Expert Interview: What is a Feeding Disorder and When Should a Parent Worry?

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 adversely affected.”

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 parent.

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.

Garlic-Parmesan Artichokes

We've had a fairly odd winter this year, as in almost no winter. So, forgive me if I am busting out with the spring recipes before the season officially arrives. It's going to be over 60 tomorrow, in February. So, let's cook something for spring.

This dish is a great Easter dinner side, either an appetizer course, or a starter to follow the Asparagus and Potato Salad with the Lemon-Mint Dressing and Hard-cooked Eggs. I see the main course as maybe a roast leg of lamb, and a light panna cotta, but I'll get to the dessert and main closer to spring!

Garlic-Parmesan Artichokes
2 large artichokes
1/2 lemon
1 cup white wine
4 Tbs. whole wheat bread crumbs
3 Tbs. grated Parmesan
2 clove garlic, minced
2 tsp. olive oil
salt and pepper to taste

First, trim the sharp points from the bottom two-thirds of the leaves with kitchen shears. Then, trim the stalks to be flush with bottom of artichoke. Using a chef's knife, cut off the top 1/4 leaves (see photo). Rub the cut edges with lemon.
Place the wine and extra water, if needed, in the bottom of a steamer, stove type or the steamer appliance. Squeeze the lemon into the steaming liquid. Steam the artichokes for 25 minutes.

Preheat oven to 400 degrees.

Mix the remaining ingredients in a small bowl, tossing the oil with the bread crumbs and cheese until its a nice crumbly mixture. When the artichokes are done steaming, lift them out with tongs onto a cutting board.

Slice each artichoke vertically in half.


Using a paring knife, remove the rough part of choke and the center few purplish leaves (see photo). This leaves the lovely, edible heart easy to get to, and makes a nice cavity for the bread crumbs.

Sprinkle the bread crumbs, a bit in the cavity, but also in between the leaves throughout.

Place on a baking sheet with non-stick spray. Roast for 7-9 minutes until the cheese is melted and bread crumbs are browned. Serve hot.

Elegant, Intimate Thanksgiving

I did a terrible job of getting this posted during Thanksgiving. We had a small holiday dinner with friends before we all had to spend our actual holiday with extended family and the big, potluck fun for that day. For the four adults and three kids here, we could cook a special menu, a bit less traditional and upscale. If you have a small gathering, this is a great alternative Thanksgiving menu to try.

For the salad course, I recommend the Fall Kale Salad, and for dessert, the ultra-easy (make ahead) and stunning Pumpkin Panna Cotta with Bourbon Pecan Toffee.

Crispy Braised Duck with Cranberry-Port Sauce

Crispy Braised Duck

2 Ducks

1 onion, peeled and quartered

1 clementine, halved, peel on
2 ribs celery, roughly chopped

salt and pepper
¼ cup mulling spices

1 gallon apple juice

Cranberry-Port Sauce

1-1/2 cups of the cooled, skimmed cooking liquid

2 cups port wine

1 cup balsamic vinegar

1/3 cup cranberry jelly

Prepare the Ducks:
Preheat the oven to 350 degrees.
Starting from the large cavity end, gently work your fingers between the skin and meat to loosen skin from the ducks, especially the breast as much as possible. Try not to tear the skin. Prick the skin all over with a fork to allow the fat to drain when cooking.

Stuff the duck cavities with the orange, celery and onion. Salt and pepper them lightly.

On the stove, bring the apple juice and mulling spices to a boil. Pour the boiling liquid over the ducks to tighten the skin. The liquid need to come up at least halfway to two-thirds up the sides of the ducks. You can add chicken stock if you need more liquid. Cover the pan tightly with foil.

Braise ducks:

Put oven rack in middle position and preheat oven to 350°F.  Braise for one hour, remove from oven and turn ducks over, cover again and braise for another hour.

Chill ducks:

Remove from oven. Transfer ducks to a large platter, draining any juices inside ducks back into pan. Pour the cooking liquid from the pan through a strainer into a large bowl. Place the ducks back in the roasting pan and chill both the large bowl of cooking liquid and the ducks, uncovered, at least 4 hours. You want to firm up the duck before the roasting step, and also solidify the fat on the cooking liquid.

Make Sauce:
Remove the bowl of cooking liquid from the refrigerator and skim off the fat. Measure 1 and a half cups of the liquid and add to a large sauce pan on the stove. Add two cups port, 1 cup balsamic vinegar, and 1/3 cup cranberry jelly, and 1 Tbs. Dijon mustard. Whisk and bring to a simmer, uncovered. Reduce over low heat until you get a syrup that coats the spoon, about a half an hour.

Roast ducks:

Put oven rack in middle position and preheat oven to 500°F.

Remove the roasting pan with ducks from the refrigerator and place in oven. Roast ducks until skin is crisp, about 20-25 minutes.

When done, transfer ducks to a platter and let stand at least 10 minutes before serving. Glaze lightly with some of the sauce, serve with remaining sauce.

Pumpkin Risotto
2 tablespoons extra-virgin olive oil
1 cup diced pumpkin, ¼-inch dice
4 cups chicken broth
2 shallots, minced
1-1/4 cups Arborio rice
1/2 cup white wine
2/3 cup grated Gruyere cheese
2 tablespoons chopped fresh sage
Salt and freshly ground black pepper

On stove, or in a steamer, steam the pumpkin until fork tender, about 15 minutes. Set aside, keeping warm.

Heat the chicken broth in a small saucepan, and keep it warm over low heat.

In a large pot, heat 2 tablespoons olive oil over medium-low heat and sweat the shallot until translucent, about 5 minutes. Increase the heat to medium-high. Add the rice, and stir until it is evenly coated with oil, and the grains just begin to turn golden, about 3 minutes.

Add the wine and cook, stirring often, until the rice absorbs the liquid, about 5 minutes. Stir 2 cups of the warm chicken broth into the pot. Now you’re free from stirring for about 8 minutes, until the rice absorbs the liquid. After this step, you need to start stirring frequently.

Add another cup of the warm chicken broth to the pot and cook, stirring frequently, until all the liquid is absorbed, about five minutes. Add just 1/4 cup of broth next, and cook, stirring constantly, until all the liquid is absorbed, a few more minutes. Taste the rice; if it has reached al dente texture, you’re done. If not, add another 1/4 cup of broth and cook, stirring constantly, until all the liquid is absorbed. Repeat until the rice is done; you may not need all of the broth.

Mix in the Gruyere, gently fold in the cooked pumpkin, and sage. Season with salt and pepper to taste. Serve alongside the Crispy Duck, drizzle with the Cranberry-Port sauce.

Serves 4-6.

Three Sisters Soup

Beans, corn and squash are known in Native American food culture as the "Three Sisters" because of the practice of companion planting these items together to feed the soil, help provide structure for the climbing beans and decrease weeds.

The fact that the beans are available dried in winter, along with my stash of winter squash, and corn that was frozen from summer, means local eating in winter, too. The hearty soup does include a smoked pork shank for flavor, but this is optional if you want a vegetarian soup. The three sisters also provide a good vegetarian protein balance without the need for meat here.

I use my handy, and rather large pressure cooker here. To do this without a pressure cooker, plan on a cooking time of two hours and 15 minutes. It makes a whole lot of soup. Plan on freezing some for an easy dinner in the future.

Three Sisters Soup

1/2 pumpkin, rind, seeds and stringy pulp removed, diced in 1/4 inch cubes
1 onion, diced
5 garlic cloves, minced
2 Tbs. olive oil
4 mild green chiles, poblano works well, seeded and diced
28 oz. tomatoes in juices
1-1/2 tsp. cumin
1 tsp. Ancho chile powder
1/2 tsp. cinnamon
64 oz. chicken or vegetable stock
1 lb. dried beans, soaked overnight, drained and rinsed (heirloom beans like anasazi or vaquero work best, kidney beans as a substitute).
1 smoked pork shank, optional
12 oz. frozen corn
1 bunch cilantro, chopped
salt and pepper to taste

Heat the olive oil over medium heat. Add the onion, green chiles, garlic, cumin, Ancho chile powder, and cinnamon to the pot and sweat for 10 minutes until the onion is translucent. Add the stock, tomatoes and juices, beans and the pumpkin cubes, and pork shank if using.

Bring to a boil, then reduce heat. Lock on the pressure cooker top, making sure it seals correctly. This will cook for 45 minutes. When done cooking, turn off burner and follow your pressure cooker manufacturer's directions to release the steam. When the cooker is ready to be opened, unlock the top and remove the pork shank to a cutting board.

Using tongs, pull the meat from the bone. Add meat back to the pot. Bring to a simmer. Add the frozen corn and simmer for about 10 minutes. Before serving, adjust the salt and pepper, mix in the cilantro, reserving some as a garnish. Freezes well. Makes about 14-16 servings.