1. Vermont Statewide Nutrition Workshop
Eating Styles Matter feeding & nourishing babies & toddlers who don’t follow typical eating progressions
Linda Piette, RD, MS, LDN
Author of JUST TWO MORE BITES
Producer of EATING LESSONS – Babies or
Vermont Statewide Nutrition Workshop
Waterbury Center
October 31, 2012
© Eating Styles Matter by Linda Piette

2. “Eat what you like and let the food fight it out inside.”
Mark Twain
SCIENTIFIC BREAK THROUGHS
Digestion/ nutrition
Immune Function
Gene Expression
NEW ENVIRONMENT
food touches every part of life

3. Malnutrition Risks - US
Obesogenic Environment
What disease will 3 out of 4 Americans have by 2020?
PROCESSED FOODS
↑ calorie
↑ salt
Kids like familiar foods…….

4. Flavor Exposure Starts early Breast milk/ formula flavor impact
Table foods by 1st birthday.
Foods introduced after age 4 more likely to be disliked.*
Nov 2002, 5-yr study J American Dietetic Assoc

5. Pediatric News- Oct 2002 Incidence of Feeding Problems
25% of young children
50+% in children with autism
80% in children with developmental delays

6. Growth the most important developmental task of childhood…
Growth the most important developmental task of childhood…..keeping score
Growth charts….
Standard charts from
WHO (World Health Organization) on CDC website
Specialized charts for:
Cerebral Palsy
Down Syndrome
Turner/ Williams Syndromes
Weight-age

7. Weekly Weight Gains Age (months) Weight (ounces) 1-6 5-6 6-12 3-5
Height can ↑ 10 in in the 1st year
Source :JUST TWO MORE BITES

8. Growth How long does it take to gain a pound ?
Infants:
3 weeks
1-year-old:
2 months
3-year-old:
31/2 months

9. No eating….no growth Eating Connections…..
Physical/ Motor
Motor Skills & Eating (mechanics)
Body Size & Motor Skills (weight-age)
Readiness
Digestive
Neurological
Social/ Cultural
Family Food Traditions/ Dynamics
Health Risks
Economic

10. Body Size (Weight-Age)
(average for age)
RANGE
8 lbs
Birth
6 – 9.5 lbs
13 lbs
3 months
lbs
17 lbs
6 months
14 – 20 lbs
22 lbs
1 year
19 – 26 lbs
27 lbs
2 years
lbs
31 lbs
3 years
27 – 36 lbs

11. Eating Milestones SOLIDS Closes lips around spoon (6-9 months)
Uses tongue to move food from side to side
(8-11 months)
Table foods by 1 year
LIQUIDS
Drinking from a cup by 16 months
Able to drink 6 oz within 10 minutes or less
Able to drink thin liquids without gagging

12. Balancing Nutrition goals (short-term vs long-term)
Maturity / readiness for food
(digestive, motor & sensory)

13. Eating Styles happy, fussy, careful / fragile?
Variations in growth, food variety (flavor & texture), skills & adaptability
Balance short & long-term goals

14. Nutrition Goals for babies & toddlers
PRIMARY
Growth
Food Variety
(Good Nutrition=
Adequate calories +
food variety (texture?)
SECONDARY
Texture Progression
Self-feeding Skills
Healthy Food Habits

15. Eating Styles variations in growth & variety
HAPPY
Good growth
Good food variety
CAREUL/ RIGID
Poor food variety
TINY
Poor growth
FRAGILE

16. Happy Eaters Focus on Long-term Nutrition Goals:
Trust baby’s ability to self-regulate calories
↓ sugary foods
Off baby foods early
Avoid restrictions
Introduce healthy table foods early (off baby foods early)
Off bottle at 1 year
↓ milk to ↑ solids

17. Fragile Eaters Poor Growth Poor Food Variety Medical Risk
Not On Schedule…..
Not Ready for Food
Medical Risk
Developmental Delay

18. Careful/ Rigid Eaters Good Growth ↓ Food Variety (flavors +/textures)
Sensitive to flavor, texture/ Temperature
Brand-specific preferences
Self-feeding?
Sensory? Behavior?

19. Careful/Rigid Eaters Ben 1-year-old Baby foods –purees Frosting only
Force-feeding
Adam
Rigid eating (flavor + texture)
Delayed progression

20. Tiny Eaters Poor Growth Good Food Variety ↑ Flavors
Volume…liquids...solids ?
Texture ?
Motor delay?
Food Aversions?
Behavior ?

21. Tiny Eaters Connor Reflux Delayed texture progression ↓ fluid volume
Poor Growth (FTT)
George
1-year-old
Eating Table Foods
Poor Cup Drinking
Growth Rate Drop

22. Strategies….. Balance long and short-term nutrition goals
- growth or oral motor skills?
-↑ sugar/ fat foods?
-↑ liquids to ↑ calories
Feeding dynamics
- use distractions?
- food as reward/punishment?
- feed while sleeping AVOID
- force feeding ? NEVER
As short-term feeding problems resolve shift to long-term goals

23. Monitoring Growth Degree of poor growth Pattern of growth fall off
Calorie intake
Adequacy
Ratios (solids/ liquids)

24. Poor Growth Fragile Eaters Tiny Eaters Medical/ developmental cause ?
Specialized growth chart ?
↑ calorie need ?
Tiny Eaters
Oral aversion ?
Motor-delay ?
Timing/ off-schedule intro?
Can’t / won’t eat ?
Family food dynamics ?

25. Poor Growth MAKE EATING EASIER ………increasing volume
Fragile/ Tiny Eaters
Liquids
Eating gear
Solids
Gradual progressions
Modify texture
Demos & reminders
Calorie concentration/ supplements

26. Breast/ Bottle Feeding Common Problems
Poor latch
Adequate support?
Poor Lip Closure/
Leakage ?
Poor Suck/ Swallow/ Breath Coordination
Rhythmic pattern?

27. POOR GROWTH….LIQUIDS ? How much is enough? Formula Breast….
Term baby …approx 2 oz of formula/ pound body wt
(note: ↑muscle tone, cardiac/pulmonary/ digestive problems
↑ calorie needs)
Breast….
5/6 wet diapers/day
Delay transition to cup?

28. Breast/ Bottle Feeding Solutions
Strategies:
Positioning
Oral Massage (promote tongue grooving & cupping)
Jaw Support
Nipple with wide base
Flow rate ?

29. Nipples Latex/ silicone Shape Flow rate (+ pause)
↑thinness ↑risk of collapse
Shape
(wide/ narrow base)
(orthodontic/ angled/rounded)
Flow rate (+ pause)
Slow to med to fast
Pliability (soft/hard)
Preemie/Newborn/older
Size (length of shank)
No flow during pause
Gerber Silicone Slow
Gerber silicone Fast Flow Standard
Avent Naturally Feeding Bottle
Flow during pause (continuous)
Gerber Silicone Medium Flow Standard
Gerber 3-hole
Parents Choice
(0+ and 6-mo +)
Haberman is specifically designed for children with cleft palate and there are bottles/nipples for preemies that are smaller in size and typically reduce the flow so that they can handle it. Avent nipple has a slot cut which provides an adjustable flow rate by turning the bottle to align with the baby’s nose (I,II,III) and allows you to thicken the liquid for better control by the baby (nectar vs

30. Special Bottles/ Nipples-Solutions
Haberman-cleft palate
Pigeon Nipple ½ firm ½ soft (Children’s Medical Ventures)
Dr. Brown reduces air swallowing
Haberman is specifically designed for children with cleft palate and there are bottles/nipples for preemies that are smaller in size and typically reduce the flow so that they can handle it. Avent nipple has a slot cut which provides an adjustable flow rate by turning the bottle to align with the baby’s nose (I,II,III) and allows you to thicken the liquid for better control by the baby (nectar vs

31. Miguelina Fragile baby
HISTORY
GI issues
Delayed/ abnormal oral-motor skills
INTERVENTIONS
Facial massage
Positioning/ feeding gear, etc
Formula change & concentration
Liquids to solids ratio
G-tube
Keeping oral alive
POOR GROWTH
stabilized with g-tube

32. Sandy fragile newborn & toddler
HISTORY
Cardiac problems
Weak suck
↑ Calorie needs
Down Syndrome
↓ muscle tone
INTERVENTION
OT (massage, nipple change, texture progression)
RD (formula concentration, growth chart, fiber & medication review)
POOR GROWTH
Began at birth
Stabilized after 2nd birthday

33. Cup drinking…new skill
Which cup?
Practice with open cup + thickened liquid
Timing
Transition
Shaping preferences
Maximize calories/ oral-motor skills?

34. George tiny toddler HISTORY Delayed texture progression
Mild torticolis
INTERVENTION
Thickened milk
↑ calorie drink
POOR GROWTH
Started at 1-year
After transition to cup
Resolved after intervention

35. Cup drinking… CUP DETAILS Height & handles Spouts Hard/soft
Rate of Fluid Flow
Dot/slit opening
Spill proof
LIQUIDS
Formula/ supplement
Texture + flavor
Cost
Shaping habits
Delay transition to cup?

36. Connor tiny infant & toddler
HISTORY
Reflux
Delayed texture progression
Oral aversion?
INTERVENTION
Medication
Thickened formula
Supplements
Food group
POOR GROWTH
Through infancy
Resolved after food group

37. Poor FOOD Variety Fragile Eaters Careful/ Rigid Eaters
(poor growth, poor variety)
Delayed progression with textures
Timing & typical development can ↑ resistance
Careful/ Rigid Eaters
(good growth, poor variety)
Typical (Flavors +/ texture
Poor adaptability
Self-feeding ?

38. Poor Food Variety MAKE EATING EASIER …increasing texture
Solids
Modify texture
Gradual progressions
Demos & reminders
Supplements ?
Ratio of calories from liquids vs solids

39. TRANSITIONS Solids (Purees)→Textures
Calorie Implications
Liquids - ↑cal (milk or standard formula 20 cal/oz)
Solids - ↓ cal (fruit/veg 10 cal/oz)
Exceptions: baby yogurt (30 cal/oz) , heavy cream (51 cal/ TB, oil/ butter (100 cal/TB), avocado, hummus

40. Eating Milestones SOLIDS Closes lips around spoon (7-9 months)
Uses tongue to move food from side to side
(8-11 months)
Table foods by 1 year
LIQUIDS
Drinking from a cup by 16 months
Able to drink 6 oz within 10 minutes or less
Able to drink thin liquids without gagging

41. Steps to Eating Oral-Motor Skills
Biting (Jaw)
Chewing
- munching
- rotary
Tongue
- side-to-side
- tongue tip
-food propulsion
Lips
-active for food removal and closure
Cheeks
-keep food contained
Swallowing
- oral phase
- pharyngeal phase
- esophageal phase

42. TRANSITION to SOLIDS Signs of readiness Sitting up
Closing lip around spoon
Tongue lateralization
Up + down munching
Has doubled birth weight and is 13 lbs.
Her head and back is straight in supported sitting and she can reach out for a toy.
Puts hands and toys into mouth easily and frequently
Shows positive mealtime communication cues
Shows good oral motor coordination to accept and swallow food

43. Self-Weaning?? Started in England Skip purees/ spoon feeding
Start with soft-solids
(ie. Steamed veggies or soft fruit)
Typically 8-10 months

44. Gradual Food Progression
Make steps smaller
Avoid mixed textures
Aim for uniform size….
Food mills
Graters
Give dry crunchy BEFORE soft/wet solids

45. Oral Motor Programs Facial massage (use fingers or wash cloth)
Nuk brush
Infadent
Vibration
Blowing activities

46. Ready or not ….Eating is a Sensory Experience
Taste
Smell
Sight
Touch
Hearing
Careful & Fragile eaters are often NOT READY
Familiar with 5 senses

47. Poor Variety MAKE EATING PREDICTABLE
Prevention
Repetition
Routines/ structure
Modulate sensory experience
Redefine eating (expectations)
Feeding Dynamics

48. Poor Food Variety MAKE EATING PREDICTABLE
PREVENTION
Avoid giving food from packages
Pre-meal activity
Food Jags vs downward spiral

49. Poor Food Variety MAKE EATING PREDICTABLE
REPETITION
Toddlers “neophobic”
Need to see a food 16-50X
Build bridges …Gradually change….flavor
texture
color OR
shape

50. MAKE EATING PREDICTABLE for rigid eaters
ROUTINES/ STRUCTURE
Schedules
Rituals (stir, stir, lick)
Songs/ rhymes (1,2,3, BITE)

51. Poor Food Variety MAKE EATING PREDICTABLE
MODULATE SENSORY EXPERIENCE
Sensory seeker/ avoider ?
“Big” food flavors
Dry foods before soft solids
Distance food contact
Squish food in baggie
Cut up straws as holders
Dry finger foods
“Comfortable” environment
(lights, mirrors, noise, etc)

52. Connor Sensory seeker Over stuffs & pockets food in cheeks
Grinds teeth
Swallows food whole or barely chewed
Messy eater; not aware of food on hands or lips
Difficulty with manipulating food with hands or utensils
Prefers big food flavors
Beth has already mentioned the characteristics but also tend to lack the good discriminative touch so difficulty with manipulation of utensils

53. MAKE EATING PREDICTABLE for rigid eaters
REDEFINE “eating”
(expectations)
tolerating/ looking
smelling
touching
licking
biting
chewing
swallowing

54. MAKE EATING PREDICTABLE for rigid eaters
FEEDING DYNAMICS
Division of responsibility: Adults (what, when & where), Child (if & how much) Ellen Satter
Force/ permission
Dance
Force
Distractions (tv, toys, computers,cars, etc)
Bribes

55. Food Fun Group Based on Kay Toomey SOS Program
12 weeks – 1.5 hour sessions
Child group (with 10 foods)
Parent group (discussion & support)

56. Picky Eaters vs. Problem Feeders Adapted from Kay Toomey “Picky Eaters vs. Problem Feeders”
Decreased number of acceptable foods (30 or less)
Food jags – burn out foods regained after 2 weeks
Tolerates new foods on plate (may touch/taste)
Eats a variety of food textures
Family dynamics may intensify
PROBLEM FEEDERS
Extremely limited range of acceptable foods (20 or less)
Brand-specific food preferences
Downward spiral – no regaining of burn out foods
Cries/falls apart with new foods
Feeding skills are often delayed

57. Age Related Problem 4-6 months = 19% 7-8 months = 25%
Carruth, et al. “Prevalence of picky eaters among infants and toddlers and their caregiver’s decisions about offering a new food,” J of the American Dietetic Assoc. supp.1 Vol 104 (2004)

58. Average Weekly Weight Gains
Age (months) Weight (ounces)
Source :JUST TWO MORE BITES by Linda Piette

59. Help Unhappy Eaters BALANCE Nutrition Goals (growth & eating habits)
Child’s Maturity
(digestive, motor & sensory)

60. Shape food attitudes… Happy, Careful (rigid), Tiny or Fragile
Set realistic goals and strategies……..
Consider eating style:
Happy, Careful (rigid), Tiny or Fragile