To advise family’s on appropriate dietary intake one must first consider the developmental age of a child and understand the “normal” fluctuations in dietary habits. Often, underweight children have not achieved developmental milestones for eating the full range of foods beyond a developmental age of two or older. For example, some children have developmental conditions that might affect their ability to eat (e.g., mental retardation, pervasive developmental disorders & autism, genetic conditions, structural abnormalities). Children with these impairments may be unable or unwilling to advance to a chronologically age appropriate diet (e.g., delayed dependence on formula, soft or pureed foods). Detailed description of developmentally appropriate menus.
Background Education for Providers
In the first two years of life, children are learning to eat. Families need to know how to identify their child’s developmental stage, what the child’s physical skills are, what the child’s eating skills are, how to accurately identify a child’s hunger and fullness cues, and what the range of appropriate foods and textures are. Some children who are underweight do not have the skills to eat a full range of menu choices. Specifically, children beyond the age of two should be able to drink all consistencies of fluids, and eat all textures of foods including: smooth/puree/mashed foods, soft cooked foods, dissolvable solids, chewable solids, and mixed textured foods.
For children with developmental disabilities, food offerings should be consistent with their child’s developmental age. Families may also benefit from additional assessment of their child’s developmental level. Therefore, consideration of a referral for a developmental evaluation should be discussed with the family.
To encourage a child to consume a balanced diet, it often is recommended that caregivers offer small portions of various nutritious foods and permit the child to determine what and how much of these items he or she chooses to eat. It is important to work closely with families to assess their knowledge of appropriate portion size, as parents may deliberately overfeed or underfeed children secondary to incorrect beliefs about children’s nutritional needs. Other parents may offer an overly narrow range of foods to support a balanced diet. It is important to consider the broadest range of foods that is appropriately matched to a child’s ability level, as this is a primary goal to meet a “balanced diet”.
Instructions for Provider
Children beyond two years of age should be able to drink all consistencies of fluids, and eat all textures of foods. Fluids range in consistency from thin liquids (e.g., water) to thick liquids (e.g., milkshake consistency). Smooth/puree/mashed foods consist of gelatin, pudding, yogurt, and meat spreads. Soft cooked foods include cooked vegetables, and canned fruits. Dissolvable solids include breads, crackers, dry cereal, chips, and popcorn. Chewable solids (foods that do not dissolve in saliva) include raw vegetables and meats. Mixed textured foods are foods which consist of more than one texture. Examples include casseroles and soups. To evaluate completeness of accepted textures, families should complete a verbal recall of foods commonly consumed by the child. Alternatively a formal food record may be completed and reviewed at a later session.
Providers are advised that exclusion of any one or more of the above categories in a typically developing child above the age of two warrants further evaluation with a developmental specialist and/or a speech and language pathologist.
Background Education for Providers
Caregivers often hold expectations for children that are developmentally inappropriate (e.g., they expect children to be able to make healthy eating choices when other members of the family are not, they expect children to be able to anticipate how current food choices will affect future health status). A major task for the health care professional is to assess and correct any developmentally inappropriate expectations. All children should be involved in making behavior changes, but they cannot be expected to implement changes independently.
Developmentally appropriate expectations for children and adolescents vary somewhat depending upon the given child. For youth with cognitive delays, their developmental age rather than their chronological age should be considered in formulating developmentally appropriate expectations.
Understanding basic aspects of children’s thinking helps us to create developmentally appropriate expectations. In general, children and adolescents think about the world in different ways than adults do.& The following are characteristics of the thinking of School Age Children:
- Present oriented (Focused on here and now)
- Trouble anticipating consequences of behavior
- Not able to think about future consequences
- Can understand basic cause – effect relationships when these occur close in time
- Concept of time still developing
- Trouble with planning skills
- Care a lot about fitting in, not being different (especially teens)
Realistic expectations for school age children related to weight management include:
- Expecting child to help keep track of goals
- having child learn about different food groups and identify examples of each
- having child learn about different kinds of activities and decide which they want to try out
- expecting child to understand the difference between everyday foods and sometimes foods.
Unrealistic expectations for school age children related to weight management include:
- creating and tracking goals on their own without parent reminders
- taking medicine on own without parent reminders
- making healthy choices on own without parent reminders or some type of concrete reward (e.g., points or stickers)
- making healthy choices about eating or activity when parents ARE NOT making healthy choices
- being responsible for doing physical activity on their own without parent reminders or some type of concrete reward
- realizing that their eating choices now will impact their health in the future.
Instructions for Provider
For families presenting in which developmentally inappropriate expectations are a concern, it is recommended that providers do the following:
- Talk with the family to understand specific ways in which parent expectations are not appropriate.
- Provide education using the points above to promote improved parent understanding of developmentally appropriate expectations.
- Develop a concrete plan for parent involvement so that the key tasks that parents are responsible for completing and that youth are responsible for completing are clearly articulated and developmentally appropriate.