Thursday, July 22, 2010

picky eating, size concerns: "don't worry about it" means different things to different people

A mom called me to talk about her teen who has been eating -almost exclusively- microwaved lean pockets for 7 years. At every doctor's visit she was told not to worry about it, that it was fairly nutritious, and he would likely grow out of it. A young pediatrician recently wrote in (A., I read your comment but couldn't find it when I needed to post! Sorry) to say when parents come to her with picky eating complaints, she too tells them not to worry. I probably gave similar advice ('mac-n-cheese is fine! Just add a multivitamin!) when I was a new doc.

I look back now at how naive I was, how misinformed, and how unhelpful ultimately to so many parents. You see, I grew up with structure, family meals, enough money for a wide variety of foods that were largely presented in a pleasant atmosphere free of pressure. (I think part of me assumed that was happening in most homes.) I had no training in feeding other than how to concentrate formula and calculate calorie needs for the "feeders and growers" in the neonatal ward, and I didn't have my own kids. (OK, a few lectures on breast-feeding and perhaps a review of a handout about starting solids, always the what, never the HOW to feed...)

In short I had no idea how many families struggle with feeding, how many moms truly agonize over intake or a child's size. I had no idea how many of the moms I was seeing had themselves struggled with eating and were terrified of feeding their child. I didn't know how normal it was for most families to feed children one meal (often the same meal of macaroni and cheese and nuggets) and feed themselves later, and how much energy went into trying to get the kids to eat more or different foods. I didn't know that most of these picky kids were "good eaters" early on but systematically coned down to an accepted menu of brown and beige foods because parents didn't know how to handle normal feeding stages, or fed out of worry over nutrition or size (see last few paragraphs of that post.)

I didn't know that most feeding advice (if parents got any) was counterproductive. I didn't know that most folks today (kids included) seem to graze most of the day. I had no idea how much pain and conflict was inflicted in the name of weight and nutrition. (The moms who call crying because a child is refusing to eat and is losing weight, or another child is showing markedly disordered behaviors at age 7...)

OK, back from "tangent land."
point 1) your doctor might not have a clue. There, I said it. I didn't have a clue.
point 2) your doctor may be giving you bad advice. Again, I did...
point 3) health care providers, be careful about saying, "Don't worry about it" in terms of picky eating or odd eating behaviors.

More on "don't worry"
for health care providers and parents, just to make it extra confusing :)

First you need to ask more questions about feeding. A normal weight or growth curve should not give false confidence that feeding is going well. As a parent, if you see a health care provider and you're worried, and you are not getting your concerns addressed, ask yourself some more questions, get help... (Or if you get advice that sounds off like, "Just serve beef and green beans for 3 days, he'll learn to like it..." don't give up!)

Docs, ask: (moms, ask yourselves...)
How is feeding going?
How do you/I feel about feeding?
Are you/we eating meals as a family?
Do you/I struggle with eating?
Do you/I continue to offer a variety of foods?
Are you/we getting into battles around food?
Are you/we worried about your/our child's size?
Are you/we familiar with or following the Division of Responsibility?

Because, "don't worry about it" might be just the right advice for a family that is otherwise doing well with feeding. Support and optimize good feeding practices.

But –and here is the sad part– a family that is really struggling who is told, "don't worry about it," as is often the case, is a missed opportunity. It is much easier to turn around a feeding issue when a child is 5, vs 15... "Don't worry about it" to some means, keep serving mac-n-cheese and nuggets every night so you don't have to fight about is as much. Keep bribing and pressuring, keep worrying. And maybe 5, or 20 years go by (seriously) where the child only eats 5 foods, or maybe the dieting starts or the disordered eating...

Ask the feeding questions, optimize best feeding, educate yourself (Child of Mine should be required reading in all med schools as far as I'm concerned...) or at least have some titles or handouts you can refer parents to. Don't worry, but do have family meals, do offer variety, don't feed with pressure, do eat foods you enjoy, and follow up.

Moms, have you been told, "don't worry about it?" Did you still worry? What wacky advice have you gotten about your feeding concerns? From whom? Family? Docs?


  1. Hi Katja,

    My comment is the one you reference in the first paragraph. I can't remember precisely what I said either, but my basic point was the point you made in the second paragraph, which is that, beyond feeding premature infants in the ICU and telling you that you should encourage moms to breastfeed, you receive approximately zero training in childhood feeding in med school. Basically every single day, I have a parent (usually a mom, really) tell me that their child is a picky eater and ask me if they should be concerned. And, a lot of the time, I do say "don't worry about it" and sometimes this is the proper advice. Problem is, I have discovered, there is a big difference in what different parents mean when they say their child is picky. When some people say picky, they mean their kids only ate two of the three vegetables served at dinner. Some people say their child is picky because they don't clean their plate at every meal or in restaurants. And some people mean that their child has only eaten lean pockets for two years. The first two are not a problem, the last one is. If the last situation was described to me that specifically, I would realize that is a problem and suggest a course of action. If you have a feeding concern or a question, describe the situation as specifically as possible. As a group, I think pediatricians want to help you raise healthy kids. I do agree that we often fail to ask the right questions or sufficiently detailed questions to really determine if you there is a concerned to be addressed. The more info you give me, the better care I give your child.

  2. Thank you so much for your comment. Sounds like you are doing a great service to parents by being aware of the issues and that there are more questions to ask. You are so right about "picky" meaning different things to different parents, and you are right on about "don't worry about it" being great advice in many cases! One parent at a talk complained about her picky eater who actually ate a good variety. Mom was complaining most about the power struggles. Other parents expressed envy at the variety! I think it's amazing how little training primary care providers get about feeding, when as you mention, it is an incredibly common concern. You also show me that the training hasn't improved much since I went through it. I do workshops with residents and medical students and they confirm this experience. I am glad you are out there doing the good work. I agree that most docs are dedicated to helping their patients, I would just like to see us have better training and better information. I know had I known this information early in my work that I would have been a better clinician, and probably had more fun and a deeper connection with the families I served... How do you think we can get this info out to clinicians?