Have you ever wondered if your child’s picky eating is “normal?” If so, you’re not alone. The next couple posts will be a series from an interview with Dr. Ramasamy Manikam, PhD, a clinical psychologist and top expert on feeding disorders with over 20 years of practice. Dr. Manikam is the Director of the Center for Pediatric Feeding Disorders at St. Mary’s Healthcare System for Children.
Dr. Manikam has been kind enough to answer some questions for me.
The first post will cover some background on what feeding therapy is
and what conditions are most often related to a feeding disorder. The
posts will also cover when a parent should — and shouldn’t — be
concerned about a food issue.
The second post, for those of us who are blessed with kids who are just “picky eaters,” Dr.
Manikam shares some of his perspective as a medical professional as
well as a parent and grandparent on some of our “common” food concerns
with our kids.
What is a Feeding Disorder and When Should a Parent Worry?
A genuine feeding disorder can be devastating. The symptoms, causes
and actual behaviors of a food disorder vary. However, one constant is
that dealing with a child’s food disorder can be especially hard for
parents who blame themselves for the disorder.
Some parents I’ve talked with have children with eating habits that
cause both the parents and children in these situations to dread daily
mealtimes. Their children may gag when eating a disliked food or have
another type of adverse reaction to some foods. Situations like this
feel anything but "normal." Where is the line between “picky” and when
there may be an actual disorder? When should a parent seek medical help?
“The index I would use is the health, growth, and development of the
child in relation to the food intake,” says Dr. Manikam. “Some children
‘pick’ during meals but then graze all day long and are healthy. If the
child is not receiving balanced nutrients with sufficient intake for
proper growth and development then it becomes a disorder that requires
medical evaluation and feeding therapy if warranted.”
Growth and development issues are gradual symptoms, but there may be short-term indications of a food issue as well.
“Weight loss, illness, allergy, crying during meals due to pain, etc.
should be a call for medical evaluation to determine the nature of the
problem,” says Dr. Manikam.
Other symptoms that can be indicators of an underlying medical
problem include; difficulty with swallowing, vomiting during and after
meals, choking and gagging during meals, poor appetite, and crying while
holding the stomach.
“[These signs] can be indicators of an underlying medical problem
that should be evaluated by trained and experienced medical
professionals,” he continues.
What Causes Feeding Disorders?
The causes of a feeding disorder are most often a medical condition.
Less commonly, a feeding disorder develops from inappropriate
interactions with a parent. Feeding disorders affect approximately 25-40
percent of children from newborns to adolescents, a statistic that
seems alarmingly high.
“These percentages are averages,” explains Dr. Malikam. “The
percentage varies depending on the definition of what a ‘feeding
disorder’ is, the time of study, and the population and even the country
where the study is conducted. The percentage can be as high as 80% for
special needs children with developmental disabilities. I consider an
individual to have a ‘feeding disorder’ when his or her health is
Feeding disorders are more common for children who are born
prematurely, or had a low birth weight as well. According to Dr.
Manikam, other physical causes of a feeding disorder, eating aversion or
failure to thrive, include:
• Celiac Disease
• Down Syndrome
• Prader-Willi Syndrome
• Heart defects
• Breathing difficulties
• Oral-facial malformations such as cleft palate
• Other Syndromes (e.g., Stickler, Cri du chat, Pierre Robin,
Russell-Silver, Fetal Alcohol, Treacher-Collins, Smith-Lemli-Opitz)
• Food allergies, including milk allergy, and lactose intolerance.
Other physical causes may include gastroesophageal reflux (GERD) and
Crohn’s disease. Sensory disorders, autism, and ADHD can sometimes be
linked to food issues.
Only about one in ten food disorders are caused from behavior issues.
These food disorders can be caused by negative interaction with a
Examples Dr. Manikam provided include a parent that has low
tolerance; has a poor understanding of developmental norms; or has been
affected by the knowledge that other children were doing better or
eating table foods earlier. Other negative interactions can include a
parent who cannot read his or her child’s hunger cues, or who forces
food on a child when the child is not hungry.
Parental aggression or anger during feeding times, a lack of
nurturing, and parental apathy are other negative parental interactions
that can lead to a feeding disorder in children.
How Are True Feeding Disorders Treated?
Treatment for a true feeding disorder can require an expert such as a
feeding therapist. Dr. Manikam is a clinical psychologist, but feeding
therapists may have different backgrounds. Feeding therapy, in some
cases, requires a team of individuals with different specialties.
“Feeding therapists are professionals trained in the assessment and
treatment of individuals with feeding problems. Generally, Speech
Pathologists, Occupational Therapists, and Behavioral Psychologists
provide feeding therapy services to individual with feeding problems,”
says Dr. Manikam.
Feeding therapy team members may sometimes include a nutritionist, or
a social worker or other medical professionals. The therapy process may
focus on the patient only, or the parent, or both. This article on Dr.
Manikam from the New York Times, has some specific examples of patient experiences.
“Depending on the patient’s age and developmental levels and the
nature of feeding problems professionals might work with the patient
and/or with the guardian. For example, therapists might work with an
adolescent who develops ‘anxiety’ or ‘post-traumatic anxiety disorder’
due to a choking incident. In the case of younger children, therapists
might work with the child and train the guardians when an effective
intervention is established. In some cases, the therapist might train
the guardian to implement the intervention strategies. The model of
service delivery depends on the information obtained from the
assessment,” says Dr. Manikam.
Many thanks to Dr. Manikam, Director of the Center for Pediatric Feeding Disorders at St. Mary’s Healthcare System for Children, for his insights shared here. In the next post, he shares his experience and perspective for all parents, including how to deal with “picky” eating issues such as color, texture, food jags and other common food concerns.