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Strategies sought.

Generally healthy happy 4.5 yr old grandson. Eats wide range of foods, including vegetables (broccoli a favourite) some reaction to dairy products so use soya and almond milk. Quite tight control on junk food, few between meal sugary snacks etc.

But mealtimes are stressful because he eats very slowly, needs encouraging to eat a full meal. Generally I would not be concerned; I come from the "if they're hungry they'll eat" school of thought. However he was severely underweight according to medics, and he looked really skinny. So parents worked really hard at mealtimes to get him to eat more, and in terms of his weight he's now back to a more standard weight for his age.

However meal times are a constant battle. Every mouthful has to be monitored. If not prompted he will sit and not take another mouthful. Each mouthful will be chewed or held in his mouth for minutes. He's mentally very alert and imaginative, his attention wanders from the meal. We don't have TV playing or other distractions, all sit together eating the same food. But a single, small plate of food can take well over an hour to consume and this usually requires us to feed him every mouthful, even though he is very comfortable feeding himself - he just seems to forget to do it!

Any ideas for ways to address this?

  • hi and welcome. How did the medics qualify "severely underweight"? And may I ask what country, if that is not too intrusive? – anongoodnurse Feb 21 '17 at 3:21
  • He's in the US. Afraid I don't have the data for degree of under-weight. – djna Feb 21 '17 at 11:42
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    "the parents", are you the parent, a concerned friend, grandparent? This is important to me because it speaks to if you want to make suggestions, or if you can implement ideas. Is the child is seen regularly by a doctor and or perhaps a nutritionist? – WRX Feb 21 '17 at 15:12
  • Grandfather. Edited accordingly. Can make suggestions and implement when involved with feeding. Child has routine check-ups, only problem was his being under-weight; that is addressed by these laborious mealtimes. – djna Feb 21 '17 at 17:41
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"Generally healthy happy 4.5 yr old grandson. Eats wide range of foods, including vegetables (broccoli a favourite) some reaction to dairy products so use soya and almond milk. Quite tight control on junk food, few between meal sugary snacks etc."

Hi, you are a lovely grandpa! I will start from the premise that he is healthy but underweight, and at the same time, ONLY dairy is out. I am also assuming that family diet is very healthy and therefore likely low-fat. I read the issue at hand as possibly (1) too little calories (2) eating slowly/ not really eating despite availability of food.

(1) Both my boys were dairy-intolerant in their early years and my mum is a very healthy vegan who has been cooking low fat for years. One thing I realized very quickly was that it takes effort to put enough calories into little kids without having dairy on standby. Consider that other kids are either guzzling full-fat milk or eating cheese as a very dense form of calorie intake, we have to really make an effort to make up for the loss in calories. Little tummies can't stretch much, and if he has been eating little for a long time, he will feel uncomfortable with a greater quantity. This is physiology. To get around this, you have to give high calorie food in small but frequent quantities.

My kids were not on a low-fat diet, but they were on a healthy fats diet - olive oil, flaxseed oil, coconut oil, sesame oil, avocados, salmon, dairy free-spreads. These were incorporated into their meals to up their calorie intake. I gave them a lot of potatoes as well in the form of mashed potatoes, in beef stews and as baked wedges because I read that potatoes were the best starch for putting on weight.

My boys loved vegetables and fruits, but I had to make sure that they were not taking so much of that that they could not fit in their carbs and proteins.

If your grandchild is taking low-fat snacks (eg vegetable sticks etc), the caregiver can perhaps add a high-calorie dip (hummus) or switch it up sometimes with something more calorie dense such as muffins or granola bars.

(2) There are perfectly sound reasons why a child may not be eating despite availability of food. One is allergic rhinitis which affects the sense of smell, which in turn suppresses appetite. Signs of this are runny nose in the morning, puffy eyes, possible snoring at night. Another is zinc deficiency which also affects the appetite. If he has not been eating enough for a period of time (eating enough as opposed to wide variety), it may be a good idea to add a multi-vitamin with zinc.

For actual mealtimes, I will go with three guidelines - tasty, visually attractive, easy. Tasty to him, attractive to him, easy to him. Both my children are on a fairly healthy diet but they still have very distinct preferences when it comes to textures and certain smells. E.g ds1 loves thigh meat and raw salad, ds2 eats only breast meat and prefers cooked vegetables. So you may want to take note of the flavours and textures that your grandson enjoys and come up with a list of corresponding dishes. Just make sure that there is at least one meal that he does like everyday.

Since he is very imaginative, the caregiver can perhaps create theme plates around favourite movies/shows e.g http://www.boredpanda.com/creative-bento-food-art-samantha-lee/ We can't all spend so much time making these, but perhaps the images can provide some ideas.

  • Thanks. Very helpful. Several ideas here that seem promising. – djna Feb 22 '17 at 14:56
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Do realize that the battle over eating is also giving your child attention from you.

Switch gears and try to plan something fun to do together after mealtime. Don't battle directly about the eating itself. Just say that when the child has finished plate that then you can do the fun thing. Think of 3-4 ways to say this.

  • After you finish your meal do you want to do X or Y?

  • When you finish eating we can do X.

  • I hope you finish soon, I want to do X with you.

  • Not finished yet? I hope we still have time for X.

  • I think we need to figure out some intermediate step. The whole meal looks like too remote a target. Problem is just endlessly taking ages to swallow a mouthful and then forgetting to take another one unless prompted. – djna Feb 21 '17 at 17:43
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    @djna this is why small plates work. I am also put off by too much food. We eat our meals off bread and butter plates. – WRX Feb 22 '17 at 22:34
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I believe @Willow Rex is right in recommending a nutritionist consult. The parents can ask their doctor for a referral.

Until then, maybe making foods available which just don't tend to spend a lot of time in the mouth might help. Pureed soups can be nutritious (and calorie dense, if necessary), but they can't be chewed very much. Smoothies can also be very nutritious, and, again, not really a chewy food.

Soft, moist foods (e.g. mashed potatoes, pasta) are often less chewy than, say, roasted meat. Choosing to offer foods in soups, casseroles, etc. might help.

If it's calories that are needed, ice cream is always welcome! You can also make milkshakes with Ensure (a nutritional supplement) as the predominant ingredient.

Having said that, I am of the school you mentioned: a child won't starve in the presence of food. It sounds like those involved are lucky in that the child chooses to eat a wide variety of healthful foods.

I am also of the school that parents who obsess over every bite will not reap many benefits for their stress. Food consumption is best done in a low stress environment.

Growth curves (e.g. weight, height) measure populations by averages and percentiles. Someone has to be on the lower end, and that is normal. Without other accompanying problems, many doctors don't worry until the child falls below the 5th %ile.

According to the AAP:

"My child sometimes dawdles during meals. What can I do?"

It is normal for children to lose interest in an activity, including eating, after a short time. They are also easily distracted. Try to reduce distractions (eg, turn off the television) during meals and snacks.

Routines are important to children. Schedule meals and snack

I was very "skinny" as a child and young adult. Unfortunately, I was teased about it by my parents and siblings. As a result, I used to overeat. I often ate ice cream, added raw eggs to shakes to supplement calories (when doing that was considered safe), etc.. I stayed skinny until I was 29, when I broke 100 pounds for the first time. Now I wish I still had that metabolism!

My point is that parents should not show judgement or worry over eating unless it really is a problem, as judged not only by a doctor, but by a nutritionist. It really stays with a child.

Prevalence of Underweight Among Children and Adolescents Aged 2–19 Years: United States, 1963–1965 Through 2007–2010
How to Feed Children (Ellyn Satter Institute)
https://brightfutures.aap.org/Bright%20Futures%20Documents/BFNutrition3rdEditionSupervision.pdf

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There are many ways to deliver good nutritious foods in tiny and fun bites. Tiny pieces go down more quickly than things that look large. Milkshakes and smoothies, pureed soups are great too. Put out a bowl of cut up melon or grapes, tiny pieces of cheese, nuts, perhaps your grandson is a grazer. Try peanut butter on little cookie cutter shaped breads, put a grape or nut or banana slice on a few. Maybe distraction might get snacks down him, as many people overeat while watching TV. Meals are best at table though.

@Anongoodnurse said it perfectly, so all I am adding is a few recipe-type ideas. I love small containers, so try little tiny plates and a child's tea set for delivery. Make themes, Harry Potter magic supper or Super Mario or other cartoon character shapes and themes. Let your grand help prepare foods.

You might try some the the kid food shows and talk about good food in a way that is about the prep and enjoyment rather than eating. Try teaching him to cook if he shows any interest.

Take the focus off eating and into other aspects of food. Visit farms, or markets -- even the normal grocery store whets an appetite.

No pressure while being mindful seems like a good way to go. I would love to know what you do and what helped. I am certain that your grandson will come around.

My brother eats to live, and is thin. He had tooth pain for years as a child, so you might suggest that during the next dental visit that the parents mention that eating is a problem, just to rule out any dental issue.

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But mealtimes are stressful because he eats very slowly

So he chews for long or he stop eating. if he chews that is actually good and you should also learn to eat well and make him learn how to eat, children naturally knows how to breath and eat (We breath from upper chest but children breath from stomach which is better)

And if he does not chew tell him about his incredible body, children are always curious of new knowledge, tell him how food goes inside and how stomach is also called the second brain

See its not his problem it is yours, because we are supposed to make them understand in a better way.

Also chew 50-60 times to drink your food and chew your water term, it will be better for you as well.

small plate of food can take well over an hour to consume

This is a problem because human brain send signal to stomach after 15-20 minutes of chewing that you have had enough food and we feel full.

So ask him to chew 40 times and then next, this will also enhance his imaginative mind more focused as well.

You have to make the eating food a interesting task, but in a very efficient way (including no speaking only eating consciously).

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