Nutrition Month: The Growing (and Sometimes Picky) Toddler

 
It’s week four of the National Nutrition Month series!  Emily LaRose, nutritionist at Children's Hospital Los Angeles, is back again, providing valuable insights into how to navigate the nutritional needs of your cardiac toddler. Thank you, Emily for partnering with Sisters by Heart to share your knowledge and advice with our families!
In this post, I am going to provide some resources and tips to address some of the challenges we face in trying to feed toddlers.  We all know that feeding a toddler can be tough!  The postings I make on this site are my own personal opinions and do not reflect the opinions or views of Children’s Hospital Los Angeles.
 
Growing (and Sometimes Picky) Toddlers
Feeding a toddler can be a challenge.  As kids grow, they develop all sorts of preferences that can change without notice.  One day broccoli looks like ‘little trees’ that are fun to eat… and the next day there could be meltdowns about the mere presence of broccoli on a plate.  So what is a parent to do?

In short, it is best to stay calm.  One of the most important things to keep in mind about feeding a toddler is that eating shouldn’t be a battle.  Sometimes toddlers exert the little control they have over their ‘world’ at the dinner table.  It’s part of learning and development.  In theory, eating is the one thing that a toddler can decide not to do… and there’s not much you can do about it (in the very short term).

There are a number of feeding experts around though Ellyn Satter (http://www.ellynsatter.com/) is widely known for her realistic and practical approach to feeding little ones.  She has a great website that’s full of tips for parents of young and picky kiddos, and she has a book called Child of Mine that should be required reading for anyone feeding young kids.  I love Ms. Satter’s approach to feeding young kiddos, and I find myself referring to her work often.

When I speak with families, I usually focus on the following as a way to get started:
 

  • Make family meals a priority.  Your kiddo is going to learn what and how to eat by watching you so eating together (without distractions like T.V. or cell phones) is really important.  If you want your kiddo to eat her veggies, you need to eat your veggies… that’s how she’ll learn.
  • If you want your kiddo to grow up eating a variety of foods, you have to feed him a variety of foods.  Your child isn’t going to like everything you give him but, by continuing to offer him a variety of foods, he will be more likely to try new things.  Putting some of each of the foods offered at a meal on your toddler’s plate, even if he doesn’t eat them all, is a good way to start.
  • Be very careful about saying that your kiddo likes or dislikes certain foods.  If your toddler hears you say that she doesn’t like spinach, she may not even really know what spinach is but it’s very possible that she will grow up thinking she doesn’t like it.
  • Make a meal and snack schedule.  If your little one doesn’t eat much for breakfast, it’s not a great idea to chase him around the house with cereal or other snacks all morning just to get him to eat something.  The best thing you can do it wait until the next meal or snack before you try to feed him something else.  
  • Kids’ tastes change really quickly.  Just because your little one doesn’t like something today doesn’t mean she won’t like it two days from now.  It’s also important to keep in mind that kids may have to see a new food 10+ times before they’re even willing to try it… and, even then, they may still spit it out a few times before they’re willing to swallow it.

What if my kiddo isn’t gaining enough weight?
Weight gain normally slows after a kiddo turns one.  Normal weight gain for kids between one and two years of age is only about 8 grams per day (which is about a pound every month and a half!).  Between two and six years of age, weight gain slows down a little more to about 6 grams per day (which is about a pound every two and a half months!).

For kids who have grown well, parents usually find there is less and less pressure on how much weight a kiddo is gaining as long as they’re on a good path.  Many times, 15 kilograms (about 33 pounds) is used as a goal weight for the Fontan with many kids reaching this goal sometime between the ages of two and five- but there are plenty of exceptions.

Having the pressure of a weight goal can make feeding feel like uphill battle for some families.  Poor heart function, oral motor problems, early feelings of fullness, and other medical problems can make weight gain difficult.  With lower weight gain norms, we have a great opportunity for catch-up growth in kids who have had a hard time gaining weight.

All kids grow differently so it’s important to know what is and is not normal for your child.  I’m a believer that we can get all kids to grow if we get them enough nutrition, but what works for one may not work for another.  Some kids need extra fat, others benefit from more protein and/or carbohydrates.

It’s always okay to ask to meet with a dietitian if you have concerns about your kiddo’s growth or intake.  Some doctors will provide you with a referral, and some insurance companies may cover visit costs.  Dietitians can help you figure out how to get your little one enough of the right foods to get him growing.  Sometimes it takes a little bit of trial and error but, with patience, things will get better.

What about supplement drinks?
Doctors may recommend nutritional supplements to help your kiddo gain weight better.  There are plenty to choose from- some with different forms of proteins, carbohydrates, and fats.

The most common supplements for kids who don’t have digestive problems are Pediasure (Abbott) and Boost Kid Essentials (Nestle) but there are a lot of others.  Many are milk based so they may not work for kids with allergies; most are lactose-free and should be okay for kids with lactose intolerance.  These products have more calories that ‘regular’ cows’ milk because of added sugars and fats, but they have added vitamins and minerals, too.

If you’d prefer, you could try making your own supplement drinks since there isn’t anything truly magical about many of the commercial products.  Of course, it’s a good idea to check with your kiddo’s pediatrician (or dietitian) first just to get an okay.

I’ve included a couple of sample recipes, but I wouldn’t use either as a kiddo’s only source of nutrition.  Either one could be added to his or her diet as a ‘boost.’  There are a lot of resources out there with recipes, but these are a couple that I have had success with.

If you were to blend the following foods you would have a drink with a few more calories and about the same amount of protein as a bottle of Pediasure (248 calories vs. 240 calories both with ~7g protein).
 

  • 6 ounces of whole milk 
  • ½ of a ripe banana 
  • 2 teaspoons of honey
  • 1 teaspoon of flaxseed oil

For another example, you could blend the following items for a drink with a few more calories and about the same amount of protein as a bottle of Boost Kid Essentials 1.5 (366 calories vs. 360 calories both with ~10g protein).
 

  • 6 ounces of whole milk 
  • ¼ cup of cooked/mashed sweet potatoes
  • 1 tablespoon of honey
  • 1 tablespoon of almond butter
  • 1 teaspoon of flaxseed oil 

Since these recipes are small, you may need to make larger batches to accommodate your blender or food processor; you can always refrigerate any extra for later.  As another option, you could use baby foods that mix into milk really easily.  The options are endless so feel free to get creative; adding cinnamon, nut butters, chocolate powder, and berries are all good options- but don’t stop there!

If you were going to use almond milk, rice milk, or another type of dairy milk substitute, the recipe would not provide as many calories or as much protein as the ones I’ve included here.  Using nut butters, cooked eggs, tofu, avocado, and other additives can help to fill in the gaps- your dietitian can help you figure out your best options.

*** If your kiddo is on tube feedings, always discuss any proposed changes with your child’s doctor or dietitian before you make any changes.  The recipes I’ve included are not intended as tube feeding formula replacements.

What if my kid is on tube feedings?
For kiddos who are on tube feedings, we make adjustments for growth a little bit differently.  Sometimes we will try new formulas to see if we can get a kiddo growing with a different mixture of fats or by giving different proteins.  Sometimes we’ll change the timing of feedings or give some feedings overnight while the kiddo is sleeping.  Sometimes we can add foods to tube feedings to help with weight gain, too.

Does my child need to take a multivitamin?
With a normal and varied diet, most kids probably don’t need to be on a special multivitamin, but it’s always a good idea to ask your child’s pediatrician about what may be best for your kiddo.  If needed, most physicians will suggest a once-a-day chewable vitamin or something similar.

I’m partial to vitamin products without a lot of sugar or extra filler ingredients.  I don’t usually recommend gummy vitamins for a few reasons (though we get asked often).
 

  • Gummy vitamins can be a choking hazard because young children tend not to chew them very well.  
  • They tend to stick in kiddos’ teeth and can cause dental problems.  Since we worry a lot about the mouth being a possible place where infections can start (especially for cardiac kiddos), we try not to encourage anything that can cause decay and other problems.
  • Dosage recommendations for gummy vitamins are usually between two and six per day (depending upon the brand) and, truly, no one needs to eat candy as a daily supplement.
  • They usually are not complete sources of vitamins and minerals.  Many of the powdered or chewable vitamins have better amounts of all of the micronutrients we’re looking for.

As the package says, always keep vitamins out of reach of small children; overdoses can be fatal.
 


For my final National Nutrition Month post, I am going to include some information about nutrition following the Fontan operation, and I am putting together some suggestions for feeding older kiddos.  I have a couple of recipes that I’m excited to share for the whole family to enjoy!