207 – Picky Eaters

Intro to picky eating 0:00

Hi, welcome to season two of the Baby Manual podcast for parents of toddlers. This season will help you feel confident as you navigate the difficulties of toddlerhood, from tantrums to sleep schedules to potty training. I'm your host, a pediatrician and mom, Dr. Carol Keim. Hello and welcome to this week's episode of the Baby Manual Podcast. This is all about picky eaters. I'm going to talk real quickly about normal development and why all children become picky-eaters at some point and then go through some basics of nutrition and how to to your children about it and some tips for trying new foods and at what point you should see the doctor.

So for normal development in children, remember for the first six months of life, all they're having to eat is either breast milk or formula or both. And so there's not a whole lot of nutrition that happens there other than you need to make sure that if you are giving them formula, you're mixing it properly. That is extremely important because it's the only thing that they are eating. So if it is too concentrated or too diluted, over time that can cause some very serious problems. After six months of age, we're adding in foods.

Children are pretty willing to try things at this age because you're just putting the food into their mouth for them a lot of the time. Or if you are doing more of a baby led method, you handing them food to put into there own mouth. But you totally in control of what they're eating. And they tend to have pretty simple pallets. They like things that only have between one and three ingredients, typically. Not really any spices, not even really salt. And then after a year of life, children love to eat pretty much anything.

So from age one to two, I see a lot of kids become great eaters where they want to taste all kinds of new foods. They're curious about food, they find it exciting, and they wanna try what their parents are eating. And a lotta 15 to 18-month-olds can even eat more than their parent in a given meal. It's pretty exciting. And then around age two to three, they go through a picky phase and that is normal. So that's what we're mostly focusing on here, where at that age they typically will eat five foods and they're usually all beige in color,

Toddler nutrition basics 2:00

things like french fries, chicken nuggets, bread, that kind of stuff, and become less willing to eat things, like fruit and veggies. It is a lot harder to get those things into them. And also around age two to three, they go through this pattern where they will eat one meal, picket one, meal and skip one. And so a lot of parents at this age will call me and say that they're really worried that their child doesn't really eat. So they are worried about their growth. and yet somehow they do still seem to grow most of the time.

So of course, if you're ever worried, call your doctor, but we're going to talk more about that at the end. Most children will outgrow that picky eating phase within a year and then start to add more foods in. I'm going help guide you through how to do that and how encourage them to eat new foods without forcing them and without having those power struggles around food. So macronutrients that are in food, we've got carbohydrates, proteins, and fat. And the way I talk about these with children is carbohydrates are another name for sugars and starches and fiber.

Fiber is a carbohydrate that keeps you full and it puts water into your intestines and so it makes it easier to poop. It also helps slow down how quickly the other sugar in the food is absorbed into the body so you don't get that blood sugar spike and the crash afterwards. So with carbohydrates, I tell children that foods that are high in sugar, meaning simple sugars, tend to give you a little bit of energy right away. But then later on, they make you feel worse and they makes you get hungrier faster.

They don't keep you full like protein and fat do. And they also trick your body into thinking it has to eat more later. So children who chronically eat too much sugar, their insulin level keeps rising to compensate for that. And because insulin rises slower than blood sugar level and stays up a little bit longer, it tricks your buddy into think it's hungrier than it actually is. Then you're fasting insulin-level, meaning when you haven't eaten the resting level becomes higher and higher over time as you keep adding more sugar into your body.

And so that can predispose to diabetes later on in life. So we want to try to avoid simple sugars for those couple of reasons and try focus more on foods that have the more complex carbohydrates, the starches and the fiber especially. Then proteins, there are complete proteins and incomplete proteins. Complete proteins contain all of the essential amino acids and there were nine essential aminos acids, and we call them essential because we can't make them in our body like we have all the other types of amino acid.

So these nine, we have to eat them from our diet. It's essential we get them for my diet meat and most animal products like eggs and dairy are complete proteins. They do have all of the amino acids in them. They are an option, but a lot of children don't like to eat meat around age two to three. I think partly because it's hard to chew. It takes a while to it. Requires a little more patience. And it doesn't give you that quick burst of energy like foods higher in sugar do. It's usually not, protein is not as tasty as fat.

And so it's hard to get kids to eat meat sometimes. So if you do a quick Google search for complete proteins, you'll very quickly come up with a bunch of options of either different vegetarian options to put together or meats, of course, that you can serve to your child. And then fats, fats are things that help keep your body full longer. It's a slower burning fuel. And so if you've ever built a campfire and you use like the tiny kindling at the beginning to get it started, that's like, the sugar that burns up pretty quickly, but gets it's started.

Then the fat is like those big logs or the charcoal that you put on at very end that stays burning for a while afterwards. So it takes a wild to start burning. But then once it is going, then it lasts for longer, And so fats in foods, especially the sort of naturally occurring healthy fats, things like nuts are high in healthy fat. Avocado has really good healthy facts in it. And I do love olive oil and coconut oil as as oils to add into food if you needed to, add a little fat into it Those are great.

The saturated fats and the trans fats, which just have to do with the shape of the bond in the unsaturated fat. But anyway, those are, we think of them as sort of like bad fats. I don't like using good and bad a lot of time with foods, but the less healthy fats are the ones that are more likely to cause damage to your arteries over time and predispose to things like heart attacks and strokes and cholesterol problems, high blood pressure, that kind of stuff later in life. And so when we're talking about fats with children, I try to just focus on the healthy fats and the good sources of fat and why those help make you feel

Macronutrients and micronutrients 7:00

full longer. So then the micronutrients, these are things like the vitamins and minerals. Vitamins A, D, E and K are the fat soluble vitamins, and all the B vitamins in vitamin C are water soluable vitamins. And so these found in all kinds of foods, but basically foods that have color in them that are naturally occurring. So like fruit and veggies. that have a variety of color tend to have variety vitamins in them. And so I try to encourage children to eat a lot of different colors of foods, but not the fake colors, not food coloring, of course.

Iron and other minerals are really important in children, but iron especially because of how it helps children to grow their blood cells and not become anemic. And so that can give children more energy. A lot of kids do become iron deficient. For children that consume too much milk, the calcium in the milk actually competes with iron for absorption in stomach. Also, milk fills them up and makes them not want to eat as much food and also can cause microbleeds in intestine where you're losing blood cell.

And so children that have too much milk have three different reasons that they become anemic. And I've seen some pretty severe anemia in children who have to much. So if they are consuming milk, you want to keep it below 24 ounces per day. 24 oz per 24 hours or less for cow's milk especially. Even though it does have calcium in it and it has fat and protein in, that's about all that is in. It doesn't really have a lot of other nutrients. So I would try to avoid milk. Really, a lots of pediatricians nowadays are saying kids don't need milk at all and its okay just to give them water and I fully support that.

Water is really the healthiest thing that they can drink. Omegas are fatty acids that are also essential that we need to consume in our diet. And you've probably seen a lot of omega supplements out there. So depending on what your child is eating and how much variety they're eating, they may benefit from some omega supplementation. Also, children who have ADHD, trouble focusing, and even some picky eaters, sometimes it's found to be a micronutrient deficiency, but omegas a lot of times are implicated or at least seem to help when you start supplementing with omagas can help with those kind of things.

Probiotics are bacteria that live in our intestines naturally. They tend to get killed, those type of bacteria get kill when we take antibiotics and so after a course of antibiotics or after eating a lack of variety of food, a lot of times we end up with lower diversity in our gut flora. And so our naturally occurring bacteria that help us digest food tend to go away. So probiotics are to replace those good bacteria to help you digest better. They help your poop better, they decrease gas, that kind of thing.

Some children need them and some don't. That's another kind individualized thing, but if your child is not eating a great variety of foods, it may benefit from probiotic. Prebiotics are foods that feed the bacteria, the good bacteria of probiotics. And so prebiotic are basically things like fiber and fruits and veggies. So all those kind of nutrients feed good the bacterias. And really, over time, as you eat healthier foods, it causes the bacteria that process those foods to grow more, and the bacterial in your gut actually sends signals up to your brain to tell you what to eat.

And so the more healthy foods you ate, the healthy food you will crave over the time. Conversely, more unhealthy foods or the processed foods and high fat foods that you're eating, high sugar foods. The more of those you crave overtime too. And so it's really, really hard actually to just completely switch a diet or to completely cut something out or completely change something. But to do this sort of slowly by adding a little bit of healthy stuff in more and more over time is a great way to gradually get kids to become really healthy eaters.

So we used to have the food pyramid when I was a kid. This was developed in 1992. And we thought, okay, we figured out nutrition, this is it. These are the amounts of different types of food that we need. It had things like starches, grains, and rice at the bottom. Then it had fruit, vegetables, meats. At the very top, fats, oils, sweets. And then that got a little outdated because we realized it was not quite that simple. They turned it into something called My Plate in 2011, which I really liked because it a visual representation of what your plate should look like.

And basically half of it should be fruit and veggies, just looking at the plate itself and then some protein. And that, but then that was actually tossed out as well. And then finally in 2020, they just decided, you know, we're not going to do anything cute and picturey and easy to understand. Let's make it a little more complicated because it is a bit more complex. So now we are just trying to focus on limiting processed foods. When you process foods, what it does is it makes the calories easier to come out of the food.

It increases the flavor and it increases that sort of like burst of dopamine that you get, which is that hormone that tells you, let's keep doing this. And so processed foods are really bad for your body in a whole lot of ways. Unfortunately, they tend to also be some of cheapest stuff available. very easy, it comes in bright, attractive packaging, they use cartoon characters to make kids ask you for it. It is really hard to limit processed foods in our society right now, but it's very important because those foods are, okay, this is one time I will use the exception, They are bad for you.

They're bad foods.

Food guidelines and the stoplight model 13:00

So also, we focus now on increasing nutrient-dense foods instead of calorie- dense foods. So nutrient dense food are things like fruits and veggies. And then limiting added sugar to less than 10% of your total daily calories. If you look on the back now, all the nutrition facts have to say how much sugar is added in addition to what's naturally occurring in it. We want to decrease saturated fat to be less than 10% of the total intake. Sodium should be 2.3 grams per day. And then for adults, we limit alcohol to two per for men and one per per woman, which I don't think is fair at all.

But anyway, I think it should the same for man and woman because we have very similar bodies. Sorry, but I'm a pediatrician. I just think this is sexist. So yeah, the 2020 guidelines are a little bit more complicated, but we're gonna go through this a lot more to understand it better. One way to think about foods is in terms of a stoplight. So green light foods are just go, go go. Eat as much as you want of those. Yellow light food are go slow, meaning eat in moderation. And red light are things that you should only save for special occasions.

It's stop and think before you just eat these things and don't eat them as a full meal. So green light foods are things that grow in the ground. These are plants, fruit, veggies, and Also, it's possible to turn a green light food into a red light foods. So let's talk about an apple real quick. If you eat an Apple, just a fresh crunchy Apple. It's full of fiber, It does have some sugar in it, but the fiber that's in, helps keep you full and it regulates how quickly that sugar gets absorbed into your body.

it will keep your full longer than an Apples that has been processed. Now suppose you take that Apple and you cook it and turn it into applesauce. Maybe you add a little bit of sugar to make it sweeter because unsweetened applesausce is It's possible to find, but less popular for sure. Usually they add a little sugar into it, maybe a lil' cinnamon as well. But even just unsweetened plain applesauce, now that you've processed it a bit, you're able to consume so much more than you could of just fresh apples.

So when you're eating fresh apples, you could eat one, maybe two of them right before you feel full. Whereas when your eating apple sauce, it cooks down and you are getting all of that sugar that was in the apples. You're getting less of the fiber in there and less the water that's naturally occurring. And so you can consume several apples worth in one sitting very easily. Now to turn it into a red light food, if you just maybe slice it up, throw in some sugar and butter and turn into an apple pie.

So apple pies, yes it does contain apples But that doesn't mean it's a green light food. So greenlight foods are things that are just sort of naturally occurring things. Fruit, vegetables, and water. Water is the only green-light drink. Yellow light foods are things like dairy products, meat products. So chicken, beef, whatever sort of meat. And these cooked and slightly processed in some way type of foods. Then red light food are the fully processed foods, so that's things that come in packages.

Just about anything that comes in a package is going to be a red-light food. Things that you would eat at birthday parties, cakes, candy, chocolate. Sweet drinks, things like that. And so all of these red light foods, you want to try to save them for later. The only thing I don't love about this classification is it still really has that underlying connotation of green light, foods are good, yellow are neutral and red are bad. We don' want that good versus bad spectrum in kids. So if it helps to talk to them about green light foods in terms of the types of foods that are so good for your body that you can eat as much as you want without it becoming a problem, that's a great way to to talking about it, okay?

Rather than thinking of it as like greenlight foods are good foods for you. So when you're talking with your children about this, try to focus on the underlying benefits. Fiber, as I've said, it makes you poop. It pulls water into the intestines. it's good for your body and that way it make you feel good after you eat to have fiber in that food because it keeps you feeling satisfied. Vitamins and nutrients also give you that sense of satisfaction. It's one of the really natural ways to feel a natural high is to eat food that is very nutrient dense and really good for you.

Like if you've ever been hungry after doing some work and then you eat like a great salad or something that has like, a bunch of vitamins in it, you're like wow, this is awesome. You focus on those types of benefits of it. Protein and fat help keep you full. They fuel your body. Sugar fuels your but wears off quicker. protein and fat fuel your body and take longer and keep you fueled for longer, and you won't get hungry as soon, they help you grow strong, those kind of things. And so if you focus on those types of benefits of foods, children will more associate like the positive with it rather than just the, it's good for you, trust me, kind Also, talk about flavors and textures.

When you're eating foods together with your child, you know, oh, this pepper is so crunchy and oh it's a little bit bitter or it is a flavorful or oh this cucumber is squishy and crunchy, and man, these carrots are a bit sweet, that kind of thing. Or even just like the colors of oh look how bright this color is, look at how orange this carrot is. like how red this apple is on the outside. You know, talking about the exciting parts of the food and the visual and texture of foods can really help children to try new things.

Encouraging kids to try new foods 18:30

And if they see you enjoying a food, they're also more likely to eat it. So if you're just sort of eating something in front of them and enjoying it, then they will be more like to ask for some of that. I want to try to focus on eating the rainbow with kids. So that means eating lots of different colors. But also remember that blue, unfortunately, does not really occur in nature. It's not the full rainbow. Makes me a little sad. Red, orange, yellow, green, purple foods are all really good for children when they are naturally occurring, not added in colors, of course.

And then when you're giving your child their food, it's now strongly recommended to put everything on the plate at the same time and not use dessert as a reward because actually research shows that if you try to bribe children into eating, they will resent you and the food more. They will like it less if they do eat it. And when have them eat something to get something else, for example, you have to eat your broccoli before you can have chocolate cake, they actually will come to hate the broccoli more and value the chocolate more.

And then that just leads into all kinds of power struggles later and disordered eating later in life. If you offer them everything at the same time, I know what you're gonna say, my kid's only gonna eat the sweet stuff on the plate. And if you haven't been doing this before, then yes, they will at beginning, but that's going to change. They're going realize how they feel after eating certain foods and having all of the options there at same times puts a lot less pressure on them. You'll find often, when you put the couple different things on your child's plate, yeah, maybe they'll have a couple of bites of cake first, But then their body is going to signal to them like there's not really any nutrition in this, and they're going actually crave the other stuff that's on the plate as well.

And so they will go and eat the stuff there. Also, try to avoid what's called the clean plate club, which means having them finish everything that is on their plate. I do understand the value in not wasting, and so if you don't want them to waste food or if that's very important to your family, you have a couple different options. But one option would be to let the child tell you how much they want of it or to serve themselves. And then maybe another option is to have someone else in the family eat it if the because forcing them to finish everything that's on their plate, again, leads to disorder eating later in life, weight problems, and a lot of power struggles.

So some tips for trying new foods and getting your kids interested. If you sit down together as a family and eat together, I know it's hard, especially in modern society with everything going on, but eating together is one great way to bond as the family, to get your kid to try new things. Remember, you get to provide the food and decide when and what you are offering, but your child gets to decide whether or not they're going to eat it. And so even trying to coerce them into tasting it or licking it, or the no thank you bite, I'm not a big fan of those things either.

I do get why some people do them because I know a lot of children are just like behaviorally resistant to trying new things. But a lotta times at this age, it's not a behavior thing, It's more of a developmental thing. And putting that extra pressure on them just makes them dislike it more. Just keep offering and trying to inspire. Keep offering a variety of foods. I know it's really easy to be like, look, I'll know he'll eat chicken nuggets every time I cook them. So we're having chicken nugget every day.

And I get that. But I have also fallen into that trap for some time with my daughter. Also, you need to keep on offering the variety food. If you have a safe food or one that you know that they're going to eat, maybe put it on a plate with another new food next to it. And once they do start to like a new food or try a food, you can try similar things around it. And so, say they like yogurt, and start eating yogurt. You can start adding different flavors of yogurt and then you start mixing in fresh fruits into the yogurt to see if they liked that.

Or try mixing oats into it or nuts into or seeds and see, if you'll eat those kind of things. You can make it a little bit more fun and visually appealing by using things like sprinkles on top of food and we did a bunch of sprinkels and things, like oatmeal and yogurt and stuff. But also things like spaghetti, things that she was just really resistant to. Sprinkles are bright and colorful and they make food look fun, so they can be added onto stuff. Also, if you just cut things into fun shapes, sometimes that's enough to make it appealing to your child.

So using small cookie cutters, For things like, say, red pepper, you can chop out little hearts with cookie cutters, and they might be more willing to try that, or stars, whatever. You know, slice the cucumbers and then cut them into shapes. That can make it a lot more fun. Also, letting them play with their food and build things out of their foods can be a great way to have them try it. So maybe provide them with slices of vegetables and toothpicks to build thing out. They can build animals out of it or that sort of a thing.

That can make it really fun. You can also let your kids help you go grocery shopping and have them walk around the fruit and veggie aisle and try to see which ones they want to pick out, what they wanna taste. And then also, let them help prepare it. Let them do some chopping. There are child safe knives that you can buy, or even just regular knives under close observation can be safe. And so just watch your child very closely, of course, with knives. But you could help them prep in that way, they can help you by, say, pulling leaves of lettuce off of the head of a lettuce or pulling the grapes off the stems or whatever kind of things they could do with their hands to help sort of prepare it for you.

And then also using we statements is a great way to get kids on board with whatever you're doing. So things like we love to eat fruit and veggies in this house is, is one way. To make them feel kind of included in that and less pressured. so more inspired, like, Oh, I want to be cool. Like everybody else. I'm also going to like these things. Yeah. Using the we-statements really helps a lot. So reasons to seek help, to see a doctor or nutritionist for your child, there are a handful.

When to seek medical help 25:00

So if your a child is having poor weight gain or weight loss, any weight lost at all is always a red flag. You need to a see doctor for that. Not gaining enough weight is one of those things that can be hard to gauge. And so if you are weighing your children, you can call your doctor's office and say, look, they weighed this much on this date and now they weigh this, and is that amount of weight gained okay? Because I'm worried about it. Now, it's typical for children in the toddler phase to start growing a lot taller without putting on a whole lot of weight.

And so you might see them just growing, growing growing. If you look at children's clothes at different sizes, you'll see that the waist size is pretty much the same for four, five, and six. It's just the length is a little bit different. So it is normal for the children between the ages of four and eight to have a low body mass index, meaning their weight to height ratio, they look really skinny. And that is normal. It is for a four to eight year old to be able to see their ribs. If they don't have a shirt on, you can see them showing, it's normal for their tummies to look small, to have skinny legs.

That is all normal, so yeah, always check with your doctor if you're not sure if your child's weight is in the healthy range, but keep in mind that it is expected that they will grow like that. Then they start filling out, of course, when they get after age eight and then closer to puberty. Any child who is not eating outside of those five foods for longer than a year, or maybe not even eating five food, that could be a red flag as well. And if your child consistently will avoid certain textures or certain flavors that can sometimes be red flags, and so if there's something that your family that likes to eat consistently as a family but your child consistently refuses it, talk to your doctor about it.

There might be a reason for it maybe your children has an allergy or an intolerance or maybe it's something else. Sometimes it can be associated with things like sensory processing disorders. Any child who gags and vomits after eating should see the doctor. It's pretty normal when children are first learning to eat, like when babies are, you know, around six months old and first thing they need to do is normal for them to gag as they're learning how to swallow. But once they've got that down, or if they never fully get that done, That's a red flag.

But yeah, once they've got it down, if it starts coming back again, or if you have a child that is say over nine months old and will only do purees without gagging or without spitting it out, that can be a Red Flag as well. So those are reasons to talk to your doctor. Children that are having stomach aches associated with food, either that get better with or get worse with the food. Those are typically medically related and can be addressed by your doctors. And then the last thing is watching your child's poop.

I'm sorry, I know I talk about poop a lot, but any child that has continuous chronic constipation or diarrhea, it is probably diet related. That could be due to something like celiac disease, which is an allergy to gluten. It could be due to just a lack of variety in the diet or not enough fiber. It can be to too much dairy, it could a dairy intolerance even. And then there are other more rare medical conditions that can cause basically just chronically abnormal poops, either chronic constipation, chronic diarrhea, or alternating, I call it consturia, but yeah, alternating consti-patient and diarrhea.

That's not a real word.

Wrap-up and next episode preview 28:30

So those are all reasons to seek help from the doctor. Now, keep in mind most doctors, most pediatricians have very little training in nutrition, myself included. I got very training when I was in residency. And so after residency, I went and took a health coaching certification to learn a little bit more about diet and nutrition and how to talk about it with children. So I certified as a family and child health coach as well. and I follow a lot of these people on TikTok and Instagram, there are a whole bunch on social media that are pediatric nutritionists.

Just make sure you find a really good one that has a lot of positive values and gives really great advice. All right. Well, thank you so much for joining us this week, and I look forward to talking to you again two weeks from now when we do another deep dive. Our next one is going to be all about toddler behavior and tantrums, so make you tune in. Subscribe if you haven't already so you don't miss it. Thank you for listening to the Baby Manual Podcast. Please hit that subscribe button below so you don't miss the new episodes as they come out.

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