Childhood nutrition and picky eating

Featured pediatric expert

Eric Ball, MD

Dr. Eric Ball is a general pediatrician with Children’s Health of Orange County (CHOC). He is currently the Vice Chair of the American Academy of Pediatrics (AAP) in California and is past president of the AAP in Orange County. He also serves on the boards of the Orange County Medical Association and the California Immunization Coalition. His interests in medicine involve quality improvement, legislative advocacy, and childhood nutrition.

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Transcription

Melanie Cole: Welcome to Long Live Childhood, a pediatric health and wellness podcast presented by Children’s Health of Orange County. Together, we can keep kids happy and healthy.

I’m Melanie Cole, and I invite you to join us as we discuss childhood nutrition and picky eating. Joining me is Dr. Eric Ball. He’s a pediatrician with Children’s Health of Orange county. He’s also the Vice Chair of the American Academy of Pediatrics in California. Dr. Ball, it’s a pleasure to have you with us. And this is just such a great topic. As a parent of two older children at this point, I just love this topic and we know that the American Academy of Pediatrics has a lot to say as well. So I’d like you to start about telling parents when, when do you try and start feeding children healthy, nutritious foods? Is it that sixth month when we’re starting the solids? When does that happen?

Dr. Eric Ball: Well, thanks so much for having me. It’s great to be here. Yeah, that’s a good question. So I think that healthy eating and avoiding picky eating starts from day one, when you start feeding babies. So the American Academy of Pediatrics recommends that we start feeding babies somewhere between four and six months. I tend to err more on the six months end of things, just because I find kids are a little more able to eat at that point. And when we introduce foods, I really encourage my families to introduce foods pretty rapidly every day or so to add a new food to the repertoire and to really serve them a wide variety of foods.

So the only thing we don’t feed babies is honey, but anything else is really okay. And I encourage families to pretty rapidly introduce foods that are similar foods that the family is eating, so fruits, vegetables, and then pretty quickly progressing to table foods and other foods that the family is eating so that they can eat together and that the infant can start to model the eating behaviors of the rest of the family.

Melanie Cole: Well, I think you just hit it right there on the head is as we always recommend eating together as a family, as much as possible, as is feasibly possible, but that’s where the role modeling begins, isn’t it? So if parents want to avoid having their child become a picky eater, let’s start with some tried and true things that you can tell us besides eating as a family, because the role modeling, that’s number one, really. Now, we’re all sitting at the table, the kid’s pushing away that stuff. What do we do?

Dr. Eric Ball: Correct. So this is the frustrating thing about parenting. So most kids are usually pretty good eaters for the first year of life. So you sit down the average one-year-old and you give them broccoli and they’ll eat broccoli and they do well. But over the next year, the vast majority of toddlers, preschoolers become picky. And it’s very frustrating as a family because you think, “What did I do wrong? Why was this child eating so well and now they’re getting pickier?”

And there’s really a few things going on with children when they hit that toddler age. So number one is that their growth velocity as a toddler, as a preschooler slows down dramatically. So babies grow very quickly. So the average baby will grow, put on, you know, 14 pounds or so in the first year of life, that same kid will put on 2 3, 4 pounds per year after that. And so their nutritional needs just go down. Number two is that most toddlers become very busy. And as the parent of two children, you know, I know that you can’t keep a toddler still for more than five minutes. And the last thing they want to do is sit in a high chair for a half an hour and eat a meal. They want to eat a few bites, get some energy and then go and do their own thing.

And then finally, what happens in the toddler years is kids start to develop some semblance of independence and they start to realize that, you know, some foods tastes better than others and they start to, you know, for lack of a better word, manipulate their families. So they’ll start refusing food, throwing food on the ground, being more picky with the hope that parents will give them more preferred foods, which I find is the biggest pitfall that parents often fall into at that age.

Melanie Cole: Well, certainly parents do. And, you know, you’ll even see other parents say, “Oh, you don’t have to give him that. He won’t eat that.” And I, as a parent and somebody who’s been in the nutrition field for 30 years say– well, I mean, you got to try not to say it, but you say, “Well, why? Why can’t I just try it with him?” So I know that this is frustrating for a lot of parents and, as we said, that role modeling. Tell us a little bit if it’s normal, Dr. Ball, that kids eat everything on their plate. Should we be forcing them to do that? Do we want to use any of those techniques in regards to eating and nutrition? Is there something that’s considered normal?

Dr. Eric Ball: Yeah, that’s a really good question. So one of the frustrating things about feeding toddlers or preschoolers or all children for that matter is there’s a lot of randomness to it. So there will be meals where kids will eat nothing. There will be days where kids will eat almost nothing. And then there’ll be meals where kids would eat more than I would ever eat at a meal. You know, I’d make my kids chicken one night for dinner and they’d eat it. And I make the same exact chicken tomorrow and they wouldn’t touch it, and you have to be okay with that.

One of the great things about kids is that they tend to eat when they’re hungry and when they’re not hungry, they don’t eat. And when they get to a point in their meal where they are full, they will generally stop eating. And that is fantastic. You want to encourage that. A lot of adults, we don’t do that. Like, I’ll finish my plate, because I liked the food, even though I was full, you know, a half a plate ago. So it’s really important for parents to respect their kids, to serve them healthy food, to eat the same food that you’re serving the kids. And if they eat the food that you give them, that’s fantastic. But if they don’t eat it, don’t worry about it. Move on with your day. They’re not going to starve to death. What’s critically important is that they don’t eat the food that you give them, do not give them other choices because that’s what get parents in trouble. So if you give a child, let’s say chicken and rice and broccoli for dinner tonight, and he or she throws it on the floor and you feel bad that they’d need dinner and you give them like pasta or yogurt or something, your child is smart and they start to figure out that, “Oh, that’s awesome. If I want yogurt, I just throw my food on the floor,” and that’s how you get a five and six-year-old who’s only eating like two foods per day. It starts early at that age.

Melanie Cole: It definitely does. And it also starts with other kids. Once they start going to school and other kids say, “Ew,” and our school had a rule that said you can’t yuck my yum, that’s what they used to say. You weren’t allowed to say yuck to anybody else’s food. So let’s speak about what if they are picky eaters at this point? How often do we try? And I think with your chicken, it was probably that it was leftovers, right? Maybe they didn’t want leftovers, because sometimes, you know… But tell us what we’re supposed to do then if they are picky, if there are certain fruits and vegetables? Do we hide them in food? Do we keep retrying? What do we do?

Dr. Eric Ball: Yeah. So I think it’s important that kids are presented with healthy food. And if the family is going to eat fruits and vegetables, that’s what you should serve them. And what I always tell my patients is if you want your child to eat vegetables, you have to serve them vegetables. If you want them to have broccoli for dinner, you need to serve them broccoli. And it might be a hundred times that you serve it and they refuse it before they take a taste of it, but that’s okay. You need to keep doing it. I’m not a big fan of like hiding it. A lot of parents will bribe their kids to eat vegetables, which I think is not a good thing, because then they feel like it’s almost a punishment, right? So if you eat your broccoli, you’ll get ice cream for dessert, which is not the right way to go about it. It’s to normalize the behavior “In this family, we are eating fruits and vegetables, or we are served fruits and vegetables at our meals.” And if they don’t need it, it’s okay. It’s okay. I’m a big fan of natural consequences for children. So the natural consequence, if you do not eat the food that was served to you is you are hungry and hunger is the best motivator for kids to eat food. So if they’re hungry enough, they’ll come back. They’ll eat those vegetables eventually.

Melanie Cole: As the youngest of six, hear, hear, because that’s what my parents did. “you don’t like what we’re serving, you can sit there for a long time or you can leave, but you’re not getting anything else. You know, we’re not short order cooks as parents,” right? Now, what about the children who are picky and yet we know we have a childhood obesity problem in this country, the children who are picky and overweight? Do you have recommendations how to deal with that? Because that would be not only the quality, but the amount of food.

Dr. Eric Ball: Yeah. So the irony of this whole situation is usually these kids who become picky and overweight start out as picky eaters, and the families are afraid that they are not eating enough, right? So, “Oh, my God, they didn’t have the chicken and the broccoli I served for dinner, so I’m going to make them pasta because I’m worried they’re not going to eat anything and they’re going to starve.” And so these are kind of the same kids, so you shift from a toddler who you’re worried they’re not eating anything to an older kid who now they’re overweight and have very bad eating habits. So we always in pediatric start young and it’s much easier to kind of teach families good eating habits early to avoid this. But unfortunately, we have a lot of kids who are older, who are overweight, who are picky.

And I think that the number one thing that we do, that I encourage families to do is to try to control the foods that are in your house. So until your child is older and has a job and a car and can go out and buy their own food, parents are in control of almost a hundred percent of the food that’s under their roof. And kids will generally eat what’s in their house. So if you have for snacks like apples and pears and chips at home, most children will gravitate towards the chips. But if all you have are apples and pears and the child wants a snack, they’re either getting an apple or a pear, because they don’t have other choices. So I think your battle is won or lost in the grocery store. And anything you bring into your house that you do not want your child to eat, either they’re going to get it and they’re going to eat it, or you’re going to have a fight over it. And so as a parent, you’re going to lose either way. So the best thing to do is to just surround your kids with healthy foods. And as parents, we have to sacrifice also, right? So if I don’t want my kid to have cookies, then I can’t have cookies at home and, consequently, I shouldn’t be eating cookies either. And that’s okay because I probably shouldn’t be eating the foods I don’t want my kids to not eat.” So battle starts in the grocery store, surround your kids with healthy food and make sure you model good eating behaviors.

Melanie Cole: You mentioned snacks, Dr. Ball. Do they contribute to picky eating or to a child not being hungry later?

Dr. Eric Ball: They do, because if you think about it, most like traditional kids’ snacks are junk, right? And so a lot of the kids’ snacks that I see my families feeding their kids tend to be like bars, which are kind of processed food full of sugar or crackers or things like that. And so these tend to be kind of preferred foods for kids and they would much rather eat these things than, you know, the chicken that’s going to be served for dinner. So a lot of our kids will fill up on snacks or they will, you know, not eat lunch because they know if they hold out for an hour, they’re going to get some crackers that they like better. So, you know, I think it’s important that families kind of surround themselves with healthier foods.

I try really hard to avoid processed foods. I think as a general rule, if something has like a nutrition label on it, it’s probably not the best food for you because it’s been processed. You know, bananas don’t have nutrition labels on it, but bars and crackers do. So, you know, I think making sure that you surround your kid with healthy food. And I don’t make a big deal of it. I think it’s important not to hold back things from your kids. In other words, I don’t think you should have like bars in your pantry and tell your kid, “It’s snack time, but you can’t eat the bars,” right? So if you don’t want them eating these like granola bars, then you can’t have them in your house. So you try to control them in that way. And frankly, for my children, we used to offer the food that they didn’t eat at meals as snack time, right? So like the chicken that they didn’t eat for dinner last night, great. That makes a perfect mid-afternoon snack the next day or, “Oh yeah. The half a sandwich you came home from school with, I’ll give that to you when you come back home from school,” because these are generally more nutritious things than the traditional childhood snacks.

Melanie Cole: That’s really great advice. Now for those children that are picky and aren’t eating their fruits and vegetables, do we give them supplements? Should they be having vitamin supplements or chewies or gummies or any of those things?

Dr. Eric Ball: Yeah. So the vast majority of kids don’t need anything. So, you know, kids who are just eating like chicken nuggets three meals a day, yeah, they probably need a multivitamin. But most kids are getting more than enough of their daily vitamins and minerals from the food they eat, even kids who are quite picky. And when we look at these older kids who are picky, it’s also important for families to remember to be patient. When you have, you know, say an eight year old who is a very picky eater and you want to try to undo some bad habits, you have to remember that that child has been developing those habits over, you know, six or seven years. And so they’re not going to be not picky the next day. It takes a long time. It’s a lot of perseverance. It’s a lot of tantrums and things in the house. But being pretty consistent about it, having healthy foods at home is really the start to it. And we always would rather kids get their nutrition from food rather than supplements like vitamins or gummies.

Melanie Cole: And I think one key thing that we’ve always said in the field is to shop the perimeter when you were talking about what you bring into the home. Speak about how important it is to get the older kids involved in gardening those fresh fruits and vegetables, cooking, shopping, kind of giving everybody maybe a recipe to try, getting them involved, because I think that really does help foster a love of colors and textures and flavors and involved in prep.

Dr. Eric Ball: That’s a really good point. We really encourage our families to cook with their children, even young children, have them be involved, even if it’s like mixing the fruit salad together, things like that. When a child is invested in the growing of a fruit or vegetable or the preparation of the food, or even the buying of the food at the grocery store, they’re much more likely to eat it. So having them be kind of part of the team, part of the nutrition team is really great, great advice. And you mentioned shopping the perimeter. Remember the perimeter of the grocery store generally is where, you know, for lack of better word, whole foods are, right? So fruits and vegetables and grains and meats and dairy products and things like that rather than the interior, which is more of the processed foods, the chips and cookies and bars and what have you that we try to avoid for kids.

Melanie Cole: As you said, the things without labels tend to be more on that perimeter. As we wrap up, Dr. Ball, what an educational informative episode this was. Please give parents listening your very best advice about picky eating, trying to prevent it in the first place, eating together to foster that love of the variety of foods and have good quality family time. What do you want parents to know?

Dr. Eric Ball: Yeah. I think the take home is start early, you know, encourage good eating habits early, even from the infant years when you’re feeding your baby their first foods. You know, it’s okay to give them foods that have a little bit of flavor, a little bit of spice. Model good eating behaviors. Make sure you’re eating the same thing as your children and make sure you’re making good choices at the grocery store because in the end, the foods that are in your house and the foods that your kids see you eat are the ones that they are going to learn to eat. And these are the eating habits that they’re going to take with them for the rest of their lives.

Melanie Cole: Great advice, Dr. Ball. Thank you so much for joining us today. And for more pediatric health and wellness tips, you can visit choc.org. Thank you so much for listening to Long Live Childhood, a pediatric health and wellness podcast presented by Children’s Health of Orange County. Together, we can keep kids happy and healthy. Please remember to share on your social channels as we’re all learning from the experts at CHOC together. I’m Melanie Cole.

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