There were many, many children all over America who had feeding problems in the 1930s, when I started pediatric practice. This was primarily because with new knowledge about nutrition but with only meager understanding about children’s emotional development, doctors where taught in medical school that it was their responsibility to impress mothers with the need for a carefully balanced diet, sufficient calories and vitamins, on a rigid and regular schedule. So conscientious physicians put the fear of God into conscientious parents, and children’s stomachs rebelled.
Today when physicians recommend flexibility with choice of food and amounts at each meal, there are many fewer eating problems but there are still some. A few cases of poor eating in childhood are due to chronic illness; but in most of these cases, the appetite was good up to a point but then turned poor. In a child with a chronic disease, there are other symptoms of illness.
Children all have different patterns of development. Some are born to be tall, others short. Some are heavy-boned, others slender-boned. Some are muscular others not. Some put on weight with the greatest of ease even though they appear to be eating lightly; others eat huge meals and remain skinny. It’s very hard for some parents to accept these individual differences. They have a picture of the ideal boy or girl in mind and can’t help but consider any other shape as unfortunate and needing correction. These parents may be unhappy if a daughter is big-boned and overly robust or if a son is short or delicately structured.
A moderate number of fair eaters are eating and growing well enough according to their genetic patterns, which considers the growth of their parents and other members of the family. Their low normal weight levels and small appetites have been that way since birth, so they aren’t the result of pushing or forcing. They aren’t really having eating problems except that their parents would like them to be huskier in build and heartier in appetite. But the parents are too wise to be urging all the time, realizing that this would only lower the appetite further.
It’s important to make this point about parents who are unhappy about their children’s genetically determined shapes because the more they urge slender children with naturally small appetites to eat a little more, the more they depress their children’s appetites. Or if they try to hold back on the intake of a plump child, they may increase her craving for food and they may tempt her to cheat between meals.
The great majority of children who are poor eaters don’t start that way but are made that way because at some period of their development their parents became anxious and tried to push or force them to eat more than they wanted.
I remember, way back in my own childhood, when I was lying in bed with a fever and smelled the lunch cooking in the kitchen and how disgusted I felt that anyone could eat something that smelled so bad. Often it takes a number of days after an illness for the appetite to return. A parent who has been concerned about the total lack of appetite during the feverish stage finds it particularly difficult to refrain from urging a child to eat as soon as the fever subsides. Yet this is a crucial period, for a temporary loss of appetite during sickness can be turned into a permanent poor appetite in just a few days if food is pushed during this period of aversion.
If you can wait a few more days, you’ll be rewarded by a better-than-ever appetite when the body has rid itself of the infection. I remember a few occasions when the appetite eventually rebounded with such vigor that the mother called me to ask if any harm could result when a child not only ate huge meals but sometimes begged for more an hour after a meal was done. So patience and trust in nature are the treatment and the way to the prevention of feeding problems after illness.
There are other typically critical times when problems begin. One, as you can imagine, is when a premature baby is finally brought home from the hospital after weeks of worry. He weighs enough that the doctors consider him out of danger, but he may still look like a starving creature to the parents. It’s very hard for them to avoid worrying and pushing as much milk as they can get into the small baby. Since the temptation is so great, so is the need for the parents to train themselves from the start to stop the feeding at breast or bottle just as soon as the baby loses interest. Don’t try to “get in just a little more.” You may succeed, but at the cost of reducing the appetite for the next feeding and the next and the next. It’s a losing game.
Some eating problems begin with the introduction of solid food, if the doctor seems to imply, or if the parent gets the impression elsewhere, that the baby will be eager to gobble up more each day. Actually, it takes babies a number of days to get used to the first solid foods: the hard spoon, the sticky consistency, the need to work the food from the front of the mouth to the rear where the swallowing mechanism can get hold of it. The whole business is so strange that most babies have a facial expression that looks more like disgust than eagerness! They leave their tongues in the front of their mouths as they work their jaws up and down, so that nine-tenths of the food is pushed right back out of the mouth onto the chin. But after four or five times, most of the teaspoonful has been swallowed.
Don’t attempt to get more than a teaspoonful in until the baby has learned the trick and is showing a little eagerness. This may easily take a week or two. I’ve often heard parents say, “If I try once more, I often get one more teaspoonful in.” It seems like a gain at that meal, but over the weeks and months it works against appetite. Stop spooning any food just as soon as you see the slightest sign of lack of enthusiasm, not when the child finally turns his head away or clamps his jaw shut. That’s the way you keep his appetite high.
Cereal is the traditional first solid food, but stewed or pureed fruit in jars, such as applesauce or raw ripe mashed banana, arouses enthusiasm sooner, so I think it’s a preferable first solid. Since babies have been on just milk up to this time, many of them are frantic for breast or bottle when hungry and are frustrated when offered the unmanageable teaspoon of solid food first. If so, give the breast or bottle first. Later, after the baby has learned that solids satisfy hunger too, you can give the solids first.
Occasionally a baby seems to lose some of its appetite around six months of age. This is a time when the monthly weight gain, which may have been averaging one and one-half pounds, is apt to drop down to a pound or less per month, with a corresponding drop in eagerness for food. It’s also a time when a baby develops new skills that stimulate a greater interest in other things around her. Sitting up without support lets her experience her parents and other things from a different view than when she was on her back. Reaching out and grasping an attractive toy with recently developed hand skills and back-and-forth baby talk are other activities that may distract some babies from a major interest in food.
The most common time for the start of a feeding problem is between twelve and fifteen months. For reasons that I don’t fully understand, a majority of babies turn against some foods that they took willingly enough before. One factor may be that their weight gaining now declines to half a pound per month. Another factor may be the baby’s increasing sense of their individuality and their impulse to make their own decisions about the foods they prefer. Most frequently rejected is some or all of the vegetables. Why these aversions to formerly accepted foods? Perhaps we will know some day. Some of them last only a few days, other for months, others for life. Many adults too experience shifts in appetite. Is it that infants’ bodies have enough of some ingredients for the time being? Is it because body growth continues to slow down, until the puberty growth spurt? In any case we need to respect these variations because we only make matters worse by trying to interfere.
You don’t need to worry or insist that the baby eat an undesired food. Serve the food that the baby still enjoys. Try a new vegetable that is easy to swallow. If all vegetables are turned down, remember that fruits and milk will cover the same nutritional needs as vegetables did. Your doctor may suggest a daily multivitamin during this brief period when certain foods are rejected by your baby.
A second food that is often rejected at this time is cereal, particularly for supper. You can branch out into other oat and whole wheat cereals—cooked or “dry.” You can offer breads, toast, plain unsweetened crackers made from whole wheat, rye, or oats. These are just as valuable as cereals.
A third food whose intake is often reduced at about a year of age is milk. This is particularly apt to alarm parents because milk has the reputation of being the cornerstone of nutrition at this age. But if a small child continues to take a pint of milk a day on the average, this should cover the needs for calcium and good protein. If the average intake of milk continues to fall below a pint, you can make the cereal with milk, mix soup with milk, offer small pieces of cheese. An ounce of firm cheese contains as much calcium as 8 ounces of milk. If all of these milk substitutes are rejected, the doctor can prescribe a calcium supplement.
Fruits continue to retain their popularity in a great majority of children. During the second year of life, vegetables, cereal, and milk usually regain their appeal, provided the parents haven’t made an issue of them.
In preventing or treating feeding problems in the one-year-old, it is crucial that the child be feeding herself, which children can do by fifteen months if encouraged. I’ve heard parents say, “She can eat the fruit by herself but I have to feed her the vegetables.” No! No! If she’s capable of feeding herself one, she’s capable of feeding herself the other. To go on feeding her the vegetables keeps reminding her that she doesn’t really like them and increases her aversion. Give her more opportunities to lead the way and to learn to enjoy feeding all foods to herself.
Let the one-year-old learn to use a spoon as soon as he shows the ambition. The sooner he takes over the feeding the less temptation you’ll have to urge. You’ll have to put up with the mess. For if you wait to let him hold his own spoon until he’s skillful, he may have lost that particular ambition and just wait for you to feed him. While he’s learning the use of the spoon, you can be using your spoon to feed him at the same time.
The treatment of poor eating is simple enough to prescribe but very difficult for most parents to carry out. It is to offer the baby or child only those foods which are appealing at the present. There is no need to urge or bribe or threaten … or scold. I mean this literally even if, as I’ve seen in a couple of families, the child was down to peanut butter on saltine crackers. Is this a good diet? No, but it will ward off starvation. And I don’t know any other way to work at it. After the child has been on a diet which he enjoys for a month or two you can try, very casually, to introduce a food he used to like. Whether or not he eats any of it, try another once-liked food in another month. Don’t be in a hurry. Don’t scold or argue or make an issue. Be friendly. Eating is meant to be a pleasant ceremony, not a battle.
My main point is, what is the alternative? I know that you can’t force a child to eat what she dislikes. So all you can do, aside from providing substitutes that the child still likes, is to accustom her to think of mealtimes as pleasurable again and hope that over a period of months and years she’ll forget some of her aversions and try these foods again. I know it can happen if the parents are able to discipline themselves not to offer rejected foods again for at least six months and not to force a food that the child dislikes. Serve small portions, to encourage the child to have to ask for more instead of the large helpings you’d like her to eat but which make her say—or feel—“I can’t eat all that!” As a teenager, I eventually got to love squash that nauseated me at four years of age.
Will a lopsided diet lead to disease, either a nutritional deficiency disease or infection due to lowered resistance? I have dealt with dozens and dozens of feeding problems, some of them quite severe, but I’ve been surprised that none of them have shown evidence of either type of disease. One possible and likely explanation is that the published standards for what are considered ideal intakes of all the elements in a proper diet are set at very generous levels, to be on the safe side. To express this the other way around, when a dietary element is in short supply the body can make do with considerably less than an ample supply.
You can see that the prevention and cure of feeding problems, at whatever stage of development, is really the same: