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Paediatric dietitian Ana-Kristina shares her advice on improving children's dietary habits around mealtimes.

Ana-Kristina Skrapac RD
– Specialist Paediatric Dietitian (London)

  • Q: Children with food allergies can develop fussy eating habits. Are there any techniques a parent can try, to encourage mealtime eating?
  • Most infants and toddlers will have a phase of fussy eating as part of their normal eating development in childhood. Children with food allergies may be at higher risk of developing fussy eater behaviours or aversive feeding problems if they begin to associate their symptoms with eating certain foods or feeling unwell or if their symptoms coincide with critical feeding periods early on in their feeding development.

    Mealtimes can also be an anxious time for parents, particularly if the food allergy is associated with acute or severe symptoms in the child. It is important to be mindful of your own responses to your child during mealtimes and normalise the experience as much as possible. Keep mealtimes fun and positive and ensure your child can safely explore food. Allow your child to let you know when they have had enough (lip clenching, head turning, etc), or simply end the meal when they become agitated and show signs of wanting to stop.
  • Q: Can you share useful points to remember around mealtimes?
  • What is helpful for one family or child may not be for another, however some general strategies for managing mealtimes may be:

    • Encourage your child to sit in a supported chair (highchair, booster seat, small table) so they feel comfortable and recognise that it is mealtime rather than playtime
    • Keep mealtimes to roughly 20 minutes
    • Introduce new foods together with familiar foods
    • Give positive reinforcement for any good eating behaviour and ignore any attention seeking behaviours
    • Be a positive role model and eat with your child, normalising the experience and showing them the behaviour you want them to display
    • For older children keeping a reward chart can help engage and motivate them to eat new foods.

    And remember that it is normal for a child not to like a new food the first time; in fact refusing a new food up to 10–15 times is common before children accept a new taste. Eating is a very sensory experience; a new food can also mean a new taste, texture, smell or colour, so keep foods simple and interesting without being too overwhelming. Children who experience physical symptoms with eating such as vomiting tend to be more orally aversive or hypersensitive, and can be more reluctant to touch, smell or taste food. Messy play is a good way to encourage a very hypersensitive child to explore food; sit with your child, helping them to explore the foods in a sensory way using their hands. The aim here is to engage your child in the process rather than getting your child to eat. Build up expectations gradually at your child's pace.

  • Q: How can a parent make sure their child is getting the nutrition and vitamins they need when eliminating allergens from their child’s diet?
  • Optimising nutritional intake in the allergic child’s diet is very important as with each food excluded, the risk for inadequacies increase. It's a good idea to give your child a multi-vitamin to make sure they're not missing out on vital nutrients. A paediatric dietitian will give more specific advice regarding single nutrients and appropriate supplementation to meet needs, for example advice regarding Calcium and Vitamin D for children avoiding milk and soya.
  • Q: How can you make sure your baby or child is getting the recommended daily amount of calories in order for them to thrive in their early years of development?
  • Energy and protein intakes can also be lower in children on exclusion diets and it's important to make sure they get enough calories. Additional prescription products or formulae may be advised by a paediatric dietitian for children in high risk groups, or where growth is of concern. A child that is gaining weight adequately so that their growth follows their centile line, generally means that they are getting enough calories. For a child that is not growing well we may also suggest specific blood tests to exclude any deficiencies.
  • Q: Parents have a tough time when faced with a fussy eater on a prescribed exclusion diet due to their food allergies. Should parents focus more on getting their child to try new things, or make sure their child eats, even if it revolves around very few foods?
  • Nutritional goals may be different for each child depending on whether the child has any growth concerns. For a child that is growing well and excluding one or more foods due to food allergy, we may suggest increasing the food variety gradually to expand what they can eat and broaden their taste experience and nutritional intake. If growth is of concern, the aim may initially be to increase the food quantity of a few tolerated foods rather than pushing variety. As a general rule, increase food variety gradually, even if very small quantities are taken of each food. We tend to aim for 1 new food every 3 – 5 days during weaning. For toddlers or older children, 1 new food per week may be a more achievable goal for fussy eaters.
  • Q: Stress levels can be high at mealtimes particularly when a parent is trying to manage feeding difficulties on top of managing their child’s food allergy. Are there any tips for the parents to manage this?
  • Parental anxiety can play a part in a child’s eating behaviour and it's been quoted that managing food allergy is as stressful as managing chronic childhood conditions such as diabetes. For acute allergic conditions such as anaphylaxis, anxiety can sky rocket and children will notice their parents' worry or concern. Anxiety or heightened stress at mealtimes can lead to children feeling anxious and this may be displayed as fussy eating, food refusal and tantrum behaviours around mealtimes.

    A good way to lower the anxiety notch and help to normalise the meal time is for parents to eat at the same time; a child will generally eat better themselves if attention is diverted away from them. Think about creating a positive environment for eating; lighting, music, light conversation all help to relax the mood. Some children will respond to distraction techniques, such as cartoons in the background or a favourite toy on the highchair tray. However be mindful that some children are easily distracted from eating and may respond better to fewer distractions. Involving your child in the preparation before a meal can also be helpful in setting the mood and defining the expectations for the meal. Get your child to set the table or help with simple food preparation, explain what is going to happen and let them know that playtime/ free time will follow.

  • Q: It can be a hard and tiring time for a parent managing mealtimes with a fussy eater – how long should a parent persist before seeking professional guidance?
  • There is no harm with seeking professional advice early on, in fact early advice can help to prevent negative patterns from getting entrenched. And the reassurance gained from seeing a professional can go a long way to help with parental anxiety and worry about feeding. It can be helpful early on to hear that other parents have similar experiences and it's useful to get reassurance about growth and nutritional intake. In addition, talking through practical strategies can prevent anxiety escalating until parents feel at breaking point.

    If you wish to find out more information, you can contact Ana-Kristina via her website.
  • January 2013
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