Chapter 4
Nutrition and Allergies: Building Blocks for Successful Eating
Parents of picky and problem eaters naturally worry about their child's nutrition. The narrower a child's diet, the more likely they're missing essential nutrients. Understanding your child's nutritional needs at different ages and recognizing signs of malnutrition or food allergies is crucial for effective intervention.
Malnutrition symptoms range from mild to severe and include fatigue, low energy, dizziness, irritability, poor growth, underweight, weight loss, dry skin, poor immune function, painful joints, hair loss, brittle nails, loss of appetite, and shortness of stature. In developed countries, severe malnutrition is rare, but children may suffer from mild deficiencies of specific nutrients like iron or calcium.
Food allergies, which have increased dramatically over the past three decades, can also contribute to feeding problems. A food allergy is an immune response to a protein in food, not to fat or sugar. It occurs when a child's immature GI tract allows large protein molecules to enter the bloodstream and contact immune cells, forming antibodies. Children are most vulnerable during their first three years when the GI lining is highly permeable. As the tract matures, cell junctions tighten, preventing passage of allergy-causing molecules-explaining why many allergies resolve with age.
Over 90% of food allergies in young children involve seven foods: milk (most common), eggs, soybeans, wheat, peanuts, tree nuts, and shellfish. Symptoms typically develop quickly after exposure-within minutes to hours-and include wheezing, breathing difficulty, itchy rashes, vomiting, diarrhea, nausea, abdominal pain, and swelling around the mouth and throat.
Establishing proper nutrition requires understanding age-appropriate feeding milestones. For infants, breast milk or formula provides primary nutrition for the first year, with solid foods introduced between four and six months when babies show developmental readiness-good head control, sitting with support, interest in food, and control over tongue protrusion. Starting solids teaches crucial eating skills while breast milk or formula still provides primary nutrition.
For toddlers, who naturally eat less as their growth slows after the first year, establishing a firm schedule of three meals with two to three snacks daily, spaced 2-3 hours apart, helps prevent "grazing" that can lead to poor nutrition. Portion sizes should be small-about one tablespoon of each food per year of age.
Many parents overlook how liquids affect toddlers' appetites. Drinking before meals dampens hunger, leading to food refusal and mealtime behavior problems. Offer liquids only with meals and snacks, providing water between meals if your child is thirsty. Limit milk to 16-20 ounces daily and juice to 4-6 ounces.
For older children and teens, maintaining family meals despite busy schedules preserves the social aspects of eating. Teens experience rapid growth requiring increased nutrients, particularly calcium (1,300mg daily) and iron. Social events can be stressful for children with limited diets, making gradual dietary expansion through food chaining particularly important as children age.
Chapter 5
The Oral Motor Connection: When Bodies Struggle to Eat
Many feeding problems stem from difficulties with the physical mechanics of eating. Speech therapists evaluate what a child eats well and why, determine appropriate utensils, bottles, nipples and cups, and select safe food consistencies based on the child's oral motor abilities.
Warning signs of oral motor or swallowing problems include loud or gurgling swallows, coughing during meals, watery eyes while eating, increasing congestion during feeding, weak sucking, formula spillage from the mouth, fatigue while eating, color changes around the mouth, mouth breathing, food refusal, multiple swallows per bite, poor chewing, food remaining in mouth after swallowing, excessive drooling, limited liquid intake, labored breathing while eating, gagging, frequent unexplained illness, and poor sleep patterns with mouth breathing.
Dysphagia-difficulty swallowing-occurs when food or liquids don't pass easily from mouth to stomach. Swallowing involves three stages: oral preparation (voluntary chewing and pushing food back with the tongue), pharyngeal stage (food enters throat, epiglottis closes to protect airways), and esophageal stage (involuntary movement of food through esophagus to stomach). Swallowing disorders occur when any of these stages malfunction.
Four-month-old Isaac was brought in for choking during bottle feedings after experiencing pneumonia twice. Evaluation revealed he was aspirating formula into his lungs due to using a fast-flow nipple and having weak sucking skills with poor lip seal. The solution involved switching to a medium-flow nipple, slightly thickening his formula, positioning him upright during feedings, and therapy to improve his lip seal and sucking strength. Early intervention was crucial to prevent feeding refusal and ensure proper development of feeding skills needed for future milestones.
Selecting appropriate feeding equipment is crucial for eating success. The right equipment can significantly impact a child's ability to eat safely and comfortably. For pacifiers, opt for long and narrow-shaped ones that encourage correct tongue placement. When selecting nipples, standard-shaped options like Gerber or Evenflo help babies learn tongue cupping-a vital skill for collecting and moving food cohesively. Flow rate matters tremendously; if liquid spills from your baby's mouth, try a slower flow rate.
For spoons, consider both material and shape. Soft-bowl spoons work better for children who dislike hard objects in their mouths, while hard-bowl spoons help position the tongue correctly. Match the spoon size to your child's mouth. When selecting cups, choose one with a spout your baby can easily seal their lips around and that doesn't flow too rapidly.
These seemingly small details can make the difference between a child who eats comfortably and one who struggles at every meal. When the physical act of eating becomes easier, children can focus on exploring new tastes and textures rather than just managing the mechanics of getting food safely into their bodies.
Chapter 6
The Sensory Experience of Eating: Why Texture and Taste Matter
When children have sensory processing disorders, eating becomes stressful rather than enjoyable, causing them to limit their diets to only "safe" foods they can handle from a sensory perspective.
Sensory processing is how our brains interpret, organize and use the constant stream of sensory information we receive. When functioning properly, our brains filter essential information from irrelevant input, allowing appropriate responses. A disruption in this process affects a child's ability to recognize and respond to sensory information appropriately, impacting all areas of life, including feeding.
Children with sensory processing disorders may show various food-related symptoms: sensitivity to temperature, texture, and smells; heightened or diminished awareness of flavor; difficulty using utensils; avoidance of touching foods; frequent unintentional spilling; chewing with mouth open; biting fingers while eating; dribbling food; fidgeting during meals; variable attention; frequent hand-wiping; and disliking carbonated beverages.
Beyond the five familiar senses, sensory processing involves three specialized "power sensations": vestibular (body movement in space), tactile (touch input), and proprioceptive (awareness of body parts in space). When these systems function properly, children feel secure, engage in friendships, handle new situations, maintain attention despite distractions, navigate physical challenges confidently, eat varied foods, and perform daily motor tasks.
The tactile system profoundly influences learning through touch receptors under the skin. It distinguishes between light touch (diffuse, alerting) and pressure touch (slow, calming, discriminating). Children with tactile processing issues often prefer bland, textureless foods and have extremely limited diets because they're uncomfortable with certain sensory properties of foods. Many become increasingly selective as they grow, seeking predictable, familiar foods to avoid sensory overwhelm.
Children with sensory modulation disorder may be underresponsive (decreased sensitivity), overresponsive (increased sensitivity), sensory seekers (craving more stimulation), or sensory fluctuators (alternating between under and overresponsiveness). Each type affects mealtime behaviors differently:
Underresponsive children have nervous systems that don't always recognize incoming sensory information. At mealtimes, they appear oblivious to the experience, struggle to differentiate tastes, temperatures, textures, and smells of foods, often describing most foods as tasting the same. They may drown food in spicy condiments to enhance taste perception.
Overresponsive children feel sensation too easily or intensely, experiencing constant sensory bombardment. At mealtimes, these children are extremely picky eaters with heightened sensitivity to food smells. They often avoid meals because the environment overwhelms them, appear to lack appetite, and avoid touching food.
Sensory seekers have nervous systems requiring enormous amounts of stimulation, which they thoroughly enjoy. During meals, they may become absorbed in exploring food's sensory properties and have difficulty transitioning to other tasks.
Sensory fluctuators alternate between underresponsiveness and overresponsiveness with no predictable pattern. One day they might crave intense sensory experiences and completely avoid them the next. At mealtimes, their behavior is highly unpredictable.
Children with feeding aversion (oral defensiveness) fear mouth-related interactions, believing they'll cause discomfort or pain. This results in negative responses to food tastes, smells, and textures. Feeding aversion can stem from sensory processing disorders or medical procedures like feeding tube placement.
In today's fast-paced world, family meals are less common, yet sitting together and teaching children about different foods is crucial for broadening their food horizons. Without exposure to varied foods, children won't learn to manage complex sensory information needed to eat challenging foods like raw vegetables, tough meats, or slippery fruits.
Chapter 7
Breaking the Cycle: Addressing Negative Mealtime Behaviors
A child's negative mealtime behavior often communicates underlying issues with feeding. By interpreting these behaviors, parents can identify where the feeding process breaks down. While some children use negative behavior for attention, most negative mealtime behaviors indicate sensory issues with food.
Research shows only 12% of feeding disorders are purely behavioral in nature, with most cases involving medical conditions, oral motor problems, or sensory processing disorders. Understanding your child's learning style helps address feeding problems effectively. Visual learners absorb information best through seeing and closely observe facial expressions. Auditory learners process information best through listening and talking, while kinesthetic learners learn best through physical movement and "hands-on" experiences.
When assessing your child's mealtime behavior, assume there's a valid reason for food protests. Look for clues by considering pre-meal activities: Did they drink milk or juice or snack before the meal? What kind of day have they had? Have they been rushing between activities?
Food refusals often stem from deeper issues than just readiness to master feeding skills. When babies experience milk spilling from their mouths during bottle feeding, it often indicates the nipple flow is too fast. This frightening sensation makes babies feel unsafe, as if they're drowning. When babies refuse spoon-feeding, it's often because they're developmentally not ready. The transition to table foods represents a major developmental challenge. Unlike pureed foods, table foods require chewing and manipulating food to the center of the tongue before swallowing.
Positive reinforcement is a powerful tool for improving mealtime behaviors. The strategy is simple but effective: ignore negative behaviors while giving attention only to behaviors you want to encourage. Even telling a child to stop misbehaving or offering alternative foods actually rewards the negative behavior.
When children throw or spit out food, positive reinforcement means ignoring the negative behavior while praising eating. If a child continues throwing food after being offered something they typically enjoy, turn their high chair away briefly without speaking, then try again. If the behavior persists, end the meal-though this is difficult for parents worried about hunger, children won't go long without another opportunity to eat.
For children who won't remain seated during meals, set clear expectations and create a monitoring system before mealtime. For example, "When we finish eating, you may get up. If you sit until we're done, we can watch a DVD afterward." Provide verbal praise while they're sitting: "Thank you for sitting in your chair" or "I'm proud of how you're sitting."
Making mealtimes enjoyable is crucial for picky eaters. A relaxed approach helps children become more receptive to trying new foods and supports food-chaining success. Strategies include creating pretend grocery shopping games, giving children limited control by allowing them to choose between two or three options, using plastic baggies as gloves to explore foods safely, using cookie cutters to transform foods into fun shapes, making food visually appealing, and involving children in meal preparation.
Chapter 8
Food Chaining: The Path to Dietary Expansion
Food chaining is a carefully crafted approach that introduces new foods gradually and non-threateningly by building on a child's current preferences. The method works on the simple principle that children eat what they like. First, examine your child's core diet for patterns in taste, texture, temperature, and consistency. With this knowledge, introduce new foods that closely resemble accepted ones, then gradually introduce items with slightly different flavors and textures.
For example, if your child loves McDonald's chicken nuggets but you want them to eat grilled chicken, start by offering different brands of nuggets, then introduce differently textured nuggets, then other breaded items like popcorn shrimp, and finally grilled meat with accepted sauces. Food chains aren't linear but branch in many directions based on your child's responses, with progress tracked using rating scales.
The food-chaining process uses specific terminology: Core Diet refers to foods your child reliably eats across all settings. Flavor Mapping analyzes your child's flavor preferences to determine which new foods to target. Flavor Masking uses condiments or sauces to cover new foods initially, gradually decreasing the amount to let the child experience more of the target food's flavor. Transitional Foods are favorites used between bites of new foods to cleanse the palate. Surprise Foods are novel items offered weekly as special treats, often prepared together with the child.
The food-chaining rating scale helps assess a child's reactions to new foods and tracks changes in taste and texture preferences over time. Foods are rated from 1 (low approval) to 10 (high approval), with results recorded in a journal to share with the feeding team during weekly check-ins.
When offering new foods, follow a sensory hierarchy-your child must first tolerate being in the same room with a new food before progressing to sight, smell, touch, and finally taste. Never overwhelm your child by changing all foods at once, and consider modifying rejected foods rather than giving up. Recognize that certain foods like meats, fruits, and vegetables are particularly challenging due to their textures and will likely come later in the food chain.
Two-year-old Braden's food-chaining program began after medical evaluation revealed significant gastroesophageal reflux requiring medication. His nutritional assessment showed he needed structured meals and snacks rather than grazing. The team recommended scheduled meals limited to 20-30 minutes, gentle appetite manipulation, self-feeding opportunities, and consistent parental responses.
Braden showed strong preferences for crunchy foods, smooth peanut butter, salty tastes, and warm or room-temperature foods. His food-chaining program built on these preferences: For crackers (Ritz, Club, Cheez-Its), they tried adding varieties like Ritz Bits with fillings, Goldfish, or thin-crust pizza. With accepted meats (fried chicken, nuggets, fried fish), they maintained rotation while introducing bacon as a new crunchy, salty option.
Eight-year-old Melissa's parents sought help because she ate only six foods and would gag or vomit when trying new ones. Despite normal medical and oral motor evaluations, she showed significant sensory issues and strong preferences for foods with uniform textures. The team recommended offering only highly tolerable foods initially, implementing scheduled meals and snacks, and family therapy to help everyone understand Melissa's sensory concerns.
For successful food chaining in educational settings, all caregivers must be informed about and committed to the child's feeding program. Parents should facilitate communication between therapists and school staff, possibly through visits, videos, or written recommendations. Schools can support children by minimizing cafeteria distractions, monitoring food consumption, accommodating special food needs, and helping with food storage or preparation as needed.
Chapter 9
Special Approaches for Special Needs
Children with special needs often have feeding problems that must be addressed despite their primary diagnosis. Though parents may feel overwhelmed by existing medical appointments and concerns, addressing nutrition through food chaining brings significant benefits-improved hydration, protection from aspiration, better sleep, and making food enjoyable rather than dreaded.
One in 150 children is diagnosed with autism, affecting more children than pediatric cancer, diabetes, and AIDS combined. Many autistic children have global sensory issues, reacting negatively to textures, tastes, and smells. They often eat in unusual ways-separating food components, preferring uniform textures like crackers and chips, and rejecting substitutes. Many prefer drinking to eating and don't naturally associate hunger with eating.
Alicia Hart describes raising her autistic son Ewan through the lens of perspective and instinct. Her breaking point came during a family dinner when Ewan couldn't tolerate sitting at the table while they ate shrimp creole, hyperventilating and shaking with distress. Through food chaining therapy, Alicia discovered Ewan didn't instinctively understand the purpose of food. Progress came when he watched shows about how foods are made, which fascinated him and made him willing to try these foods.
Children with autism struggle to interpret, organize, and act on sensory information, making mealtimes overwhelming. They're bombarded by sensory input-lights, people, noise, chair feel, clothing, food aromas, textures, and tastes. Many prefer foods with uniform textures that don't change when chewed, finding meat, fruits, and vegetables aversive due to their complex textures. Unable to predict food textures, an autistic child may freeze with food on their tongue, forgetting how to chew as their brain processes competing sensory inputs.
Research suggests that foods containing gluten (protein in wheat, oats, rye, barley) and casein (protein in milk) may affect autistic children's neurological processes. The opioid excess theory proposes that incomplete digestion of these proteins creates peptides that act as opioids, disrupting neurotransmitters and causing behavioral changes. While this diet remains experimental, parents considering it should consult their pediatrician and understand its implications.
Children with Down syndrome have health complications beyond typical childhood illnesses-about 40 percent have congenital heart defects, and they experience higher rates of infection, respiratory, vision, hearing problems, and thyroid conditions. Their weak muscle tone affects feeding abilities, making breastfeeding difficult and slowing the development of sucking, swallowing and chewing skills.
Visual impairment affects how eyes and brain work together to process images. Since early development depends heavily on visual feedback for practice and refinement, vision impairment profoundly affects feeding skills. These children benefit from coordinated care between occupational therapists, speech pathologists, vision specialists, early intervention providers, and family. Effective interventions include color-contrast place settings, sensory trays, rope lighting to outline eating areas, and techniques that facilitate independence while teaching children to explore food using their other senses.
For children who are undernourished, tube feedings may be necessary. Tube feedings support children who are premature, failing to thrive, or have conditions like dysphagia, aspiration, heart disease, neurological impairment, or structural anomalies. Transitioning from tube to oral feeding requires that the child's medical condition be resolved, they be well-nourished, show interest in eating, and find it pleasurable.
Chapter 10
From Mealtime Battles to Family Celebrations
The food chaining approach transforms how we understand and address feeding problems in children. By recognizing that most feeding difficulties stem from underlying medical, sensory, or oral motor issues rather than behavioral defiance, parents can shift from frustration to compassionate problem-solving.
The multi-disciplinary approach-involving pediatricians, dietitians, speech therapists, occupational therapists, and psychologists-ensures that all aspects of a child's feeding challenges are addressed systematically. This comprehensive evaluation identifies the root causes of feeding problems and creates a tailored intervention plan that builds on the child's existing preferences and abilities.
What makes food chaining so powerful is its gentle, gradual approach to dietary expansion. Rather than forcing children to eat foods that trigger sensory aversions or physical discomfort, it creates bridges between accepted foods and new options through carefully planned modifications. This respects the child's sensory experience while slowly expanding their comfort zone.
The success stories throughout the book-from Colin who expanded from five foods to over thirty, to Bart who reduced his dependence on tube feeding-demonstrate that even the most challenging feeding problems can improve with the right approach. These transformations don't just improve nutrition; they fundamentally change family dynamics by making mealtimes enjoyable rather than stressful.
Perhaps most importantly, food chaining empowers parents with understanding and practical strategies. By learning to interpret their child's behavior as communication rather than defiance, parents can respond more effectively to feeding challenges. The structured approach to introducing new foods provides a clear path forward, replacing the desperate cycle of bribes, threats, and power struggles that characterize so many family meals.
Through food chaining, children learn that eating can be safe and pleasurable. Parents discover that mealtimes can be opportunities for connection rather than conflict. And families find their way back to the true purpose of sharing food-nourishing both body and relationships in an atmosphere of acceptance and joy.
