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SPOON Foundation Joint Council on International Children's Services

Ask the Expert


» Do you have questions about your child’s nutrition? You can “Ask an Expert” and check back here for answers!


Q: Hi, we are fostering an 18 year old young lady and I am a bit at a loss for what to do with her nutritional intake. She grew up fending for herself (she had access to enough food calorie-wise, but hasn’t the first clue about vitamins, protein, minerals and why those things matter). She is in a residential college and has a meal plan, but she will often skip meals or simply eat crap. When she was with us this summer, I didn’t make any deal about it, but tried to get her to eat at least a few fruits and veggies each week. She is home again for the holidays and is training for athletic participation in the spring. But physically, she really cannot exert herself much. She is quickly exhausted and extremely lethargic. Twice this past semester she was hospitalized for fainting/syncope spells and she was found to be very anemic. The thing is, she’s 18 and thinks she knows everything! She can’t seem to make the connections between nutrition and physical strength. I’m trying to tell her a few things every day in the hopes that something sinks in, but I’m afraid she’ll get back to campus in a few weeks and end up kicked off the team for medical reasons. I really WANT her on the team: I think the exercise would be good for her insomnia, and the discipline required for training is really great. She would also really benefit from the social components of being a part of a team. I don’t want to lecture at her (not just because she doesn’t listen well :)) and I don’t want to make food a huge deal, but I need some advice on how to help her understand what her body requires.

A: Your impulse to avoid lectures is right on. Ashley Rhodes–Courter, author of Three Little Words described the conflict with her adoptive mother over food, “… for some reason, I resisted every attempt she made…. I was annoyed by the way she preached to me about eating healthy foods.”

The fact that your foster daughter is not with you most of the time adds a sense of urgency. Unfortunately with eating, as with many things we try to “get” young people to do, even the hint of pressure can backfire. With privacy concerns in mind, enlisting the coach’s help isn’t possible as it might be if she was younger. This answer will attempt to address your situation as well as more general strategies for families fostering or adopting older children.

One thing to consider is that when children hear, “That food is junk” they may feel belittled for eating what they did when they had no control or choice. That ambivalence can make it hard for children and teens to nurture themselves when the foods they like are “bad.”

A mother I recently met talked about her 16 year-old foster daughter who was used to eating “junk” foods. Though this wasn’t the kind of food this foster mother wanted to serve, she started from a place of honoring her daughter’s experience and preferences. When they shopped together, the teen picked out comforting and familiar foods like pizza rolls, which were served with balanced meals. The teen also suggested sides like canned corn or mashed potatoes. The foster mom was able to get a favorite recipe from the girl’s grandmother. Within a few months, the teen was branching out and eating more nutritious foods. Avoiding conflict and not inviting resistance helped her to progress.

Toddlers and teens in particular (no coincidence that their behavior can seem so similar) are working on identity and independence. Conflict may feel safe if they are working on trust, or coming from a place of trauma. What helps is setting up the structure around them so that their internal motivation kicks in: they want to try new foods because they are curious, bored with the same foods or something looks tasty. They want to eat regularly because they feel better. Alas, we can’t make them see this, but maybe we can help them discover it for themselves.

These are complex issues that go beyond nutrition and involve autonomy, trust, concepts of self-care and growing up. These ideas should give you a place to start.


Q: I have adopted a sibling set of 5 from foster care. The three older boys (now 8,9,10) are displaying signs of hoarding. They have been with us for 6 years now. Throughout those years we have dealt with food issues with them. I am quite confused as to why we are seeing these issues, such as hoarding, still continue. Why does it seem like this behavior cycles?

A: We consulted with Dr. Katja Rowell, who sits on SPOON’s Medical Advisory Board. This is what she had to say, although she prefaced her answer with a note that this answer is just a beginning to quite a complex issue and question. I hope it helps you get started with your boys:

Without knowing more, my guess is that their anxiety from their history of food insecurity is triggered by something. Let’s explore some options.

Perhaps their (or for one child) increased interest in food or portions may coincide with increased nutrition needs of a growth spurt? I remember one client where the food obsession began around five, with a noticeable increased interest in more bread. Mom worried about her weight and the portions of bread, so she strictly limited it, while allowing as many “green light” foods as the girl wanted. This led to battles and more interest in foods/portions in general. At the same time, this little girl was beginning to process her adoption story. All the food battles meant that meals were a flashpoint for conflict and a lost opportunity to connect. Interestingly, a review of her growth chart revealed a two-inch growth spurt only a few months after the initial pasta cravings. Just want to acknowledge that there are times when appetite increases and slows, naturally.

Back to your sons. I wonder how the past hoarding issues have been dealt with, since you allude to food issues in the past. Are you worried about weight? Maybe the oldest one has increased energy needs pre-puberty? Are any or all of the boys being limited in any way? Is there a lot of talk about “sometimes” or “green-light” foods, or being “healthy”? Are they learning about nutrition (usually messages about eating less) in school? Is someone close to them dieting or talking about food/nutrition/weight? Are there forbidden foods? Are they being teased, or going through other stresses at school, home or with friends? All of these factors could lead to a return or intensifying of the hoarding behaviors like eating quickly, large amounts, or sneaking and hiding food.

We know from research that when we try to get children to eat less or weigh less, they are more likely to eat more and weigh more.

These are such complex issues. Children who have known food insecurity, I believe, are more likely to feel anxious and triggered than other children when food is limited, but I’m not sure if this is a new issue that triggered old anxieties, or if the initial food anxieties of not getting fed enough, or at regular intervals was not quite healed. Most often there is some trigger or anxiety about weight or amount of food.

I hope that helps in terms of thinking about how to help your boys. You are wise to look for help and answers now rather than wait. The book, Love Me, Feed Me: The Adoptive Parent’s Guide to Ending the Worry About Weight, Picky Eating, Power Struggles and More, deals with hoarding and food obsession, and would apply to your sons at their ages, even 6 years on.

Good luck to you all!


Q: My 2 year old adopted daughter has been home from China for 3 months and is a healthy weight and has a clean bill of health from our pediatrician. But she is absolutely obsessed with food! She will eat more than her 9 and 5 year old brothers, often eating their leftovers. She is constantly under foot in the kitchen while I am doing anything in there, be it cooking, cleaning, emptying the dishwasher or putting away groceries. She will cry a horrible fit when I tell her that all the food has been eaten and there are no leftovers following a full meal with the entire family. If I leave food out for her to graze on by herself during the day, giving her control of the food (which I highly disagree with but my social worker recommended), showing her that food is always provided in our home, she will consume it all and will cry for more. I have no doubt that she would eat an entire box of cereal, crackers, an entire bag of grapes, etc. and then follow it with a full meal. Her stomach will get very distended when she over eats but she cannot help herself. I need to limit her intake because she will clearly eat until she makes herself vomit. I have had to resort to placing her in the portable crib in another room within eyesight while I am cooking because she will charge at the sight of hot food coming out of the oven or boiling on the stove. Please tell me how I can stop this behavior and huge obsession with food for her health and for my sanity!

A: Congratulations on the new addition to your family and a clean bill of health. What you are experiencing with your daughter is not uncommon. Your intuition is telling you that this is a problem, and what you have tried so far isn’t working and doesn’t feel very good for you or your daughter. Pay attention to those feelings, it will help guide your feeding.

Assume that your daughter’s feeding history was less than ideal. Assume that she was not fed in a responsive way. Assume she didn’t get enough food, or couldn’t count on when she would get it. Now imagine how terrifying that is, and that what she is doing now is a perfectly normal response to her early feeding experiences. She doesn’t understand when she will get food and if she will be allowed to eat enough, so she feels anxious, probably most of the time, and frantic when she sees food. The survival instinct to eat as much as she can, when she can, kicks in.

With that said, those survival behaviors of sneaking, hoarding, eating large amounts very quickly etc. should improve over the first year or so, but increasingly with my clients, I am seeing this behavior persist and even get worse. A common example is a child who has been home for two years or more and is still obsessed with food, with family life revolving around controlling access.

The worry about “overeating”, and even the calorie restriction that some adopted children are put on within the first year to “treat” or “prevent obesity,” fuels the obsession with food and backfires. Moms tell me that being the food cop sucks the joy out of parenting, and even hampers attachment, “How can she trust me if all I do all day is say ‘no’ to food?” The very control and limits makes many children more anxious and food centered and more likely to overeat when they have the chance.

So, what to do now? As Dr. Dana Johnson, IA pediatrician and researcher says, “Don’t worry about overeating in the first year.” Your daughter may even gain weight for a time, even into the “overweight” or “obese” range, but trust that her eating and weight will even out as she learns to trust she will be fed. Though she is in the “normal” range now, she may still have some catch-up growth to do. Here are a few tips to get started. Use the Division of Responsibility:

As her anxiety decreases, she will be able to tune in to fullness and hunger cues. Within a few weeks (days for some children) the pace of eating slows, the frantic energy and clinging begins to resolve and you may even see her leave food on her plate. As one mother of a formerly “food obsessed” toddler adopted from Ethiopia said, “I find the more we let the anxiety and control around food go, the more he lets go of the obsession surrounding food (what a concept). I am not going to lie, it can be tough, but he is a whole new happy little mischievous toddler now and I LOVE it!!!!”

This is an introduction to a complex topic. For more information on feeding with a history of food scarcity, please see, Love Me, Feed Me: The Adoptive Parent’s Guide to Ending the Worry About Weight, Picky Eating, Power Struggles and More. Chapter 5 focuses on food obsession, and transitioning to the Trust Model of feeding.


Q: As you probably know many, many women sustain their pregnancies in
 Haiti by eating dirt.  They don’t receive prenatal or medical care either.  This 
doesn’t seem to be concerning to the doctors either.  Just wondering if you
 have any good resources on this topic.

A: The condition you’re referring to is a type of eating disorder known as
 pica, characterized by a person eating non-food items such as dirt, clay, 
ice, or laundry starch. Pica can occur during pregnancy and the cravings are 
thought to be triggered by a nutrient deficiency, typically iron, calcium,
 or zinc. It is more predominant in certain cultures (such as 
African-American women in the southeast US), but is still relatively
 uncommon overall. Complications include bezoar (a mass of undigestible
 material trapped in the stomach), infections, and intestinal blockages. 
Pregnant Haitian women are more likely than American women to be anemic or
 have other nutrient deficiencies, in part due to less access to medical care
 and limited diets, which may explain the increased incidence of pica in this 
country. Children adopted from Haiti should be tested for iron and zinc
 deficiencies with their routine lab work and may also benefit from parasite
 testing if there was a concern for pica during their gestation. You can
visit PubMed Health (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002505/)
 to learn more about this condition.


Q: My almost 3 year old daughter has been home for almost 5 months from China. She will take pedisure in a sippy cup but no other food or liquid. While she is getting her basic nutritional requirements met and is growing, we would like to see her expand her diet. She sits with us at meal times and will hold food and even “play eat”. We have been working with a speech therapist but have had little success. What suggestions do you have for such food aversion?

A: In helping a child with such severe food aversions increase the variety in her diet, the first bit of advice is to consider that progress will be slow. You should consider from the beginning that you are working towards changes in behavior that may not fully take place for months or quite possibly years. With this time frame in mind, it can help take the pressure off of your daughter and yourselves. With that said, here are some things you can try:

  1. Institute an “absolutely no pressure” rule. Don’t coax, bribe, or demand that your daughter try things. Educate others to avoid such tactics. You want to avoid mealtime power struggles at all costs.

  2. Consider giving her the pediasure after meals so she is not filling up on liquids.

  3. At mealtimes give her a plate with small amounts of the foods you are having with no expectation that she taste it. Let her serve herself the food family style. If she does taste a new food, be nonchalant about it.

  4. Start with anything she will consume and try to expand her repertoire. If she will drink one flavor of pediasure, try another flavor. If that is too big a jump, try adding a little bit of the new flavor to the existing flavor, for example 90% preferred flavor with 10% new flavor. Very gradually increase the amounts of the new flavor until she will accept it. Similarly, if there is any food she will accept, make small changes to a new similar food. For example, if she will eat applesauce, you can slowly work in a flavored applesauce and slowly transition her to the new flavor.

  5. Participate in a lot of food-related activities that your daughter may not associate with eating. Again, no pressure to taste or eat during these activities. The idea is to let your daughter experience food through other senses so that eventually it is not so threatening. Ideas include, berry picking, pudding painting, making peanut butter playdoh, gardening, and helping in the kitchen by stirring, pouring, etc…

  6. It sounds like you are already getting professional help from a speech-language pathologist. By all means, continue with therapy. You might want to consider a comprehensive feeding clinic with a physician, SLP, OT, and dietitian as well.

Good luck and please let us know how your daughter progresses.


Q: My son’s bio mother (Ethiopia) was undernourished while pregnant with my son. He was born between 6 and 8 weeks premature. He was undernourished himself. When we picked him up at age 3.8 he was comfortable in a size 18 month clothing and was about the size of a small 2 year old. He had a huge stomach and stick arms. In the three years he has been home he has gained more than 30 pounds and is now over 6. He is the normal size for 6 but on the very heavy end. While we feed him a normal diet and are careful about sweets and carbs, he continues to gain weight. He has not had any hoarding issues or worries about food that have lasted. He does like to eat, and we are able to limit it without causing him stress, or so we think. We checked out a variety of ideas that could be causing the issues, the most probable is the lack of metabolic ability due to malnutrition in utero. Our doctor directed me to the research on this sort of issue regarding mothers being malnourished and the results in children. I am wondering if you know about this and have any information on what to do practically without causing more food issues.

A: What a strong little guy that he is thriving after such a rough start! Your son certainly has had some early feeding challenges and nutritional concerns. Prematurity is a risk factor for feeding problems, with low muscle tone, suck and swallow problems, developmental delays, and just plain getting tired out. He was behind the ball right from the start. For instance, he didn’t likely get supplemental tube feedings until he could suck and swallow. Was he then fed aggressively? Was he pushed to eat more to try to get him to gain weight? There are so many factors: from attachment concerns, to the realities of the food and the feeding in an institutional setting where the child has no control over amounts, timing and rate…

What I am getting at is that there is more than just the quality of the nutrients. It sounds like he was malnourished for sure, that WHAT they were feeding him was likely woefully inadequate, but also, consider that HOW he was being fed was inadequate as well. And, for the good news, he has done some amazing catch-up growth! You obviously took great care with WHAT and HOW you were feeding him. He is thriving. In fact, there might not be a problem with his size. Carefully looking at his growth is important. He may have stabilized at a higher-than-average, but healthy-for-him weight. If the rate isn’t continuing to accelerate, that is, he is staying around the 95% for example, he may be just fine (assuming he is done with catch-up growth.) Also, some kids who experience catch-up growth tend to “overshoot” the mark initially, that is seem to get relatively fatter, and then this trajectory gradually slows and settles in at a lower percentile. We don’t know yet what he will grow into. He may always be bigger than average, but he can be healthy, and he can have a stable weight.

As to your question, no, I do not believe that he is incapable of metabolizing and regulating his intake due to his in-utero conditions. While there is some epidemiological correlation, the research on this topic is far from conclusive. There are many, many individuals who experienced in-utero malnutrition and do just fine with self-regulation (knowing how much to eat to get the body that is right for them.)

His obvious hoarding and worrying about food seem to have resolved, but remember that he has had a powerful history of food scarcity. You mention that you are able to “limit” him. What does that mean? Do you try to get him to eat less than he wants? Do you try to push him to fill up on low-calorie foods and restrict higher calorie or fat foods?

Trust that he can do it. Assume that his experience of food scarcity means that any attempts to limit his eating may cause anxiety and distress and actually contribute to his seeming overeating. When you stop limiting, (or telling him to take smaller bites or slow down) his eating will seem to get worse for awhile. He will confirm your worst fears and eat more. But with time, he will be able to tune-in to his internal cues and learn what is the right amount to eat-for him. In the meantime, enjoy family meals together, be disciplined about offering planned meals and snacks every 3-4 hours that include fat, protein and carbs, and let him decide how much and if to eat from what you provide (The Division of Responsibility in Feeding.) Continue to monitor and limit screen time to 2 hours or less of TV a day, offer plenty of opportunities for fun and rewarding physical play. A great resource for you might be Ellyn Satter’s Your Child’s Weight: Helping Without Harming.


Q: Our three year old Ethiopian son has been with us a little more than a year, and just tested low for iron at his last check up. We have been giving supplements, but are having a hard time figuring out what the appropriate dose is, even with our pediatricians assistance. I would rather not give supplements, as I feel that he eats a healthy diet, and is not extremely deficient. I also worry about teeth staining, and it is not easy to get him to take it. What should his iron level be? When are supplements necessary? How much does he need each day? How much is too much? His hemoglobin tested at 11.3 in Ethiopia, around 8 at his recent checkup, and about 10 at his last two rechecks after we started supplementing (all a month apart).

A: I appreciate the concern about giving iron supplements, but the hemoglobin of 8 is very low (not moderately low). A hemoglobin that low will not simply respond to dietary supplements, or at least, it will take a long time to replenish iron stores and brain iron. So, treatment through diet alone will leave the brain iron deficient for an even longer period of time and potentially risk long term neurodevelopmental problems. Also, the child has clearly responded to supplements, raising his hemoglobin to 10 in an appropriate time frame (about a month). Most of us recommend doses of 3 to 6 mg/kg body weight per day. In this case, since the hemoglobin is very close to normal, I think 3 mg/kg would be the better approach. The goal is to get the hemoglobin above 10.5.


Q: When I adopted my daughter from China, she was malnourished. One thing blood tests showed was her zinc levels were low. This can affect a child’s taste buds and many foods may not taste that good and can lead to kids only wanting salty or sweet foods. Trying to get her to take zinc suplements was a losing battle (they taste nasty!). A dietician friend said to take zinc oxide cream (the kind used for diaper rash) and put it on her feet at night and cover her feet with socks. The zinc is then absorbed through the skin. i tried this and after only a few nights it made a huge difference in what she would eat. This is a very simple, inexpensive, low risk thing for parents to try. Just wanted to share this as it also helped another friend of mine get his child to eat better.

A: Zinc deficiency can develop from poor nutrition or following a lengthy bout of severe diarrhea. One symptom of the deficiency is dysguesia, or taste changes, making it difficult for the affected child to eat an adequate variety of foods. Prolonged zinc deficiency can also weaken the immune system, impair wound healing, contribute to chronic diarrhea, and lead to stunted growth. I am not able to find any research showing that topical zinc is absorbed adequately enough to correct a deficiency, nor have I found a recommended dose and duration for a topical zinc treatment, so I recommend continuing oral supplements until your child’s zinc deficiency is corrected. Be aware that long-term zinc supplementation can lead to a copper deficiency, so only give your child a zinc supplement if a deficiency has been confirmed and then only under medical supervision (usually a 10- to 14-day supplementation period is sufficient to replete zinc stores).


Q: Our adopted daughter (from Guatemala) seems to have an aversion to drinking liquids–doctors cannot find a physical cause. Our doctor thinks her “thirst trigger” was turned off from so many years of food/drink deprivation. At the age of 12, she already suffers from constipation, hemorrhoids, and urinary tract infections. We have to make her drink fluids (juice, milk, water–her choice) in the morning and evenings, and she will go the entire day at school without drinking a drop of anything. We can’t convince her how important it is for her body to be hydrated. We would appreciate any suggestions you might offer.

A: Keep in mind that total fluid intake includes more than just beverages. Try sending soups and broths in her school lunches–both count towards her fluid goal–along with juicy fruits and vegetables such as watermelon, oranges, peaches, cucumbers, celery, and bell peppers. At home, offer popsicles, sorbet, Italian ice, and ice cream (to cut down on added sugars, make your own treats by freezing fruit juice in popsicle molds). Continue her home drinking regimen, but try offering club soda or sparkling water–she may prefer the carbonation to flat water.

Additionally, you might consider an evaluation by a speech-language pathologist or occupational therapist who specializes in feeding issues to determine if your daughter has a sensory aversion to drinking liquids. If so, the therapist can set up a therapy plan to help her overcome the aversion by desensitizing her to the type of sensory input to which she is averse.


Q: I adopted my son from foster care. He had several placements in his life, including living with his birth mother for two years. Can I assume that his nutrition is impacted with that kind of background? Are there things I should look out for?

A: Studies show that growth in children coming into foster care is suppressed. Anemia is more common in these children as well. International adoptees and children from foster care share backgrounds of poverty and, hence, poor nutrition, so it’s reasonable to assume they share nutritional deficiencies as well.


Q: My daughter, now two and a half and home from India nearly a year, just doesn’t seem to have much interest in food. She’s not a picky eater; it’s quantity that’s the problem–three bites of anything and she’s pretty much done. I know she needs to feel control over what goes in her mouth, but are there ways I can encourage her to increase her intake? Or do I just trust her to know that enough is enough? (It sure doesn’t look like enough to me!)

A: Without doing a thorough exam of your daughter it’s hard for me to know if your daughter is on track with her growth. My objective would be to determine if she’s experiencing consistent, regular growth, and if the answer is yes, I wouldn’t worry too much about her eating habits. It’s fairly normal for toddlers to cut back on their intake of food, and they may do this for a year, two years, or until another big growth spurt comes along. As a parent it’s completely normal to worry that your child isn’t eating enough and you’re probably wondering how they make it throughout the day on so few calories. Remember, children require much fewer calories than adults. Your daughter only needs 900 calories, whereas you require around 2000 calories. If she’s eating small, frequent amounts throughout the day and drinking nutrient rich beverages-like dairy milk, soy milk, 100% fruit juices, and smoothies-she’ll reach her calorie allotment. If you’re still worried, you could introduce her to some high calorie, nutritious snacks – but remember, if she refuses them, don’t push. As long as she’s growing, active, and healthy, I’d let her be the boss of how much she wants to eat.


Q: My recently-adopted son just eats so much. Is that normal?

A: Although there is no clear cut definition between “eating so much” and gorging, rest assured that many kids eat a lot after arriving in their new homes. Interestingly, food intake is a predictor of catch-up growth. Try to feed your son healthy foods as much as you are able, but don’t try to influence his growth and size by pressuring him to eat or restricting how much he eats. Children who are pressured to eat tend to eat less well and gain less weight, while children who are restricted from eating tend to eat more and gain weight. Trying to limit portions, or even trying to get a child to “slow down” can feel like restriction to a child. A child with a history of malnutrition or neglectful feeding will feel anxious and prone to overeat if you try to limit how much he eats. Try to follow Ellyn Satter’s “Division of Responsibility“: you decide what, where, and when to eat; your son decides if he wants to eat and how much. Your son’s growth should be monitored to make sure he is catching up if needed, or at least following roughly along his own growth curve. Many children will experience rapid catch-up growth, and then settle into a stable pattern. Try to support your child with optimal feeding while his body catches up and learns to tune in to hunger and fullness cues again. For more information on children who eat excessively, see our hoarding page.


Q: My daughter probably did not get enough to eat at her orphanage. She seems to have a lot of anxiety related to food. How can I help her?

A: One way to help your daughter overcome food-related anxiety is to make sure she knows that food is always available to her. You can dedicate a shelf in the fridge for her snack foods that she is allowed to have any time. Similarly, she can have her own area in the pantry with food that is just for her. She should probably not be expected to share food with other children during snack time. Instead of eating from a communal bowl with siblings, make sure she has her own dedicated bowl. Other ideas include not eating off of her plate even if you think she’s done (many parents tend to sneak bites from their children’s plates), giving her a snack to put in her backpack for outings, and keeping mealtimes low stress. Well-meaning advice from friends and family members to try new foods or clean her plate should also be discouraged. See the section Diet Tips & Tricks for more ideas.

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