zmuda. Dr. Zmuda is a pediatrician and fellow of the American board of pediatrics and the American osteopathic board of pediatricians.

And she’s the director of medical education at Ohio health doctors hospital, where she oversees the training of residents and fellows in 12 different medical specialties. She’s passionate about nutrition, physical activity, and strong emotional skills as critical components in academic performance and overall wellbeing and children. As the mother of four children, she believes that her kids make her a better pediatrician and her experience and knowledge gained from her work makes her a better mom.

And I think that’s a wonderful place to be welcome to the show Dr. Liz.

[00:01:24] Liz: Thank you for having me.

[00:01:25] Melissa: So excited to chat with you again. We’ve had some pre-calls to kind of – there’s so many things we could talk about which child nutrition. And by the way, is it okay if I call you Dr. Liz or do you prefer Dr. Zmuda

[00:01:36] Liz: Dr. Liz is fine. That’s usually easier for the kids anyway.

[00:01:39] Melissa: Okay, great. Now, before we hear more about your background and how you even became interested in pediatrics, I do want to share with our listeners that this episode is sponsored by the American dairy association Mideast and the American dairy association, Indiana.

And we thank them for their sponsorship and support of the podcast. And my regular listeners know this, but I also worked for the dairy council for eight years back from 2003 to 2011. I worked for the Midwest dairy council and I was a national dairy council spokesperson. So I dunno, like hashtag former employee, however you want to look at that.

But I’m really excited. I have not talked about dairy’s role in child nutrition, or even very much about child nutrition on the podcast. So I’m just thrilled to have you on. And like I said, I would love to hear more about your background and how you got interested in your line of work and the work that you do today, as well as any disclosures that you have to note.

[00:02:38] Liz: Well, I will disclose that I am also a fan of the national dairy council and all of the dairy groups. They have been really committed to pediatric health and wellness, and that’s really how I’ve become involved with them. And it’s just a natural fit in some of the things that we’re going to discuss today.

From my perspective, how I got into this line of work was a journey that I probably couldn’t have anticipated. Honestly, I started in medical school and as I went through my rotations, I was interested in just about every single thing that I did. And I wasn’t sure where I was going to land until I did my pediatrics rotation.

And I think the thing that really stood out to me on that rotation was that every other rotation prior to that I had watched the outcomes of decisions and health challenges and all of these things for adults. And it felt really hard to change and not impossible and still great work being done.

But what I noticed about pediatrics was the opportunity to really work with that family, to prevent some of those other outcomes. And it’s also really fun. So that’s how I, I landed in pediatrics and I’ve always been interested in the mechanics of the body. And as a former athlete, I think fueling was really important to me.

And during my residency, I had the opportunity to meet Dr. Bob Murray. Who was at the time, starting the center for a healthy weight and nutrition at nationwide children’s hospital. And I heard he was there and what he was working on and I walked into his office and said, I want to work with you. And that journey began.

And so we started. I was so lucky to work with him and Dr. Amy Sternstein, as we worked on some of the early years, as far as ounce of prevention and trying to look at how we feed children which ultimately led into a program called pound of cure. And then now we’ve added the parenting component, which resulted in a really great program that’s lasted for several years now called parenting at mealtime and playtime, which is sponsored by the Ohio chapter of the American academy of pediatrics and Ohio department of health. And so that was the beginning of the journey that has just continued and really allowed me the privilege to get involved in this work and in many, many areas.

[00:04:56] Melissa: Wonderful. And we have some links to those resources. We’re going to have a lot of resources that we’re sharing with the listeners today. And we’ll recap that all as we wrap up at the end, but the ounce of prevention and pound of cure and the parenting at mealtime and playtime.

[00:05:14] Liz: The parenting at mealtime and play time was the culmination of all of those programs put together with the parenting component.

And you can find all of those resources at the ohioaap.org website, under resources. They divide it into resources for providers and for families. Very good.

[00:05:31] Melissa: Well, before we dive into the topic at hand I’m just curious, you said you were a former athlete.

[00:05:37] Liz: I did many sports, but really predominantly I was a gymnast.

And then after I retired from that sport, I mostly participated in track and field. So a lot of running and I’m still a runner too.

[00:05:49] Melissa: Wonderful. Wonderful. Well, I don’t know if you know this, but I’m a former ballet student. I went to a performing arts high school. So kind of a lot in common with gymnastics in some respects.

So definitely. Well, let’s start off with your approach or your philosophy for picky eating. We have a lot of specific detailed information, but I think this would be a really great place to start because I found it very interesting. And I want our listeners to hear about that. Yeah.

[00:06:17] Liz: So I think my approach, when I talk to parents about picky eating is very different than what they expect, especially coming into the pediatrician’s office.

And it’s one where I challenge a lot of the things that we’ve told ourselves over the years, parents and myself included, and I think picky eating in general. It’s something we can all agree on that there are children that struggle more with food variety and flavors and textures. And there’s a definition for picky eating, which is depending on the source that you look at, either less than 10 or 20 foods.

And that alone suggests that there’s a spectrum of eaters. And I I’ve always found it really interesting that we have separated out how we teach our children to eat and how our children learn to eat from all of the other skills that we help them learn in the course of their lifetime. And it’s just so interesting to me because we have an increase in expectations around feeding and almost wear it as a badge of honor if we have really healthy “eaters”, when really this is a skill and it truly doesn’t have anything to do with the skillfulness of the parent or the child. And so I start there and I really try to remove all of the stories that the parents are telling themselves about what their child should do, what they should do.

And really just take a step back and try to understand where that child is, where the parent is and how to meet them where they are. So it’s a different approach. It’s not a forced approach, which I think is what probably many of us experienced as children, but it’s one that allows us to be on a level playing field.

And I think it’s really important when we look at skill development to start there.

[00:08:11] Melissa: Great. So your approach to picky eating and child nutrition in general, just aligns with this global approach to parenting that you have, where it’s more about this learning process. And we’re going to dive into some of the fun aspects of that.

And, and also the fact that parents bring a lot of fears, they bring their history. I should say we, because I’m a parent too. I mean, there’s so much that we bring to the table literally and figuratively, that I do think it takes some time to sift through that and think through that. But certainly just reassuring parents right off the bat and trying to like bring down the tension of the situation and the fears.

So how common is picky eating and I know that we’re focusing on toddlers ages two to five, we’re going to touch on maybe a little at the younger ages and little older as needed. It doesn’t just stop on a dime or start on a dime at certain ages. But what age do we typically see?

The picky eating behaviors and how common is it?

[00:09:18] Liz: So I, again, would say that picky eating is part of normal child development, and it’s incredibly common for children to become selective in that exact age group two to five. And I call it selective more than picky. Although we’ve already talked about that definition for picky eating, it’s something that I would rather parents look at and expect to happen so that again, we can remove some of the fear and emotions that are surrounding that and really support that child’s growth and development in a way that doesn’t make things harder. Because sometimes I think our efforts, when we function out of our fears because we love our children so much and we want to do so well.

And we know how important their nutrition is as they’re growing and their brains are developing and they’re doing all of these things. We want them to be fed well and be well. And so we function out of fear of what if I’m not. And I think there’s a lot of things we can do to mitigate those fears. So I guess just starting with the fact that this is normal and it’s not you and it’s not your child. It’s every person, every child out there.

[00:10:30] Melissa: Yeah. So it’s almost like we need a new term because picky eating is normal. Even if we could just add that to the title or the phrase picky eating is normal and it’s all about the developmental phases and the learning. And I think parents can relate to the fears for sure. There’s a lot of pressure, but it’s also kind of difficult to address all of that if you’re not even aware. So I think just being aware that there’s a lot going into this equation. Now let’s talk more about some of the specific picky eating behaviors, quote unquote, like how do you know if you, you have a picky eater?

Are there some signs or common issues that arise or does it really vary from child to child?

[00:11:15] Liz: It varies a little bit. I think I’m laughing a little, because I was thinking, as you were talking that you and I could have a child that eats the same things. And your perspective and your expectations and your hopes for your child might result in you saying my child is a wonderful eater and my expectations for that same child could be different.

And therefore, I will presume that they are a picky eater because my expectations are higher. And so I think just knowing that and being aware of that is really important, but there are children that, because this is a spectrum and you will see kids that just like with sports or school or reading, they have different abilities at different times and strengths and weaknesses.

And I think that we start there. But you’ll find that some kids will have trouble with different flavors or different textures. Textures is really common because it’s learning how to chew something up to a point where you can actually safely swallow it. And again, it’s a skill that we don’t really think about.

We take for granted, but it’s something that everybody has to learn in those early years. So you’ll see some of those things. I think times that I would be more concerned. There are a few times I’d be more concerned if the growth charts, if their growth and development is not in line with where they were or where they are expected to be.

And that would be something that you would, of course, want to have a conversation with your pediatrician about, and they would be monitoring as you’re going through those well-child visits throughout the course of the child’s life. Or if you’re noticing that there are times where the child is avoiding eating. So they’re not able to participate in a family meal, or maybe they’re a little older and they don’t want to go to a birthday party because they know that they don’t have their preferred foods there. So if there’s an interference in normal development, whether it’s social and emotional or physical wellbeing, I think those are more, if you want to call them red flags that I would take more notice of.

[00:13:26] Melissa: Thank you. Yeah, absolutely. I always say that I’m lucky that neither one of my kids were picky eaters, but maybe my standards aren’t that high, I’m just joking based on what you said earlier though. Yeah. I always say this, like my daughter, who is graduating college this year, she always had like, this really good sense of when she was hungry and when she was full.

And I just told her, oh, just hold on to that. As you get older and I have to laugh. Earlier you said sometimes parents wear these things as a badge of honor. And I have to say, I was excited to share on this podcast that my son who’s in eighth grade, they just had this section in their health class where they did this MyPlate activity and he got, he was rated as a hall of Famer.

And so I’m looking at proud dietician mom, but, well,

[00:14:09] Liz: it’s certainly not that you shouldn’t be proud of your child. An area that they’re skillful. I just don’t. I think it’s the opposite that I, I don’t love is when someone feels badly because their child is struggling. It is not their fault. It is just part of that child’s growth and development. And I think that’s a really important thing for us in my profession is we really need to be empowering parents to support their child and not to be comparing their child with everybody around them, because that’s really, when you start to get into trouble. Then it becomes the game of the harder you try, the less results you get.

And as pediatricians, we often say, kids control two things, eating and pooping. And those are the two things they control and they will find a way to control it. If we start to have power struggles at dinner tables. So.

[00:14:58] Melissa: Absolutely you’re ratcheting up the stress and the tension. And then it turns into what I like to say, the food fight.

And at that age, two to five so much is going on. It’s really interesting to see how some of this does play out at the table. So how do you, for parents who have these worries? Certainly there’s a lot of reassurance that you want to give them and I’m sure it depends on the specific behaviors that the child is exhibiting, but can you talk about like how you help them and support parents through this?

And is it fair to say. It’s just a phase most kids go through it, it resolves on its own. Obviously there are watch outs. Like let’s, I always say, like, I just don’t want to make the situation worse. Right. But how can you help parents? Are there some do’s and don’ts, there’s some guidelines that we can share.

[00:15:50] Liz: Definitely. So the first thing I do, if I’m in an office visit with a parent is pull up the growth chart. And talk about it and talk about what I would expect to see in their child’s growth and whether I’m concerned or not. And I think there’s a lot of misunderstanding about what a child should look like at a certain age.

And it can create fear, but if we provide education, we can minimize that fear for parents. So in this very age group, the two to five, you’ll see that they actually get a little bit leaner and there’s a dip in the growth chart. That’s normal and their height velocity is increasing, but their weight is increasing at a slower pace than that’s just normal because they’re moving around and active.

Living life. And so sometimes parents will notice that their two year old now four year old is looking a little thinner and become worried that they’re not getting what they need. And so it’s really about looking at those growth trajectory lines to make sure that their trajectory is on track.

And I think that’s really important for a parent to have the visual of that. And then I would just ask them what their meals look like and what are their concerns right now about their child’s eating. And then if we are talking about ways to support improved nutrition or long-term diet quality or nutrient density, I would start to talk about the experience of feeding.

And again, try to take it back to everything in childhood is learning, including this. And so when you’re feeding, think about feeding with the five senses. So instead of do you like it or not like it, what color is it? What does it smell like? Is it hard to chew? Is it easy to chew, how does it compare to something that that child knows and likes? And really talking about food in a more objective way and letting the child be part of that and teaching the parents that this is part of the fun.

So when we can remove that fear, it gives them permission to focus on the skill development without being so worried about their growth. If their growth is on track. And then there’s some simple things that we can do. We know kids are learning and some of the foods that we hope that they will ultimately incorporate into their diet are more challenging for a young child to accept.

And it’s just part of life. It’s part of the learning. And again, like we were talking about before, some kids will accept it readily. But most won’t. And so there’s some simple things that we can do. And I know we’ve talked about the dietary guidelines, but when we look at this age group and beverages, I would say a simple thing for a parent to remember that can help relieve some of the stress about nutrition is to just to offer milk with meals and water in between.

And they don’t have to remember anything else. And the great part about that is that for the large majority of children, having that milk incorporated into the diet three times a day, gives them some flexibility because of the nutrition in there to start to develop the skills to tolerate or accept the other foods that will provide some of the similar nutrients ultimately when they have a more adult looking diet.

[00:19:09] Melissa: Okay, excellent. You shared some important information. And one of the things that I was thinking as you were talking was learning, but also exploring you talked about fun and sounds like just like letting your child explore the different types of foods. And, and I had read that the first two years of life, so we’re coming up to that two year old mark that’s a really important window of opportunity, but it’s also we’re born with this innate taste preference for sweet and a rejection of sour and bitter.

So the vegetable flavors. So there’s a lot going on there that could seemingly work against trying to make sure your kid gets all the food groups and everything, but you had mentioned the dietary guidelines and I do want to say. For those listening, who aren’t aware – the dietary guidelines for Americans provides advice on what to eat and drink to meet nutrient needs, promote health and prevent disease.

And it’s really developed and written for professional audience, policymakers, healthcare providers, nutrition educators, and federal nutrition programs use this information to create their programs, but this and the USDA and health and human services release an update every five years. And this version, the 2020-2025 was the first time that the dietary guidelines included birth to 24 months.

So I know our focus is on picky eating and two to five, but I did want to take this opportunity to kind of ask you to comment on any of this. This is a new guideline area for us finally we’re, we’re looking at birth to 24 months. Was there anything in that information that you wanted to speak to that could relate to setting that stage and that foundation for the toddler age and maybe helping mitigate any picky eating?

[00:21:03] Liz: Definitely. And I think for those of us that function from this mindset of feeding, this was a victory. So having guidelines that support development from that birth to 24 months reminds us of the skills that we’re growing. And so some of the recommendations that came out are Preference to feed human milk/breast milk for the first six months of life.

And in cases for a lot of reasons, when people aren’t able to do that, then to provide iron-fortified formula. There are some recommendations on vitamin D. But the, some of the call-outs that I was really excited about is that focus on responsive feeding, which I would say is the same thing as responsive parenting, which is the focus on hunger cues and fullness cues.

And what does that look like in an infant? It allows you to start to observe those things in an infant to support the same hunger and fullness cues for your toddler and school age child. And so if that is the area that we are functioning from, it just becomes part of the skill development in our nature of parenting that child through refeeding.

And so I think that’s really powerful. Some of the other things that are new, new call-outs in the guidelines I would say are that exclusive breastfeeding until six months. And then the introduction of complimentary foods for the remaining six months up until a year. Knowing that most kids transitioned to full table foods by 24 months.

And so it focuses on a lot of the transition stages and more of that child’s ability to tolerate the next stage then specific ages. And I think that’s really important again, because it’s all about skill development. An infant who can sit up and hold their head up and is interested in feeding, interested in trying solid foods or purees or whatever phase they’re in.

That’s a child that’s ready. And that again, brings the parent back to that relationship with the child, the observation of their skills and meeting them where they are. And so to me, it just builds the foundation for the challenge of those picky eating ages. So they know what to do, then it just feels more natural.

So I was so excited to see that there were guidelines for the early age group.

[00:23:25] Melissa: Okay. Yeah. Tell me a little bit more about this responsive feeding because this is not, my youngest is in eighth grade, so this is new to me, I guess I should say. So what would that look like? Like you’re just trying to observe your child and watch for those cues and respond to that.

Is there more you can say about that?

[00:23:44] Liz: Exactly. I mean, it’s, it’s supporting the child really and understanding their own cues is what it is. And that’s really what parenting is all about, right. Is, is helping your child go from the supported phase to the independent phase and anywhere along the spectrum. And so for an infant, if you were looking for hunger cues, we would ask the parents to look for sometimes the child is smacking their lips or they put their fist in their mouth, or they may turn their head to the breast and show signs that they’re ready to eat.

And then signs that they’re full would be the opposite, pulling away, closing their mouth. And allowing them to honor those cues allows them to learn the power of hunger and fullness, which as adults, we all know is a challenge for many, many people. And so if we build it as a skill, it becomes a habit and it’s less likely something that they’ll be challenged with later in life.

[00:24:37] Melissa: Interesting. Yeah. So, because this is not the main focus of today’s topic. I’m not going to spend a lot of time on this, but I just have to mention, and I’ve shared this story on the podcast before, when my son was six months he weighed less than he did at 4 months. And that’s when I knew it. We were just starting, we were just going to start introducing solid foods.

And I just, I had to, as a dietician, I had this timeframe in my mind, like wait till six months and if I was doing more of the responsive feeding, I would have thought more about, is he developmentally ready for solids? And of course, I didn’t expect him to weigh less at six months than four months. And we jumped on it and took care of it, but of course he fell off the growth chart, so to speak.

So that was a really scary time for us, but you know, ultimately it wasn’t serious and it was quickly resolved. But to your point, I think that there are these guidelines and these ages, but it’s this developmental process and the skill building and when different children are ready for different phases. I wanted to also ask, you had mentioned about beverages – I really loved the simplicity of milk at meal time and water in between, but was there anything else you wanted to say about beverages overall?

Because I know. On the one hand, like you said, something like milk can provide some really important nutrients that can mitigate some of the nutrients that they might be missing. If they’re going through food Jags or just those picky eaters. But at the same time, some like other beverages could fill the belly up and make them not hungry.

So is there anything else you wanted to say about beverages overall?

[00:26:17] Liz: Well, I, again, we’ll put this back into the Dietary guidelines, supporting all foods fit. But when we look at recommendations and really where I want parents to put their energy, the reason I say milk with meals and water in between is because milk covers most of the dietary requirements or the nutritional requirements for a child.

And again, gives them the flexibility to build some of the other skills. Now, when you look at some of the other parts of the dietary guidelines, there are some new call-outs in some of the micronutrients that are important and specifically when it comes to brain development. And so what we’ve learned, and this was new information for me this time around as well was the importance of things that have fallen out of our diet because of other trends. And so things like iodine, where we’ve learned that there’s an increased demand for iodine in pregnant and lactating women, as well as during infancy. And when you look at the foods that you would need to consume in order to meet that requirement.

And you think about that in the context of a child, it’s really hard to get those requirements in. And so the call-outs were for iodine and Choline and B12, which all happened to be in milk. And so when we’re looking at some of those early years, of course, cow’s milk we wouldn’t want to introduce until one year of life for several reasons.

But other dairy products that have those same nutrients could be added into the diet earlier. So things like smaller curd cottage cheese, and yogurts, and things that smaller children would be able to accept and do okay with. So there were some really interesting guidelines that came out in these 2021 reports.

[00:28:16] Melissa: Great. Thank you. Yes.

I know when I worked for the dairy council we encouraged dairy as a great way to increase fruit and vegetables in the diet – pairing milk, cheese and yogurt with fruits and vegetables at meals and snacks – like fruit with yogurt and veggies with cheese. And there are 4 nutrients of concern listed in the dietary guidelines – calcium, potassium, vitamin D and fiber. Dairy provides 3 out of four – the calcium, potassium and vitamin D. When you pair dairy with fruits, veggies or grains you get the fiber, too.

Liz: I think it can get kind of complicated sometimes as a parent when you’re trying to think about all the details and the nutrients that need to go into your child’s diet. That’s part of my job as a pediatrician is to help you understand what those important foods are to provide that nutrition. To be clear I want to point out that MILK actually provides 13 essential nutrients in an 8 oz serving including high quality protein, calcium, potassium and vitamins D and B12.

But it’s not just milk – so sometimes children aren’t in the mood for that and might prefer to have something like yogurt or cheese. Likewise, yogurt provides 7 essential nutrients and cheese provides 6 essential nutrients. So you can feel pretty comfortable when you’re serving your child dairy that you’re getting some of that powerful nutrition in their diet.

Melissa: Thank you for clarifying that. Let’s talk about maybe some of the, some more of the guidelines or guard rails. I’ve always heard that it’s the parent’s job to bring nutrient rich foods into the home and the child’s job to choose what and how much they eat, which seems like a good rule to follow.

But I would love to hear your input on that. I know that can seem really daunting and scary to some parents because they’re like, well my kid’s not going to eat anything or certain foods don’t come into the home at all. How do children learn then to have those or whatever? So I would love to hear your insight on that.

[00:29:16] Liz: Definitely. So that’s the Ellyn Satter method. I value it so much. And certainly hold that in high regard as one of the founding principles of all of this truly. I think. That’s a great place to start. So as a family, there’s so many things going on. So if you look at a family meal, it’s all about the modeling.

And so while I do encourage families to understand that all foods fit, sometimes you have competing interests with children. And so really being thoughtful about what’s available. And what you’re okay with as a family and what you’re not okay with. That’s where I would start from. And then when I look at providing a meal to a child or, or for the family, I prefer to talk about it in the context of the whole unit, because there are so many things going on, social and emotional skills, developing well through conversation and through observation and modeling and all of these things that, again, we take for granted, but it’s part of the learning around feeding. That’s why it’s important to put in the context of the family.

So for example, if you’re putting down a family meal and you know that there’s a very selective child, I again would encourage that exactly. That Ellyn Satter method, where you provide what you want to provide for the family, but be thoughtful about having at least one food that, that child prefers.

So that they can have a place where they feel kind of safe and comfortable. And if that’s the majority of what they eat, what I would tell a parent who’s concerned is I would leave that alone. I wouldn’t stress about that. I would encourage – just exploration of the other things without emotion, without forcing, without any of those things, because what we want is the child to be willing to try what everybody else in the family is eating without feeling the pressure, because the second they sense the pressure they go the other way.

So I think that’s a really important place to start.

[00:31:18] Melissa: Oh, I love that because it just gives a sense of that familiar, favorite food that, that child likes. It’s sort of like a little security blanket and it just helps make them happy and give them some confidence to try something new. And that, that leads me to another rule or guideline that I’ve heard as I’ve heard that it takes dozens of tries before a child gets used to a new food. This makes sense. Is this typical? Is there anything special that you wanted to speak to that?

[00:31:47] Liz: Often, we say it takes 20, I think more than 20 tries for a child to tolerate a new food or to accept, I should say to accept a new food. And I think knowing that is really important for parents because there’s a lot of great literature out there that shows that children will reject or spit out a food or make a face or do all kinds of things. And it doesn’t necessarily mean that they don’t like the food. It’s just that it’s new and they’re experiencing it in a different way. And they don’t have all of the knowledge and skills that you have as an adult.

And so that repetition allows them to build the familiarity with that food in order to accept it. And sometimes it takes. One try. And sometimes it takes 200 tries, but I think that just allowing them to be wherever they are on that without suddenly saying, well, I’ve given it to him 23 times. It’s not happening.

The other thing that you brought up is one of the ways we can sort of trick children into trying new foods is by putting something they’re comfortable with, with a new food. So either pairing it side by side. So I give you some new berries with a cheese stick and the cheese stick is new. So something feels comfortable to them and safe to them.

And they may only touch the cheese stick or whatever they do play with it, but they allow it to be on their plate. And that’s the first step to accepting that food. The other thing you can do is you can allow them to dip into things. Children love to dip and tear things up and. Make a mess. And I know parents get frustrated, they say well, but I hate when they throw the food, they make such a mess.

And I said, that’s just teaching them cause and effect. So they’re learning even when they’re doing that. And the second that we shut it down, we, we stifle that learning. And so within reason I think all of those things are part of the exploration that make the experience of trying new foods fun and not fearful for kids.

[00:33:57] Melissa: Again, keeping it fun. Yeah. So when you said that the child might spit the food out, it does not necessarily mean that they don’t like it. It’s like, whoa, that’s what the parent is bringing to that equation. And we need to just take all that, that judgment and those assumptions out of the picture and I love how you’re talking about we always talk about role modeling.

I always say parents need to be good role models. The apple doesn’t fall far from the tree, but I like that family context that you’re saying, because it’s really painting a picture for me. And I’m reflecting on my own family, how, how much is going on at that time and keeping the family table time, just positive, supportive, encouraging, and open.

And you said something too. I was wondering what your thoughts are on sneaking nutrients into foods or hiding them. I know there’s kind of two different camps, but really curious, like if somebody wanted to put pureed carrots or something like in Mac and cheese, And there’s probably pros and cons.

You’re getting some more nutrition in there, but is it better to give your child the experience of the food itself? And when I’ve heard that when kids, I never did this but I’ve heard that when kids find out that you’re doing that they all of a sudden are like not sure that they trust you.

A lot of kids don’t like their food all mixed up either. They like it kind of separate.

[00:35:25] Liz: I would suggest it’s all in the approach, because like you said, there’s pros and cons. And so one of the things we know. Breastfed babies is that they get to experience the flavors of the food that the mom has eaten.

And there is a lot of evidence to show that that makes them accept foods more readily later in life. And so I think any way we expose kids to flavors, textures tastes all these. I think it has an impact, a positive one. And so I wouldn’t say it’s wrong to put the cauliflower in the Mac and cheese. I think the sneaking part is the challenge.

So where I would try to encourage a parent would be to work with the child to have them help prepare the food. And help the child understand that I like the food in this way. I like it when it’s mixed with my macaroni and cheese. And I don’t prefer it when it’s on its own, but maybe someday I will prefer it on its own because I like it here.

And I think that’s where we sometimes go wrong. Is. The fear again, I’m fearful. You’re not getting the nutrition you need. And so therefore I’m going to hide it in your food and then the child finds out and then they stop eating it. Versus I’m going to have you be part of this discussion. I know you’re learning.

I care about you and your nutrition. And so we’re going to work towards this place that we both think is a healthy place for you. And. Always, always, always argue to involve the child. As a matter of fact, even allowing them to be part of food preparation for food that they don’t end up eating in the end.

We know that they will be more likely to ultimately eat those foods later in life because that’s part of the acceptance. That exposure. Exactly. And it takes longer and it’s more challenging and it can be really, really fun. So I think. Again, it’s like taking the emotion out of all of it. And remember that you’re building skills, no matter what you’re doing and skills around food are skills that help build a healthy diet in any way you look at it. So just small things have a huge impact.

[00:37:32] Melissa: Yeah. And, I love that when you’re getting kids in the kitchen, it could just be sometimes a lot of times with my kids, they were just in the kitchen with me while I was preparing maybe I wasn’t going to take the time to have them help or whatever, but I love what you said too about maybe I like cauliflower mixed into my macaroni and cheese cause we all know especially with vegetables.

I prefer cooked cauliflower over raw cauliflower. My son prefers raw broccoli over cooked broccoli. Like it’s just, that’s just normal the two taste very different. Right. So even just introducing that concept and. That’s okay. Now I know that there is an extreme form of picky eating. I believe it’s called ARFID.

I don’t know if that’s an acronym, but I do want to address that when picky eating goes beyond that, of what you would consider normal or normal development, what would you suggest or what does that look like? And what do you suggest?

[00:38:29] Liz: ARFID is an extreme form of picky eating. So it does stand for avoidant restrictive food intake disorder.

And I would tell parents that that’s something you’re not going to miss. It will eventually show its face. And that’s what I was alluding to a little bit before when it starts to interfere with your child’s ability to participate in what feels like normal family meals, normal eating experiences, if they’re avoiding experiences because they don’t want to eat the food, or they’re extremely limited in their food variety. That’s when I would start to have a conversation with your pediatrician and more than likely, we would need to have some type of a feeding therapy or a comprehensive feeding clinic involved. And a lot of those kids have underlying medical problems.

Not all of them, some of them may have had an experience that was really frightening around food. And sometimes then that causes them later to have this very selective aversion to food. So it’s not something I would be worried about. I think it’s something that I always tell parents your child the best and if your radar’s going off, you’re probably right.

So it’s one of those you won’t miss it kind of things and would be an important discussion to have with the pediatrician.

[00:39:49] Melissa: Okay, great. Thank you. I wanted to ask you – a lot of parents – in getting back to the fears – is my child getting the right nutrition for growth and development is my child underweight is my child overweight – is there anything you want to say as far as this approach to picky eating child nutrition in general and just parenting in general about obesity prevention or eating disorders God forbid we don’t want to think about that in the two to five-year-old range, but are there things that parents can do to decrease the risk of, of those as well?

[00:40:27] Liz: So I think that’s a really great question and it is interesting because when I started working with Dr. Murray long ago, our ounce of prevention and pound of cure programs were about obesity prevention. And the more we learned, the more we realized we had to take a step back and look at how we were developing the skills.

And so whether the outcome is obesity or an eating disorder or whatever the challenge is for the child. The answer was probably earlier in how we approached the development. And I would say it’s everything that you and I have just talked about is just really focusing on that relationship between the parent and the child, losing the emotion, developing the skills, exploring foods, working on variety and allowing them to be where they are in their little food journey.

Because at the end of the day, all we really want is happy, healthy adults. There’s not a victory at the end like you have the healthiest diet of anyone it’s, that’s not where we’re headed. And so just really empowering parents early, I think, is our strongest effort against all of those outcomes.

And there’s no perfect way. And so if somebody ends up and their child has a challenge. It’s not a failure. It’s just part of that child’s journey. And the same skills applied at that point in their life will also help the child overcome that challenge. And so again, I think for me anyway, and, and this is where it comes back to me being a parent as well.

I just look around and this is where we’re all connected. We’re all struggling. We’re all trying to do the best for our children, but at the end of the day, there’s not a perfect way. It’s just about focusing on the child. So I think it’s what is exciting about this is that it’s pretty simple and it can apply to things outside of feeding too.

[00:42:33] Melissa: Wonderful, wonderful, great. Well, so as we’re wrapping up, I know we have a ton of great resources but it would be helpful to hear whether it’s a simple recommendation, like milk at meals, water in between just about food groups in general. And different ages have different requirements, but if you had anything you wanted to share about any guidelines or goals, I should say feeding goals that parents should be aware of.

[00:43:00] Liz: Some general feeding goals would be around the age of six months around there to have the child start some complimentary feeding of purees and advance as that child is ready. Around 12 months, that’s when we start to incorporate things like cow’s milk into the diet. Typically starting with whole milk.

As long as that child will tolerate the whole milk. And that’s when I start to focus on the milk with meals and water in between. In general, I think looking at food groups, looking at macronutrients is helpful for parents. MyPlate is a great guideline for them to pull out if they’re looking for specifics on food groups, but looking at things like carbohydrates and proteins and fats first, and then the part that I like to focus on when it comes to micronutrients is that you’re pretty safe. If you’re doing these things, right, you’re looking at your macronutrients and you’re getting your dairy in. And we know that gives you the flexibility. The micronutrients is where you need to get the variety in.

And so it’s working on the skills to get those things into the diet. And I try to remind parents, don’t look at each meal as if it has to have everything that that child needs, that is not realistic for anyone. Look at it over the course of the day or the week or even the month – did I try today to give myself or my child something different for breakfast than yesterday?

And did I change the fruit up today? Did I try a new vegetable? And if there’s a day where you didn’t do any of those it’s okay. And just really trying to make it flexible, focus on variety and again, skill development.

[00:44:45] Melissa: Excellent. And I’m just realizing that we didn’t talk about juice or milk alternatives. I definitely want to address that. I’m pretty sure that the AAP guidelines are still four ounces a day for children, but not sure what the specific ages are. So could you speak to that?

[00:45:03] Liz: So in the early childhood age group, it’s truly that juice has not recommended that it is milk with meals, water in between. And if you are going to choose juice, that it should be a hundred percent fruit juice and no more than four ounces a day.

[00:45:19] Melissa: That wouldn’t be until at least two years old?

[00:45:22] Liz: Right. Under two years, we really try to avoid anything that might have added sugars or salts or things like that.

[00:45:28] Melissa: Okay, great. And if somebody has lactose intolerance or a milk allergy, or for some other reason wants to try a dairy alternative, we recommend the fortified, soy milk and yogurt.

I’ll just say this and you can chime in here. I think a lot of people don’t realize that the fortified soy milk is as close as you can get to regular white cows milk. But things like almond milk rice milk I don’t know there’s Cashew milk.

[00:46:01] Liz: Any of the others, none of the others,

[00:46:04] Melissa: Right, they are typically not fortified with the same vitamins and minerals.

They don’t have that nutrient profile. So I think even the dietary guidelines, point out the specifics. So I’ll put that in the show notes as well. So I think it would be unsweetened fortified, soy milk. If the child is allergic to dairy milk or someone in the family has made a specific dietary choice.

[00:46:26] Liz: I think it’s important to know too. This goes back to the fear thing that dairy allergies over the course of a lifetime are actually pretty rare. And even some infants that have been breastfed that had some type of a reaction when the mother was consuming dairy, maybe a rash or they didn’t tolerate it well, ultimately end up tolerating dairy quite well later.

Because it’s such a simple way to get nutrition, before I would want to exclude that from a child’s diet I would want there to be a conversation with their pediatrician and/or a pediatric allergist to make sure because it is, it it’s a huge challenge. If it’s a food group that we have to remove – any food group that we have to remove, honestly.

Right. And I think knowing that, I want to remove the fears, but in the case, like you said, if a child cannot have a dairy product or for any reason, either it’s allergy or by choice, soy is really the only approved alternative. The other ones just don’t have the same nutritional value.

[00:47:31] Melissa: Right. Great. Thank you for clarifying that.

And you brought up another point that I also want to make sure that we address, because this has changed since, since my son was a baby about the early introduction of potentially allergenic foods. And so I’d love for you to speak to that. I have a related episode on peanut allergies. I don’t remember the number, but I’ll put the link in the show notes at soundbitesrd.com, but that’s a newer recommendation. So can you speak to that?

[00:47:57] Liz: Definitely. So what we know now is that early exposure to those more allergenic foods actually prevents children from having allergies in the long run, because it’s that slow exposure over time, because like every other part of their body, their immune system is developing too.

So we expose children to things like eggs and dairy and peanut butter as early as six months, sometimes earlier, if they actually are a higher risk. And usually that’s after having a conversation with the pediatrician or an allergist to talk about that, but really there’s no disadvantage to that early exposure.

And even some literature that supports smearing peanut butter on the lips of an infant to start to build that exposure over time. So it’s a huge difference from when I was raising my kids as well. I remember being told that I couldn’t give them eggs or peanut butter till two. I can’t say that I really listened, but that was the recommendation at the time.

It’s very different from what many of us grew up with.

[00:48:58] Melissa: Absolutely. Well, that makes me ask, are there any stories that, that you can share about your kids? Cause I know we’ve connected on the aspect that I’m a dietician, you’re a pediatrician and we’re not perfect parents by any means. So I’d love it if your kids have approved for you to share any, any stories with us.

[00:49:16] Liz: Oh, without question. It’s interesting. I have four kids and four different eaters, and I don’t want to say they were just born that way, but they sort of were. And I would say my oldest is more of the traditional picky eater and over time has become he’s 18 now and he has a relatively typical teenage diet, low on the vegetables, but working on it. And is more willing to adopt that healthy diet of an adult, I guess. I do actually have a child with ARFID and so I have some experience with that process. And if that speaks to anything is you can know as much as you can possibly know and there are some things that just are part of their nature.

And my experience with that child has been so humbling and such a great journey to watch and learn and those skills have helped me with lots and lots of patients over the years. So I think that’s one I like to call out a lot because I think again, what I want to do is connect with parents on the level of parenting and not on the level of, I somehow know information that is privileged to me and not you. And it just doesn’t work that way. We’re all, in this together. So, and I would say my two middle ones, they’re more explorative in their diets. They tend to tolerate and accept things quickly and be interested in new things and want to try new things.

And so I can’t say that I did anything different with them, but out of four they each have their own personalities and skills and just like everything else that in life for kids, they have strengths and weaknesses. So, that’s our story.

[00:51:03] Melissa: Thank you for sharing that. Very interesting. Well, like I’ve mentioned several times, we have a lot of great resources.

We’ve got handouts, videos, tip sheets, I’ll have all the links to websites and social media in the show notes at soundbitesrd.com. But if there was anything specific that you wanted to share, and I know you are also working on revising a chapter in the pediatric nutrition handbook, I’d love for you to share that with us as well.

[00:51:30] Liz: Sure. So resources wise, where I usually direct parents, the national AAP website, healthychildren.org is a wealth of resources, including nutrition resources. They have their own group there, as well as the Ohio chapter of the American academy of pediatrics that I mentioned earlier has a tab on resources – you can find just about anything you.

The dietary guidelines are written for professionals, but I find them to be very easy to understand. And so I wouldn’t hesitate as a parent to reach out to that website and look dietaryguidelines.gov. Go to the age group of your child and look through them.

I think they’re really easy to understand and I think will support a lot of what you and I have been talking about. And since we talked a lot about dairy, I think going to the websites for national dairy council or dairy Mideast, there’s a dairy group in every area of the country. And they have so many resources, recipes, information on sustainability, things like that.

So. I think those are great websites to go to as well.

[00:52:34] Melissa: Excellent. Thank you. Yes, drink-milk.com and winnersdrinkmilk.com. Those are two, but to your point, there’s also usdairy.org, and there’s regional and state dairy councils all over the U S and just a ton of great resources there and ways to get kids into the kitchen or recipes and snack ideas, fun games and all kinds of wonderful resources there.

Thank you so much, Dr. Liz, I have really enjoyed our conversation and just the very interesting and important insights that you’ve shared with us today. Thanks for having me. And for everybody listening as always enjoy your food with health and mind and help your children do the same till next time.


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2 Comments

  1. MARIA CASTELLI on October 3, 2022 at 10:12 am

    N/O

  2. Rosaura Oyekanmi on October 4, 2022 at 10:35 am

    The content of the webinar was very educational ,and interesting definitely, I can use it at work . Thanks

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