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Kaitlin B. Proctor, PhD
William Sharp, PhD,
Jordan Gilleland-Marchak, PhD, ABPP

Long-term survivorship care involves comprehensive medical monitoring, including weight, growth, and nutrition. Survivors who received certain treatment agents are at increased risk for cardiac, bone mineral density, or metabolic problems, making adequate nutrition and weight management especially important. Aspects of the cancer treatment may also place some survivors at higher risk for difficulties with feeding and weight management. Side effects from some cancer treatments may lead to difficult or painful eating experiences. These experiences may create an association with feeding that may result in a child avoiding food due to fear of pain or discomfort. Alternatively, a young child may have missed some developmentally normative experiences with learning to feed during treatment due to reliance on internal feeds or required changes in dietary intake (e.g., focusing on meals involving highly preferred foods to meet caloric needs). A subset of survivors experience ongoing challenges related to feeding or food aversion which continue even after active symptoms causing pain or discomfort with eating have resolved.

What is normal: Periods of pickiness and/or changing food preferences, as well as variations in hunger, appetite, and interest in eating. This may include changes like suddenly refusing a previously enjoyed food or refusing all foods with certain characteristics, like foods that are green. For children who are exhibiting developmentally normal pickiness related to food, you may consider trying one of the following strategies:

1. Provide consistent, structured mealtimes with predictable expectations.

2. Provide multiple opportunities to try novel foods prepared in a variety of ways, as research has shown that it takes eight to 15 exposures for a child to develop comfort with a new food. When offering new foods, present small amounts of the new food initially as this experience will likely be challenging for children with picky eating. For example, provide a few bites rather than a heaping portion until the child is consistently more comfortable with the food. Reducing the amount of food may increase the child’s likelihood of exploring the new food and promote success.

3. Enrich the meal environment through the use of praise for desired mealtime behaviors, such as sampling bites of non-preferred or new foods, as well as other mealtime behaviors like remaining at the table, using good table manners, etc.

4. Minimize attention (even negative attention, like coaxing or scolding) for undesirable mealtime behaviors like whining or negative statements about food.

Beyond picky eating: A subset of survivors may restrict the volume and/or variety of food being consumed during meals based on their medical history. This may present as severe food selectivity (such as complete rejection of one or more food groups along with high preference for snacks, fats, and processed foods), as well as frequent and intense behaviors to avoid food, which may be confusing and challenging for families. Children with this level of mealtime concern meet criteria for Avoidant Restrictive Food Intake Disorder (ARFID).

Possible symptoms include:

. Poor weight gain/growth or significant weight loss
. Dependence on a bottle, formula (e.g., Ensure, Pediasure), or feeding tube
. Mealtime tantrums or prolonged meals lasting longer than 40 minutes
. Distress and anxiety with foods, especially new foods
. Inability to increase the texture of foods (e.g., moving from purees to table foods)
. Extreme pickiness (accepting less than 12 foods)
. Excessive weight gain as a result of severe food selectivity.

Children whose feeding problems impact health or nutritional status may require higher levels of support. If you are concerned, talk with your child’s survivorship care provider or primary care physician to discuss whether a referral for additional assessment would be beneficial. It is important to match the level of support with the severity of the feeding problems. For mild feeding concerns, nutrition education with a dietitian or outpatient intervention with speech-language pathologists, oral motor therapists, or behavioral therapists can be beneficial to address specific feeding difficulties.

Children’s Healthcare of Atlanta offers a multi-disciplinary feeding program for children with more complex feeding problems. This program has demonstrated excellent effects for patients and families. Additional information on pediatric feeding disorders can be found at feedingmatters.org.