Kids' Nutrition & Growth: Interview with Susan Hui, Mom of 3 & Dietitian

What is the role of a pediatric RD? How do you help parents and kids?

My role as a pediatric dietitian is to assess and provide strategies for parents/caregivers and children to encourage healthy feeding behaviours and food choices. As part of my role as a Registered Dietitian, I assess and monitor children to ensure that their growth is adequate – not too much and not too little.

What does it mean when someone says Failure-to-Thrive (FTT)? Is this term still used?

Failure-to-thrive is a broad term used to describe children who are unable to gain weight (and/or height/length) at a rate than other children of his/her age and gender. Looking at FTT, we consider things such as age, gender, medical complexity, genetics, under-nutrition, etc.  Failure-to-thrive has evolved from simply looking at the growth chart. The term "Failure-to-Thrive" is being used less, as it has a very negative connotation. It is being replaced with terms like "growth faltering".

How do you know if a child is growing enough or on the right growth percentile?

Typically a child should follow their growth percentile on their own growth curve and should not ‘cross percentiles’ significantly. Not all children should plot at the 50^th percentile. To see if a child is growing well, we need to see more than one weight plotted at a certain time. Looking at serial measurements (a number of weights over time) plotted on a growth chart can provide us with the details needed to assess if a child is growth adequately. 

How much food should a 2-year-old eat at each meal?

I would tell you if I knew – because a toddler’s appetite and intake will change at every meal and every day! It can depend on all sorts of things such as – Are they hungry? Too tired? Too excited? Mindlessly eating? Mealtime distractions? Did they do their ‘number 2’ (had a bowel movement) today/yesterday? Sick?  There is no set amount or measurement. What we need to pay attention to is their feeding cues and follow them. We can encourage, but not push/pressure (whether the pressure is positive or negative).

What advice would you give a parent if they feel stressed at mealtimes?

As a pediatric dietitian and a mother of 3 – tell me about parent mealtime stress! What to feed? How much did they eat? Did they have enough? It really doesn’t matter how much I know about feeding a child and nutrition – a caregiver is a caregiver – and we think our role is to make sure they are ‘fed’. Yes, in a way, but what we really have to understand is that children are the ones to decide how much (or if at all) they will eat. When you are stressed out at mealtimes, try the following:

• Look at the child’s cues rather than the volume
• Look at the positive little steps that are happening
• Take your conversations away from food/take a bite – instead, talk about the bird on the tree, or the snow on the ground
• Sometimes, you just have to turn away (while ensuring they are safe) for a second and take a deep breath

What if a picky eater refuses to eat a certain food group, like vegetables/meat?

Definitely no quick fix for that! Whatever the ‘non-preferred’ foods – start by allowing them to be present with the food/explore the food (touch/smell, for example).

Role modelling is another important tip  – if the child has never seen anyone eating carrot sticks, it’s unlikely that they will pick up carrots and eat it.

If the children are a bit older (not infants), encourage them to help with handling the food (e.g. washing/cutting vegetables; feeding a doll; passing food to mom; etc.)

One other thing to mention is that if you are really concerned about your child's overall nutritional intake, you should ask for an assessment of his/her diet to determine if there are certain nutrients (vitamins/minerals/proteins, etc.) missing and how to obtain them from other foods/supplementation.

What are some ways to add protein for a child that won’t eat meat?

Many caregivers are concerned about inadequate protein intake, but in my experience, most kids who don’t eat meat still get enough protein from other sources such as dairy products, seafood, eggs, legumes, and nuts/seeds. If a child is really lacking in protein intake, there are strategies we use such as adding ground nuts and seeds and using milk in cooking.

Should parents give picky eaters a supplement or vitamins?

Typically I would not suggest supplementing unless assessed/recommended by the doctor or a dietitian.  Most pediatric supplements and vitamins found on store shelves are very low doses and likely pose no harm; however, sometimes these can give a false sense of security to caregivers. There are also some liquid nutrition supplements, which have a lot of calories and protein in them as well. I always suggest caution when using these, as I have seen many cases where the child becomes dependent on them to a point where they don’t feel the need/hunger to eat or learn about actual foods.

Should a toddler be on a meal schedule?

I would say a meal/snack schedule is one of the most important foundations for children to learn about foods, develop a variety of foods accepted and to eat enough! Typically a toddler should be eating every 2.5 - 3 hours, with meals no longer than 20-30 minutes.

Does your family eat together? Why is this important?

Yes, my family eats together often. With today’s crazy work/school schedules research has shown that family meals help promote healthier eating, more variety of foods accepted, and overall weight control. One misconception is that family meals are always elaborate and involve a lot of preparation – not really. A family eating together at a designated location at the same time is already a family meal. For example, you can be having breakfast (milk, cereal and fruit) together or grabbing a sandwich together at lunch – those are all good! 

How much milk should a child drink each day? How much juice?

Typically we recommend that children over a year old should not consume more than 16oz milk (or ~500ml/2 cups). Drinking too much milk will affect their appetite for other nutritious foods.

As for juice, I would usually recommend no more than 4oz juice a day for toddlers. Even if it is freshly made juice, it can contain a significant amount of the fruit’s own sugar. Not only is having too much sugar in the diet a potential cause for cavities, it can also decrease the child’s appetite.

What if a child refuses to drink milk?

This depends upon the age of the child. If they are < 1 year old, seek advice from a dietitian.

Milk is a great source for calcium, protein and vitamin D. Milk itself is not a good source of vitamin D, but regular cow’s milk in Canada’s food system typically has added vitamin D. We generally recommend full fat milk (3.25% homo milk) before the age of 2 years. If a child does not drink milk, then it is important to see if they are getting enough calcium, protein and vit D from other sources in their diets.

Alternative milks (e.g. rice/hemp/almond) are not recommended to replace homo milk as they are typically low in fat, low in protein, low in calcium and may not have vitamin D nor calcium added to it. Some are also loaded with sugar.

Does constipation affect eating? What can parents do to help?

Constipation can definitely affect intake. I often ask parents to imagine a ‘hose’ representing our gastrointestinal tract from top to bottom. If there is some stool on the side of the wall of the ‘hose’, it is harder for our foods to pass through, and as the build up gets worse, we don’t feel like putting more food in.

In terms of dietary strategies, you want to make sure that the child is getting BOTH adequate fluids and fiber in the diet. Depending on the situation, the cause and the age of the child, there are different ways of addressing constipation. Consult your child's doctor or Dietitian for help if your child is constipated.

How can parents increase calories to help their child gain weight?

If there is a concern about poor weight gain pointed out by the doctor, one of the strategies we recommend to caregivers is to make ‘every bite count’. I tend to recommend adding (healthy) oils/cheese/ground nuts and seeds mixed well into foods. This does not increase the overall volume by much, but increases the overall nutritional content of foods.

If it is an infant who is not eating enough to grow, consult your doctor or dietitian to discuss fortifying the formula/breastmilk (if it is pumped breast milk). If the infant is only (or majority) breastfeeding, seek consult from a lactation consultant. 

How do you support children that need tube feedings?

The role of the dietitian to help a tube fed child is to make sure that the child is getting enough nutrition from their tube feeding formula and gaining weight appropriately.

Additionally, I often work with other feeding therapists to support tube weaning and promoting oral intake. It takes a concerted effort to help wean a child from tube feedings.

What’s the most important tip you would share about feeding kids?

Emotionally: Don’t worry too much and trust your child's eating instincts. (assuming they do not have any medical conditions that may affect their intake and hunger/satiety senses).

 Strategically...two things: Routine and Role model (family meals!)