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Poor appetite in young children
Psychologic Aspects of Pediatrics POOR A P P E T I T E IN YOUNG C H I L D R E N I-][ARRY B A K W I N , M . D .
N~w Yo~s:, N. Y. about poor appetite in young children continue to be freC OMPLAINTS quent, despite a clear understanding of the mechanisms involved.
Etiology.--The period between one and 5 years is one of relatively slow growth. Whereas infants gain about 15 pounds during the first year of life, tripling their birth weight, the average annual weight gain during tho next four years is only about 5 pounds. Moreover, while infants generally gain steadily, the weight gain later on is likely to be irregular, and months may pass without any increase in weight at all. Corresponding to the relatively slow weight gain, there is a lessened need for food and, in turn, a smaller appetite. Though the gain in weight is only slightly more rapid during the early school years, the need for food (and henee the appetite) is increased because of greater muscular activity. Parents often fail to understand the reason for the lessened appetite of their children and they show their concern by pleading and, often, by trying to force them to eat. The years between one and 5 are years of rapid psychologic development. The child is becoming aware of his environment and is becoming' increasingly independent. He registers his emerging self-dependence by resisting parental direction (negativism) and by insisting on doing things in his own way (aggression). The child of 18 months is no longer the pliable, acquiescent being that he had been a few months earlier. He now takes a certain delight in resisting his parent and in seeing her agitate herself. He may not eat even though he is hungry, simply because he has learned that in this way he can gain attention. In addition, he may use refusal to eat as a means of annoying his parents when he feels that he has been neglected. A prominent cause of eating difficulty in young children is insistence by the parent that the child eat certain foods which she considers are " g o o d " for him. Related errors are continuing to feed " b a b y foods" and failure to prepare food interestingly. I m p r o p e r training is another etiologic factor. It has become fashionable among physicians to introduce solid foods into the diets of babies before they are developmentally ready to receive them. Babies are ready to handle solid food at about 3 or 4 months of age. At this age, they start to make biting movements and are able to transfer food from the front to the back of the mouth F r o m the D e p a r t m e n t of Pediatrics, New York University College of Medicine. 584
PSYCHOLOGIC ASPECTS OF PEDIATRICS
585
with the tongue. A good sign of readiness is the response of the baby to insertion of the tongue depressor into the mouth. A young baby tries to eject the tongue depressor forcibly, making inspection of the throat difficult. The ease with which the baby accepts the tongue depressor is a good measure of readiness for solid food. Premature attempts to feed babies solid foods are likely to be unnecessarily difficult, and hence lead to early maternal concern about the eating situation. A common error in child training is failure to transfer from the pureed foods to the foods which require chewing. This change can ordinarily be made between 7 and 10 months of age. Children who continue to receive pureed foods too long are likely to be poor chewers. They may refuse to swallow coarse particles and they sometimes hold food in the mouth for hours, even days. Many mothers continue to feed their children after they are able to eat by themselves. They do this because they fear that their children will eat less if they feed themselves or will be too messy or too slow. The mechanisms described above account for the large majority of eating problems in y f n n g children. In a certain number of cases, however, the feeding difficulty is but one manifestation of a deep-seated emotional problem. An unhappy child, like an unhappy adult, is likely to eat less (sometimes more) than a normal one. Any disturbance in the emotional life of the child may present itself as an eating problem. Excessive demands for attention and spiteful behavior are characteristic of the emotionally disturbed child. Whereas children with an eating problem generally maintain a normal weight gain, there is often a weight loss where the difficulty is primarily emotional. Such children require careful study. Relief of the eating difficulty will only lead the child to seek outlets for his emotional discomfort in other ways. Poor appetite sometimes has its origin following an acute infection. In such instances it may require days or even weeks for the appetite to return to normal. At this time the parents are likely to be overly concerned about the child and they need reassurance. T r e a t m v n t is successful in the large majority of children. It requires three to f o u r weeks and generally as many visits to educate and reassure the parents. Treatment depends on a clear understanding of the etiologic mechanisms: 1. The parents should be told about the relatively slow weight gain between one and 5 years of age, the lessened need for food and, consequently, the smaller appetite. 2. There should be no discussion about eating in the child's presence. No attempt should be made to force the child to eat, nor should he be bribed or rewarded. Parents should be urged to forget calories, vitamins, and minerals and rely on the chilcl's appetite. It is reasonable to assume that we were endowed with appetite for some purpose. 3. Children, given a free choice of diet, like meat, butter, fruit, ice-cream, and milk in that order. Their attitude toward vegetables differs just as does adults'. Raw vegetables are often preferred and should be recommended. They
586
THE
JOUI~NAL OF PEDIATRICS
are especially useful for children who are poor chewers. Cereal is the food most often refused and it may be safely omitted from the diet. Excessive ingestion of milk should be avoided. A quart is maximum, a pint adequate. There should be no insistence on this or that food. The food likes and dislikes of children should be respected just as in adults. Baby food should be avoided: Food should be prepared interestingly. There is no contraindication to fried foods, sauces, and gravies. Young children often p r e f e r highly seasoned and exotic foods like anchovies, olives, etc. 4. The child should feed himself. His table manners will not be good at first but he will learn better by example than by precept. The food should be served attractively and in small amounts. The child should be permitted to sit at table a reasonable time and the food then removed without comment or show of emotion. Food, a crackeI, fruit, etc., should be given between meals if the child requests it. The punitive attitude implied by " Y o u did not eat y o u r lunct~, so now you cannot have a n y t h i n g " should be avoided. Meals should be served at regular hours. The child should be warned a few minutes ahead of mealtime, so as to avoid taking him away abruptly from interesting play. E n t e r t a i n m e n t at mealtime is generally overdone. Certainly excessive antics to entice the child to eat should be discouraged. Nevertheless, eating" is, to a large extent, a soMaI function. W e all eat better in good company and, when we have to eat alone, we seek some entertainment like reading, listening to the radio, etc. A certain amount of entertainment during mealtime, therefore, is probably desirable for children. 5. W h e r e the feeding difficulty is a manifestation of a deep-seated emotional problem, an investigation of the total situation is necessary. The parents m a y be overanxious and overprotective because the child has had a previous illness or because there has been a death of a child in the family or because the child is an only one. The parents m a y be indifferent toward the child or overtly or covertly rejecting. The child may be resentfuJ because of preference for another sibling. 6. Tonics and vitamin supplements to increase appetite should be discouraged. They are not only unnecessary, but they tend to divert parental attention away from the real mechanisms underlying the eating difficulty.
N~w Yo~s:, N. Y. about poor appetite in young children continue to be freC OMPLAINTS quent, despite a clear understanding of the mechanisms involved.
Etiology.--The period between one and 5 years is one of relatively slow growth. Whereas infants gain about 15 pounds during the first year of life, tripling their birth weight, the average annual weight gain during tho next four years is only about 5 pounds. Moreover, while infants generally gain steadily, the weight gain later on is likely to be irregular, and months may pass without any increase in weight at all. Corresponding to the relatively slow weight gain, there is a lessened need for food and, in turn, a smaller appetite. Though the gain in weight is only slightly more rapid during the early school years, the need for food (and henee the appetite) is increased because of greater muscular activity. Parents often fail to understand the reason for the lessened appetite of their children and they show their concern by pleading and, often, by trying to force them to eat. The years between one and 5 are years of rapid psychologic development. The child is becoming aware of his environment and is becoming' increasingly independent. He registers his emerging self-dependence by resisting parental direction (negativism) and by insisting on doing things in his own way (aggression). The child of 18 months is no longer the pliable, acquiescent being that he had been a few months earlier. He now takes a certain delight in resisting his parent and in seeing her agitate herself. He may not eat even though he is hungry, simply because he has learned that in this way he can gain attention. In addition, he may use refusal to eat as a means of annoying his parents when he feels that he has been neglected. A prominent cause of eating difficulty in young children is insistence by the parent that the child eat certain foods which she considers are " g o o d " for him. Related errors are continuing to feed " b a b y foods" and failure to prepare food interestingly. I m p r o p e r training is another etiologic factor. It has become fashionable among physicians to introduce solid foods into the diets of babies before they are developmentally ready to receive them. Babies are ready to handle solid food at about 3 or 4 months of age. At this age, they start to make biting movements and are able to transfer food from the front to the back of the mouth F r o m the D e p a r t m e n t of Pediatrics, New York University College of Medicine. 584
PSYCHOLOGIC ASPECTS OF PEDIATRICS
585
with the tongue. A good sign of readiness is the response of the baby to insertion of the tongue depressor into the mouth. A young baby tries to eject the tongue depressor forcibly, making inspection of the throat difficult. The ease with which the baby accepts the tongue depressor is a good measure of readiness for solid food. Premature attempts to feed babies solid foods are likely to be unnecessarily difficult, and hence lead to early maternal concern about the eating situation. A common error in child training is failure to transfer from the pureed foods to the foods which require chewing. This change can ordinarily be made between 7 and 10 months of age. Children who continue to receive pureed foods too long are likely to be poor chewers. They may refuse to swallow coarse particles and they sometimes hold food in the mouth for hours, even days. Many mothers continue to feed their children after they are able to eat by themselves. They do this because they fear that their children will eat less if they feed themselves or will be too messy or too slow. The mechanisms described above account for the large majority of eating problems in y f n n g children. In a certain number of cases, however, the feeding difficulty is but one manifestation of a deep-seated emotional problem. An unhappy child, like an unhappy adult, is likely to eat less (sometimes more) than a normal one. Any disturbance in the emotional life of the child may present itself as an eating problem. Excessive demands for attention and spiteful behavior are characteristic of the emotionally disturbed child. Whereas children with an eating problem generally maintain a normal weight gain, there is often a weight loss where the difficulty is primarily emotional. Such children require careful study. Relief of the eating difficulty will only lead the child to seek outlets for his emotional discomfort in other ways. Poor appetite sometimes has its origin following an acute infection. In such instances it may require days or even weeks for the appetite to return to normal. At this time the parents are likely to be overly concerned about the child and they need reassurance. T r e a t m v n t is successful in the large majority of children. It requires three to f o u r weeks and generally as many visits to educate and reassure the parents. Treatment depends on a clear understanding of the etiologic mechanisms: 1. The parents should be told about the relatively slow weight gain between one and 5 years of age, the lessened need for food and, consequently, the smaller appetite. 2. There should be no discussion about eating in the child's presence. No attempt should be made to force the child to eat, nor should he be bribed or rewarded. Parents should be urged to forget calories, vitamins, and minerals and rely on the chilcl's appetite. It is reasonable to assume that we were endowed with appetite for some purpose. 3. Children, given a free choice of diet, like meat, butter, fruit, ice-cream, and milk in that order. Their attitude toward vegetables differs just as does adults'. Raw vegetables are often preferred and should be recommended. They
586
THE
JOUI~NAL OF PEDIATRICS
are especially useful for children who are poor chewers. Cereal is the food most often refused and it may be safely omitted from the diet. Excessive ingestion of milk should be avoided. A quart is maximum, a pint adequate. There should be no insistence on this or that food. The food likes and dislikes of children should be respected just as in adults. Baby food should be avoided: Food should be prepared interestingly. There is no contraindication to fried foods, sauces, and gravies. Young children often p r e f e r highly seasoned and exotic foods like anchovies, olives, etc. 4. The child should feed himself. His table manners will not be good at first but he will learn better by example than by precept. The food should be served attractively and in small amounts. The child should be permitted to sit at table a reasonable time and the food then removed without comment or show of emotion. Food, a crackeI, fruit, etc., should be given between meals if the child requests it. The punitive attitude implied by " Y o u did not eat y o u r lunct~, so now you cannot have a n y t h i n g " should be avoided. Meals should be served at regular hours. The child should be warned a few minutes ahead of mealtime, so as to avoid taking him away abruptly from interesting play. E n t e r t a i n m e n t at mealtime is generally overdone. Certainly excessive antics to entice the child to eat should be discouraged. Nevertheless, eating" is, to a large extent, a soMaI function. W e all eat better in good company and, when we have to eat alone, we seek some entertainment like reading, listening to the radio, etc. A certain amount of entertainment during mealtime, therefore, is probably desirable for children. 5. W h e r e the feeding difficulty is a manifestation of a deep-seated emotional problem, an investigation of the total situation is necessary. The parents m a y be overanxious and overprotective because the child has had a previous illness or because there has been a death of a child in the family or because the child is an only one. The parents m a y be indifferent toward the child or overtly or covertly rejecting. The child may be resentfuJ because of preference for another sibling. 6. Tonics and vitamin supplements to increase appetite should be discouraged. They are not only unnecessary, but they tend to divert parental attention away from the real mechanisms underlying the eating difficulty.