Managing Picky Eating in Kids

Podcast Transcript

Dr. Richard So: Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time.

In each session we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now let's talk little health.

Do you dread dinner because you're worried about what your kid will eat or won't eat? It can be extremely frustrating, but you're not alone. I'm Dr. Richard. So a pediatrician at Cleveland Clinic Children's. And on this special episode of Little Health, we're focusing on a topic that challenges a lot of parents: picky eating. We'll talk about why kids can be so selective with their food, and more importantly, how can you make mealtimes less stressful?

My guest today is Danielle Griffin. She's a Cleveland Clinic children's occupational therapist who specializes in pediatric feeding disorders. Welcome to Little Health, Danielle.

Danielle Griffin: Thank you Dr. So, I'm excited to be here. Um, so like you said, I'm an occupational therapist. I have 18 years of experience in pediatrics and in board certified in pediatrics through um, America's Occupational Therapy Association. Um, and I consider myself an advocate for early screening and identification of pediatric feeding disorder. Thanks for having me.

Dr. Richard So: Welcome. Picky eaters - it's emotional. It can be stressful and for a lot of families it's supposed to be a good social time with them. What is picky eating and when do you think it becomes a problem?

Danielle Griffin: Yes. Um, so when we use the term picky eating, the general public is really referring to what is part of typical development. So we see pockets or windows of time in development, uh, where children commonly refuse foods. Um, so the first stage that comes to mind is when you have children that are maybe one or two years old and you're offering them new foods that they've never seen before. Uh, it's common that they may avoid eating those because they're still learning about them.

So we say that you really need 10 to 15 positive exposures with a food before a child might try it. Another time that's really common is when we get to that preschool age and kids are getting a little more autonomous at that point in time, they start to verbalize to us what their favorite foods are and what foods maybe aren't their favorite. And they're starting to make some decisions and some requests about what they would have. Those things are part of natural development. So when I get concerned that a child might have problematic feeding or pediatric feeding disorder, um, is when we meet kids that are eating less than 20 foods total in their repertoire.

Dr. Richard So: At what age?

Danielle Griffin: I would say basically we're talking about like post infancy. So we're starting to give kids solids and now they're very limited. So in those early stages where we're still breastfeeding or providing formula, I don't worry so much about that repertoire, but as kids are eating table foods, that's when we need to kind of track how many they're eating.

And then another flag would be if they're omitting entire food groups. So commonly I'll see kids that are missing fruits and or vegetables or proteins and that can be a flag that there's some reason that they're not eating those foods. Um, and then another problematic behavior that I see really commonly would be like rituals, routines. I want specific brands or I need a certain cup or a certain spoon. Those are little flags to us that maybe we should look farther into their picky eating habits.

Dr. Richard So: Gotcha. Let's take a step a little back 'cause I start kids in my office at solid foods four to six months depending on what the parents' wishes are. But, and I'm a vegetable before fruit kind of pediatrician because I always say, Hey, if you start the foods, they get the sweet tooth and they're never going to eat their vegetables.

Danielle Griffin: Sure.

Dr. Richard So: But go going with along with what you're saying is that a lot of babies will purse their lips, you know, it's like, I don't want that. I don't want that. And parents will opt out a lot and give something else. I agree with you that the most important thing that you can do with your kids is don't give up and Oh, my kid doesn't like that. And then you're not gonna give that to for, to them for the rest of their lives. You have to try each food at least 10 to 15 times before you can say they don't like it.

Danielle Griffin: Exactly.

Dr. Richard So: Most parents stop at three.

Danielle Griffin: Well, I think that some families worry too about waste. Uh, and maybe we have families that are experiencing food insecurity and so they don't want to waste food that's available. So an easy way to address that is to offer our children food that we're already having and to offer that exposure in, in a smaller quantity.

So if I am eating, um, a fruit or a vegetable, maybe I'm gonna offer just one piece. Um, or just a teaspoon of something so that if they don't eat it, they still have the opportunity to learn about it and to experience it. Maybe what it looks like or what it smells like. But I don't feel like I'm throwing a lot in the garbage if they don't eat it.

Dr. Richard So: So on that same note, what do you think is the difference between picky eaters of today versus picky eaters of a generation ago? Because back in the day there wasn't a lot of food and grandpa says, you get what you get, this is it.

Danielle Griffin: Yeah. I mean, I feel that our generation really didn't have the opportunity to be picky. The parenting style was a little more authoritarian and so we weren't given options. If you didn't eat then you probably didn't get an alternative. Right now we're experiencing kind of the gentle parent generation and they're willing to make more accommodations and, and do some bargaining, um, to get their kids that caloric intake. There are pros and cons to each style.

Dr. Richard So: I think that one of the common things we have on this podcast is that people parent out of fear. Fear of their kid getting not enough nutrients, fear of their kid starving. But generally speaking, there's not a lot of hungry kids. But kids will often skip meals, you know, and that's completely normal where they will catch up and eat more at the next meal.

Danielle Griffin: Yes, it can be. So, uh, if you have a child that is occasionally skipping meals, that's what we would consider part of that typical development. And that happens sometimes there are gonna be windows of development where they eat a lot or they're asking for more snacks, or they're eating larger quantity of meals. And then there may be timeframes where they're skipping breakfast or they're tired in the morning and don't want to eat. The key is recognizing is that happening over a long period of time or really is it just these pockets of time?

Dr. Richard So: Yeah. I'm gonna switch to like a lot of family values. Mealtime is very special, it's very social, but it gets stressful for parents and they'll often make two meals and you just don't have time. What do you suggest for the ones who are like, okay, I just don't wanna fight with my kid today and I just want to just have a good meal and sit down with my family and enjoy, but they're creating more stress just because they have to make two meals?

Danielle Griffin: For sure. So typically I recommend just making one meal for your entire family and making sure that what you have available is something that the child who doesn't eat this large repertoire still has something to eat and participate. Even when we're looking at therapeutic meals, sometimes the best time to address and learn about new foods isn't actually during our social family meal. Sometimes it's better to have those food opportunities to learn about food that we don't like outside of our mealtime so that we don't make this kind of negative feeling around what is our family meal.

Dr. Richard So: Yeah, I like what you said where you make stuff that everybody can eat during the meal. For example, one of my kids is like a picky eater and a lot of kids just eat the carbs. But what we'll do at my house is that we we're having steak, we'll also make the pierogis and the kid will prefer the pierogis and the carbs or the potatoes. And what we'll say is that okay, you have to try at least two bites of each meal, but it doesn't mean that you have to like it, but you just have to try the new food. And then the most important thing that you can do is reward them. Good try.

Danielle Griffin: Yes. And for your child, that might be what we call the just right challenge, right? So sometimes when we bring kids to the table, um, especially kids with sensory aversions, the smell or the sight of a new food may already be really overwhelming. So to tell that child that you have to try this new food or take two bites of this new food might be a little too far, like too high of an expectation. So if you have the kid that's crying or running away, when you set that type of boundary, maybe you start with something smaller.

So I might say tonight, like everybody at our table is having peas. I understand that this is a food you're still learning about. You can just leave it on your plate. So by putting it in their personal space, they're getting exposure to the smell of that food and the color and you know, they're learning some properties about it. And over time you may be able to push your child a little farther. The goal is to challenge them a little, but you still want them to feel comfortable and safe at your meal.

Dr. Richard So: Yeah, I heard that there's like 15 steps before the food actually makes it to your mouth. You mentioned smell, you mentioned touch, but sight is one thing too.

Danielle Griffin: Yes.

Dr. Richard So: One thing that parents can do, all right, to introduce your kids to these foods. Number one, when you're reading your books and you're, you're learning your words, you know, you're pointing at the fruits, you're pointing at the vegetables, they learn how to say banana. Take your kids to the grocery store, all right, look and go Hey, which ones would you like to try? They see banana when you get home. That's the first thing they want to try is because they picked that food.

Danielle Griffin: Right.

Dr. Richard So: It could be even a vegetable. Another thing that you can do is involve your kids in the meal. As they get bigger, they can help you cook. Just like even part of the meal. It could be just opening the package, dropping them in the pan without getting burned, alright? And another thing that that I use with my kids is gardening.

Danielle Griffin: Oh, that's a really fun one. Yes. They can pick the, the fruits or vegetables from your own garden and bring it.

Dr. Richard So: Because they're vested in the food. [Mm-hmm <affirmative>.] If you can get your kid vested in the meal, vested in the food, they're more likely to try new things. And then remember up to age four, not if your kid needs three meals and two snacks, alright. One day it'll be three meals next day, two meals and one snack next day just the snacks. alright? That's completely normal. And, and in my practice, most kids up to four, they're in the beige diet. Grilled cheese, mac and cheese nuggets, french fries, chips. That's okay. You win your battles on that one. But when they hit about four, I start to play a little bit more games with them. With food, I try to make the food fun, alright? Or the meals fun. You're not necessarily like forcing them. Like when you have your toddlers, when we eat scrambled eggs, oh, we're eating the flowers today, right?

Danielle Griffin: Sure, yes. You really want to make it a playful activity to explore the food.

Dr. Richard So: Yep. The rice could be snow. Uh, I've made little dioramas with the grilled cheese. Okay. I go, do you want to eat rectangles today or do you want to eat squares depending on how you cut it? Or do you want little triangles or do you want big triangles? I set up a diorama. I set up the Dino nuggets. I make a pyramid with the grilled cheese. The meatballs are the boulders. The broccolis are the trees. Are you gonna eat the broccoli first? Are you going to eat the boulders first? I'm going to eat the boulders.

Danielle Griffin: Yes. This sounds really fun. Um, and as I think about that and all the sensory and play kind of activities and painting with pudding and things that I do with kids, some parents get overwhelmed by the expectation of that in the time and thought process into coming up with those place games. So one thing that I recommend that I think is really simple to implement is what I call a mini meal.

So when you do a mini meal or a therapeutic meal, it should only take five to 10 minutes. And I ask a parent to pick three different foods. Um, so I'm gonna sandwich two preferred foods that the first food that we learn about and the last food that we learn about are things that we like. And in the middle I put a new food or a non-preferred food and I ask the parent to think about on that plate, let's just do everything as one color or everything as one shape so that the child can associate what's similar about the new food to foods that I already like. And we can sit down and play with all of those foods without a whole lot of thought or preparation in the play scheme.

Dr. Richard So: Speaking of that, there, there's some kids who are ultrasensory. I have different levels of pickiness, I have picky, I have a limited eater. And then there's some restricted ones. Just thinking about some of the things that parents ask me in my office, what do you do to the parent whose child only eats one kind of nugget? I don't know what the arches puts, what kind of pixie dust they put on theirs, but the when I try a grocery brand, they won't eat it.

Danielle Griffin: Yeah. So when we talk about processed foods in general, they become very predictable, right? So if I eat this certain brand of chicken nuggets, it is always the same texture and it's always the same flavor. It's likely that my parent always makes it in the oven or always makes it in the air fryer. So it is very predictable to me. We also see this in our snacks. So our crackers, our pretzels, they're always going to be exactly the same. And kids that have sensory needs, um, or even oral motor needs, they grab onto that because they consider that a safe, predictable food. Not to mention that these things have been chemically structured to make saltier, to make us want them more.

Um, in comparison, when we offer something to a child, like a fresh produce, so let's, an example might be a blueberry. Blueberries come in different sizes. So sometimes they're small and sometimes they're large, sometimes they're bitter, sometimes they're sour. So now I've offered a kid a food that should be the same in their mind, but it's actually very different for each exposure. So for those kids that are really like things that are always the same, I try to teach flexibility within that.

So if you only eat one brand of something, can I break it? Can I change the shape but it still tastes the same? Can I offer you two different brands at the same time? And we can talk and learn about how they're different and the same. And then for those foods that are already just intrinsically different, I try to stick to fruits or vegetables that will have less changes. So if I want to introduce a food to a kid that's already very brand specific about their chicken nuggets and maybe I wanna do green beans, I might choose, uh, frozen green beans or canned green beans because they're going to be predictable from one presentations kids to the next.

Dr. Richard So: The kids at school, my kids like, [Oh, for sure] my, my kids like the green beans at school better than the fresh stuff.

Danielle Griffin: They, they add some salt to those.

Dr. Richard So: Yeah. There was a study that showed where kids would only eat a certain fast food cheeseburgers and wouldn't eat the ones at home. But in the study they took dad's cheeseburgers and they wrapped them in the yellow wrapper and it took out the visual aspect and the kids actually ate their cheeseburgers. You think that would work with like nuggets?

Danielle Griffin: Well, so for some kids it, it does work that way. Um, but for a lot of our sensory avoiders, they recognize that something's different. The other thing that I tell families to avoid is hiding food. Because if I have a kid that really is um, you know, let's say your mouth is really sensitive to what you put in there and you hid something in the food, that kid will be the first one to find it and spit it out and let you know that it's in there. And now they may not trust me. So I try to be very transparent about the foods that I'm offering.

Dr. Richard So: Yeah, we, we do that in pediatrics all the time. I tell parents they think that when it's time to give them medicine, that they'll mix it with something. But I agree with you that it does break the child's trust where you're not really fooling a kid because sensory, they can taste that. It doesn't taste what it tastes like normally. And you totally lose that person. That child thinks you're poisoning them.

Danielle Griffin: Yes. And then you're at risk, you lose trust risk for, for a new food avoidance.

Dr. Richard So: Or the kid will get sicker 'cause they won't take their medicine ever.

Danielle Griffin: Sure.

Dr. Richard So: Let's talk about snacks. Toddlers, that's all they want. Snack, snack, snack, snack, snack. And they don't eat their meals.

Danielle Griffin: Yes. So when we were talking about the number of, of meals and snacks in a day, typically I use that three and two rule. So three meals and two snacks for my families that are allowing their kids to graze all day. What happens when we're snacking all day long is the child doesn't receive those interceptive cues, those hunger cues. So really they're eating more for pleasure than of feeling that I was hungry and need to fulfill that.

Dr. Richard So: I agree a hundred percent. So in our office, parents are, they're scared. They're scared that their kids aren't eating, they're not gonna grow, they're not gonna develop. But when we talk about the grazers, alright, to put it in, in other terms, they're like the cows in the field. I get a little bit of grass here, a little bit of grass there, but I'm never really hungry.

So when we talk about your snacks, number one, they should be scheduled. You shouldn't let, you shouldn't have goldfish, a bowl of goldfish on the coffee table where your kid can just run up and do it. No, I like, I like to sit down with my kid in their high chair and we schedule our snacks and we read a book at the same time. And then sometimes I'll play the game. It's like, oh, even during meals, sometimes when you're sitting down I'll play the games. Oh, you want me to turn the page? Oh gimme two more bites. You fight for those bites sometimes.

Danielle Griffin: Yes. I definitely, uh, agree about having a schedule for feeding even when it is snacks because then that creates some hunger windows and the child's body starts to decide when to eat. As far as making healthier snack options, one of the things that we do in my house, I have twin boys who are now eight years old, but it's always easy for them. I feel like most of us have this cabinet in our house or a place where we're setting cereals or dry snack foods that a kid can grab quickly. And so then the kid becomes autonomous in getting that snack. And that's sometimes how grazing happens.

So at my house I have food that I feel is healthier options prepped and ready to go. So, uh, we love cheese blocks. I cut them up, it's already in the fridge and ready to go. Fruits and vegetables are cut up. They often help me cut the grapes, cut the strawberries, we rinse them and clean them. But so then they know the first place to look for a snack is actually not the cabinet, um, where those processed foods are. But to check the fridge first for a choice.

Dr. Richard So: Yeah. Eating out a packages would be the way to go with, with the snacks. And you gotta have some balance, you know, because parents are always on the run removing, you can't put a plum in in your purse during the summertime or something that is more perishable.

Danielle Griffin: Yes. But the caveat to that is I love preparing things in advance in small containers that you can take with you that are healthier options and still give some sensory exposure. A lot of us are in the like pouch territory and when we feed our kids it, it's great you're get this resources for he uh, fruits and vegetables, but then you lose any sensory exposure to those things. And I have a lot of kids that I meet that that's primarily their fruit and vegetable source and then they can't even identify fruits and vegetables when I'm showing them things or asking them what they are.

Dr. Richard So: Yeah, I think it's a cop out to parents to do pouches.

Danielle Griffin: It's easy and convenient.

Dr. Richard So: It's easy, it's convenient, but they don't know what a real apple is when they can just get the apple sauce. Uh, I would save the pouches for the astronauts.

With the holidays coming up. It can be stressful for meal times. Just preparing them. You're spending hours together, you know you have your family's traditions of what you're cooking. How can parents manage the stress of holiday meals and sometimes even just going out to eat when your child's a picky eater?

Danielle Griffin: Yes. There's quite a few things that I recommend. The first is preparing your child for the event. So you want to let them know where they're going and who's gonna be there and what foods that they enjoy will also be available there. So if the child's expectation is that they're gonna go somewhere new and there might not be anything that they like, they might feel a lot of stress around that.

The other kind of hot topic around meals is electronics and I see a lot of families who bring electronic devices to maybe a restaurant. And so what you want to think about is setting up in advance what your expectation for that is. So if you walk into a restaurant with a device and the child is maybe using that as their transitional object or as a distraction and then you decide mid meal that you're gonna take it away, your child has kind of this meltdown or this fight or flight response 'cause now they're upset not just about the food and the social environment but also you've taken away this favorite thing. So if you're using those in any of these social situations, I just lay out the expectations first.

Dr. Richard So: While you're in the car.

Danielle Griffin: Yeah. On your way there. So we're gonna say, you know, we're only gonna use the tablet after we've finished eating and and the grownups are still talking because I know it's gonna be a long wait for you. So those kind of conversations you wanna have in advance, not in the moment when the food is in front of you.

Dr. Richard So: Don’t fear that your kid's not gonna like you, you know, by getting them to eat. Because what is the age limit when you shouldn't be picky?

Danielle Griffin: Mm-hmm <affirmative> Well I will say it's easiest for us to address from a skill standpoint, whether it's sensory development or oral motor development, it's an easier skill for us to address five and under, right? The older you get the the longer that you may need therapy to expand your food repertoire. But the key is that it really shouldn't be a fight or a battle. It should be fun exposure. And when your kid feels in that safe zone, they're more likely to try and to expand.

Dr. Richard So: Yeah, I like that. Adults are picky too.

Danielle Griffin: For sure. We all have preferences.

Dr. Richard So: We all have our preferences. But I think exposing them to as many as you can when you're younger instead of limiting them at an early age and saying, oh they're never going to eat that. No, you have to have that growth mindset. You just haven't tried it yet.

Danielle Griffin: Yes. I always use the term we're still learning about that food rather than I don't like it.

Dr. Richard So: So I have three kids and they were all different. Like my oldest she'll eat anything, she'll try anything. We played the games that we mentioned, you know, hey, turn the page, take two more bites. When they're two years old you fight that, that kid will eat anything, try anything. And then I have another kid who was very, very sensory. The feeding clinic, that's where I learned where there's 15 steps, there's visual, there's touch, there's smell. Even just getting them to that, that's where we started like grocery, getting the cook to the meal. We made those accommodations where we wouldn't make separate meals. There were times where I had to eat mac and cheese and I just had to live with it. And then we, we bargain for those two bites.

Danielle Griffin: But also what it sounds like you did is you shifted the focus from the food to the experience.

Dr. Richard So: That's exactly right because that was part of my family values and part of my family values too at the table is you're not allowed to complain about the food or you can go eat somewhere else, but you still get fed.

Danielle Griffin: Yeah. And I think it's important for grownups to think about that too is the negative, um, stigmatisms that we have about food, food that I don't like. That could be someone else's favorite. So if I'm saying he's never going to eat that or I think that's disgusting. Kids are picking that up. So we almost have to overemphasize our positive experiences with food.

Dr. Richard So: Yeah. So that kid was extreme alright, was limited. She only preferred crunchy. A lot of parents think their kid is picky 'cause they won't eat a few things. I have a kid in my practice, he only eats white foods. My daughter only preferred crunchy foods. There's a kid that I know, he only eats food that's piping hot. It's not hot, it's not, it's not hot. So in the middle of the meal you have to put it in the, you have to put it in the microwave for 20 seconds and then after like two more minutes, it's not hot. It's not hot, it's not hot. Then you have to put it in the microwave again. Those are some extremes. So bottom line is, is when you get someone's sensory, you know, what are the red flags where, first of all, if you have any problems with feeding your child number one, call your pediatrician. But what are the red flags where as a pediatrician I need to call you?

Danielle Griffin: Sure. So at this point I'm definitely recommending like early screening and early referrals. I know...

Dr. Richard So: What ages?

Danielle Griffin: Um, for all ages. So a lot of pediatricians will say, well let's talk about it at the next well child visit. But if in that first visit with a parent they're telling you that their kid's only eating five foods, it's already time. And some parents wait until they're really, really worried before they tell you.

Dr. Richard So: When is you that, what age is too late, do you think in your, in your opinion?

Danielle Griffin: Um, I don't know that there's ever too late, but it's much harder. So if you, if you are referring a child, to me that is 10, we are gonna have a lot more hurdles and a lot more habits to overcome. We're looking at it from a different perspective. A lot of times by that age there's more of a mental health perspective and we have to get a clinical psychologist involved. So I really want to see these kids between their first and fifth birthday. It's like we want to get in there and be...

Dr. Richard So: Ideally I like three to four is when I'll send them 'cause I think six is too late.

Danielle Griffin: Sure.

Dr. Richard So: Because I, you can train a three to 4-year-old, like proper values, eating habits, you know, they can get the buy-in for the cook. But I think by six it's a lot harder [Yes.] because number one, they can fight back.

Danielle Griffin: Now what I will say is often overlooked is around that one year timeframe. So we will see kids that their parents are transitioning, um, them either maybe from purees or just to more solids in general. And that child might be doing some gagging or avoiding or crying at meals. And sometimes what happens at that stage is they haven't developed the oral motor skills to eat foods.

If we don't address it early, these kids then develop sensory aversions because we avoided foods that I didn't have the motor skill for now I haven't had exposure to it. And at three I need a lot more therapy. [Hmm.] A lot of times if you make an early referral for a child who's in that first year and we can address their motor needs, we can eliminate the need for feeding therapy later.

Dr. Richard So: Gotcha. From a medical standpoint, you know, there's, we, when we talk about sensory issues, it can be visual, it can be taste, it could just be the texture in their mouth. It could be smell, but there's other red flags. So from a pediatrician standpoint, my third kid, he wanted to try everything that his sisters tried. And we thought, okay, the girls loved peas. We kept on giving him peas and he would refuse. He would refuse and then he would want to try it. Then eventually he tried it and then he started puking, alright? And you get the kids who puke a lot. A lot of those kids can't be texture kids, but it turned out that my kid was allergic.

Danielle Griffin: Oh sure. Yeah. Food allergies is a common cause for refusal.

Dr. Richard So: Yes. So be careful when you're out there if your kid has like refusing and vomiting after the meal, because some kids, if they're texture kids, they'll vomit behaviorally because they know if they vomit you'll give them a different food. But just be careful for those kids with allergies. My kid ended up also was allergic to pea, which is related to nuts. So he had a nut allergy.

Danielle Griffin: Okay. The, the one thing that I think we really haven't discussed that I just wanna mention, um, being an OT, we've definitely talked a lot about sensory stuff. I know I mentioned this oral motor piece, but just, um, some things that we watch for so a parent might know if their kid doesn't have the motor skills for the foods that they're offering. Um, if you have a child that's gagging with food in their mouth, yes it could be sensory, but it also may be a protective mechanism that I didn't have the skill and I'm trying to protect my airway because I couldn't chew it well enough. And then also watch, if your child is spitting out food that is not fully chewed, they may not have the endurance or if they're pocketing. So we see a lot of kids go away from the meal and there's still food in their cheeks. Those are signs that we may need to work on some skill.

Dr. Richard So: We hope we've helped you feel more confident about managing picky eating. Remember that every single exposure to a new food is a win. So stay confident and keep trying.

If you would like to schedule an appointment with the Cleveland Clinic Children's pediatrician, please call 216.444.KIDS. That's 216.444.5437.

Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts. Or visit clevelandclinicchildrens.org/littlehealth.