Diet Interventions

 Increase Calories

Strategies to increase calories (or other nutrition) are used to stabilize a child’s nutritional status (e.g., improved height to weight ratio) and promote catch up growth. Calories are added by selecting calorie rich food when menu planning and/or adding calories to foods already well accepted by the child (e.g., adding fat). Another strategy is to increase the typical volume of intake by the child at meals.

Background Education for Providers

Pervious studies have shown that increasing caloric intake in undernourished children helps to achieve catch up growth. Children need calories for both metabolic energy expenditure but also for growth and weight gain. By increasing the caloric intake a child presumably will accelerate their growth velocity to a point which energy intake will exceed calories used.

Treatment Issues

Calorie rich foods – Choosing foods that are higher in fat content will increase calorie intake by the child.

Adding calories – Adding calories to foods that the child already accepts will also increase calorie intake. Typically fat is added in the form of oil, butter, creams, sauces etc.

Increased intake – Increased volume of intake also increases the total number of calories consumed by the child. Strategies to increase the volume typically stem from behavioral interventions including goal setting with differential reinforcement applied for reaching volume goals.

Typically, children will have an easier time drinking calories than eating them (e.g., whole milk, formula). Fat content of foods/beverages will also increase caloric intake. It is important to remember that the nutritional quality of the foods remains important. The general goal is to maintain a healthy diet while increasing the calorie intake. Families may inquire about increasing calorie dense “junk foods” which should be avoided as these foods offer little nutritional benefit. Instead, families should be encouraged to use one of the strategies described above to increase the intake of nutritious foods.

Instructions for Provider

First, a dietary assessment of the child’s current intake should be completed. This is typically done by way of 24-hour recall interview or by written diet record. Gross assessment of food intake can be estimated, and strategies to increase calories may be discussed with the family.

Generally, adding a high calorie beverage is the easiest intervention. Switching a child to a 30 calorie per oz formula is the first step (e.g., PediaSure, whole milk with Carnation Instant Breakfast, whole milk with heavy whipping cream). Next, clinicians should consider having the family add calories to already accepted foods (e.g., adding oil, butter, cream). Families should also consider switching menus to include new foods that are more calorie dense (e.g., ice cream v. popsicle for a snack, introducing guacamole, smooth puree foods with higher fat content). Generally, behavioral interventions to increase the intake of currently accepted foods is the most difficult in the outpatient setting, and therefore should be considered last. These techniques may require the support of an appropriately trained behavior therapist. Typically, these techniques include volume goal setting, differential reinforcement techniques, and adjustments to the feeding schedule to promote hunger at the expected times.

If you have been working with a family for some time and you are not seeing a positive change to the growth velocity, then you should consider a consultation with the Nutrition Network staff. Typically, infants and young toddlers should be monitored more frequently than school age children.

Supplemental Materials

 Correct Nutrient Imbalances and/or Deficiencies

A primary area to consider for a child who eats too little is the risk of micro and macro nutrition imbalances and/or deficiencies. Our goal is to provide strategies which will correct and/or prevent imbalances through food selection changes or supplements.

Background Education for Providers

Deficiencies or imbalances can vary widely from one child to another. Therefore, clinicians must assess the full range of nutrition for each child. Macro nutrient assessment includes estimating the proportionality of carbohydrate, fat, and protein. Micro nutrient assessment includes estimating intake of vitamins and minerals.

First, we encourage families to follow the recommendations of the USDA to meet their nutrition needs through their diet. Please refer to www.choosemyplate.gov for specific recommendations. This may require support by the clinician to help the family find and understand basic nutrition for a healthy diet. The second, and perhaps the easier strategy, is to supplement nutrition by adding a daily multivitamin.

Clinicians are advised that a child with a well balanced diet does not need nutrition supplementation (e.g., vitamin). Also, for families that require or desire a vitamin, NOT all vitamins are equal. Recently, gummy vitamins have increased in popularity but be advised that this product is nutritionally incomplete (does not contain a broad coverage of vitamins and minerals). Furthermore, clinicians should be aware of any herbal or holistic supplements, and any use of these products should be made known to the providers. These products may or may not have an affect on the nutritional or medical disposition of the child.

A primary practice is to recommend vitamins that are “COMPLETE” and should be designated as such on the label. Dosing of the vitamin should also be checked on the label. Generally, a toddler between 1-2 years of age is given ½ of a tablet, and children older than 2 years receive 1 full tablet. Above 12 years children are recommended 2 tablets. Individualized micronutrient supplementation should only be provided in consultation with your medical treatment team.

Supplemental Materials

 Increase Food Variety

Strategies to increase the variety of foods consumed by the child are used to stabilize a child’s nutritional status (e.g., improved micro & macro nutrition). Typically, foods are selected when menu planning for inclusion into the child’s diet. Strategies typically include exposure, appetite manipulation, differential reinforcement techniques, and shaping/chaining of foods (e.g., selection of new/non preferred foods which share characteristics of foods already accepted).

Background Education for Providers

Previous studies have shown that increasing food variety is difficult in young children. Often children will “outgrow” picky behaviors, but many children maintain or show a worsening of selectivity in food choices as they grow. Recent studies estimate food selectivity in 25-45% of typically developing children at some point in their development. Efforts to treat selective eating habits primarily consist of exposure strategies. Some previous studies have shown that children typically need multiple exposures to a food before it becomes a well accepted item (e.g., typically between 10-15 exposures). Therefore, by increasing the frequency of exposures to new and non preferred foods, a child presumably will expand their diet and reduce the probability of nutrition compromise.

Treatment Issues

Assessing the existing diet – Caregivers and providers must understand where food deficiencies exist in the child’s diet. Typically, diet records are reviewed by professionals to assess “Macro Nutrient” deficiencies.

Menu Selection – Introducing food groups that are not represented or are underrepresented in the child’s current diet.

Response Burst – Efforts to introduce or expose the child to new foods will typically be met with resistance. At these times, it is important to maintain efforts to complete the exposure as withdrawing the non preferred food will inadvertently reinforce the child’s food refusal strategy. Similarly, if parents do not maintain their efforts to expose the child to new/non preferred foods, there will likely be a return to food refusals in the future.

Typically, we prefer to use more “positive” or “neutral” strategies to complete food exposures. Caregivers are generally instructed to use mealtime structure and routine along with positive reinforcement techniques. If additional intervention is needed, consultation with a behavioral health professional is recommended.

Instructions for Provider

First, a dietary assessment of the child’s current intake should be completed. This is typically done by way of 24-hour recall interview or by written diet record. Gross assessment of food intake can be estimated and strategies to increase calories (exposure, appetite manipulation, differential reinforcement techniques, and shaping/chaining of foods) may be discussed with the family.

Supplemental Materials

 Nutrition Education on Typical Feeding Patterns

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 (PDF).

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.

Supplemental Materials

 Nutrition Tracking/Diet Record

Tracking of dietary intake can offer additional nutrition details to the providers in their treatment of nutrition disorders.

Background Education for Providers

Typically, families that are asked to complete food records are asked for three to seven days of data. Generally, families are provided with tracking forms which they are asked to complete after each meal or snack their child eats. Studies have demonstrated that verbal recall of range of foods and volumes consumed beyond 24 hours is unreliable. Thus, the quickest and least intensive assessment of dietary intake is a guided 24 hour food recall. However, families of children who are underweight may over-report intake and report dietary practices that are consistent with the overall dietary recommendations for good health. Diet journals (daily written food records) have been shown to be more reliable but unfortunately are also subject to the halo effect (families biasing their report in a direction they believe the provider wants). Therefore, providers are advised to interpret all such materials cautiously. Families that complete tracking each day are the most likely to provide accurate data, and research has shown that daily tracking of food intake, and dietary practices are beneficial to help achieve goals and may be considered an intervention in and of itself.

Instructions for Provider

Food records can be used for the purpose of obtaining additional detail of typical intake or assist the patient and family in making nutritional modifications to current intake. Families should be given a copy of the food record and provided with an example of how the form should be completed. It is advisable to read the instructions aloud as this will likely cue the family to ask any questions that they might have and to overcome any confusion that the family may have related to the tracking task. Families are strongly encouraged to complete the form immediately after each meal and with as much detail as possible to enhance the reliability of the report. After a family has been asked to complete diet records, they should return shortly after completing the prescribed duration of tracking. At this return visit, it is best to review the diet records with the patient as this will help to reduce any errors due to poor documentation and enhance the provider’s ability to extract accurate information from the family by way of oral interview.

In underweight children, clinicians completing an analysis of food records commonly find: snacking/grazing throughout the day, lack of structured meal and snack times, excess juice intake (>8 ounces/day), excess intake of refined carbohydrate snacks (e.g. crackers, chips, sweets), small volumes with meals, limited food variety or disproportionate balance across food groups.

Supplemental Materials

 Behavior Management

Behavioral management procedures systematically apply positive and negative consequences contingent on specific child behaviors. Behavior management procedures consist of techniques based on learning principles that can be applied to problems to strengthen adaptive behaviors and weaken maladaptive behaviors. Of particular interest in clinical feeding interventions are 1) aspects of the feeder’s responses that have an inadvertent affects on feeding patterns and 2) planned techniques for “unlearning” or modifying maladaptive feeding patterns by rearranging social and environmental consequences for feeding. Behavior management techniques have been particularly recommended for problems related to food selectivity, mealtime conduct problems, and delays in self-feeding, as opposed to problems with quantity of intake which may be more affected by appetitive variables.

Background Education for Providers

Considerable evidence supports the use of behavioral approaches in the treatment of feeding disorders. Behavioral treatment goals generally consist of (1) decreasing behavioral problems at meals; (2) decreasing parent stress at meals; (3) increasing pleasurable parent-child interactions at meals; (4) increasing oral intake or variety of oral foods; (4) advancing texture (e.g. moving from purees and smooth foods to chewable solids); and (5) increasing the structure and routine of meals. Behavioral treatment strategies include implementation of mealtime structure and a feeding schedule, appetite manipulation, behavior management, and parent training. Ongoing consultation with other specialists, especially a dietician and speech pathologist, is frequently necessary to monitor the safety of the therapeutic plan that can result in transient weight loss, or that may unmask oral motor or swallowing deficits as behavioral resistance to feeding begins to resolve.

The essential elements of behavior management are (1) to identify the targeted behavior for change; (2) select techniques to increase or decrease behaviors congruent with feeding goals; and (3) develop a treatment plan that consistently pairs a contingency (positive or negative) with the targeted behavior. Strategies to increase positive behaviors include use of positive and negative reinforcement and discrimination training. To reduce negative behaviors, treatments typically include extinction, satiation, punishment, and desensitization. Typically, behavioral strategies are used in combination to create the strongest treatment effects in the shortest period of time.

Overview of behavior management principles and strategies (PDF)

Instructions for Provider

Principles to INCREASE behavior

Underlying PrincipleDescription of ApplicationExampleSupplemental Materials for at Home Behavioral Management
Positive Reinforcement (PDF)Positive consequences for desired behaviorGive praise, physical affection, or tangible rewardsBehavioral Parent Training-Increasing Positive Behavior (PDF)
Positive Reinforcement Strategies (PDF)
Feeding Sticker Chart (PDF)
Token System Placemat (PDF)
Negative Reinforcement (PDF)Terminate aversive stimulus contingent on desired behaviorRelease physical restraint when child accepts foodReferral Form for Behavioral Psychology (PDF
Discrimination (PDF)Reinforce target behavior in presence of defined stimulusPraise modeled behavior of eatingTips for Modeling (PDF)
Shaping (PDF)Reinforce successive approximations toward desired responsePraise 1) looking at food, then 2) allowing food to touch lips, then 3) opening mouth, then 4) accepting foodThe 5-Senses Challenge (PDF)
Sample Behavioral Contract (PDF)
Behavioral Contract Template (PDF)
Shaping Placemat (PDF)
Fading (PDF)Gradually remove assistance and reinforcement needed to maintain behaviorDecrease extent of guidance and rewards as child gains self-feeding skillsTips for Weaning Off Rewards (PDF)

Principles to DECREASE Behavior

Underlying PrincipleDescription of ApplicationExampleSupplemental Materials for at Home Behavioral Management
Extinction (PDF)Withholding rewarding stimulus contingent on target responseIgnore mild inappropriate behavior; Continue prompts during escape behaviorTips to Extinguish Unwanted Behaviors (PDF))
Punishment (PDF)Present aversive stimulus or remove rewarding stimulus contingent on undesired behaviorUse timeout; Give verbal reprimand; Restrict toys; Use overcorrectionTimeout (PDF)
Referral (PDF)
Desensitization (PDF)Pair conditioned aversive stimulus with absence of aversive events or with presence of positive eventsDistract child during fearful procedure; Use gentle massage to promote acceptance of touch<The 5-Senses Challenge (PDF) Desensitization Tips (PDF)

Contact Us

E-mail the Nutritional Disorders Telehealth Network Project Team

Please contact us if you are interested in using any of the project materials or if you would like more information regarding the project.

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Milwaukee, WI 53226
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Page Updated 03/16/2015
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