GNS Vietnam 2025: Nutrition for the Growing Child – Developing Positive Mealtime Behaviours

Marion Aw, FRCPCH

Narrator

Introducing Associate Professor Marion Aw, head of the Division of Pediatric Gastroenterology, Nutrition, Hepatology and Liver Transplantation at the Department of Pediatrics, National University Health System, NUHS Singapore. Professor Aw currently serves on the Nutrition Subcommittee for the Asian Pacific Society for Pediatric Gastroenterology, Hepatology and Nutrition and was previously the chair of the GI subcommittee. Alongside her clinical work, Professor Aw is deeply committed to educating and mentoring both medical, undergraduate and postgraduate pediatric trainees.

She was the Program Director for Pediatric residency training at National University Hospital. She currently serves as the vice Dean of students at the Yong Loo Lin School of Medicine. Please welcome Professor Aw.

Professor Marion Aw

Okay, so, hello again. And I think I'm probably the last speaker before lunch. So, while you're still sitting there thinking when you're going to be hungry or not, I am going to go through some really important talk and some practical tips about nutrition for the growing child. But I'm going to really focus on developing positive eating behaviors.

And I think this is a really important topic because a lot of our patients, parents or caregivers come in always concerned about ‘my child's not eating’ and ‘my child's not sitting down to eat’, and ‘my child's very fussy and picky about their eating’. I'm just going to cover, these two things in my talk over the next 20 minutes or so. Before I jump into the talk, this is the first question.

When do children experience the fastest rate of growth? Answer that on your own. First year of life? Second year of life? Sixth years when they start going to school? Or at puberty? Excellent. First year of life. Well done. Okay, so this is a graph that shows pictorially how fast a child grows in the first year of life.

Average length at birth is about 50cm at one year. They are about 75. So, they've grown 25cm in the first year of life. Nowhere else in the rest of their life will they grow so fast. There is a little blip at puberty. But really, the fastest rate of growth, is in the first year. Of course, not counting in utero.

And really, there are some critical windows for growth. You’d not be surprised to know that skeletal muscle protein dominates the postnatal protein accretion in a unit, and that the weight of a baby at birth and at one year predicts 10 to 15% of their fat free mass. Perinatal and the first year of life is a very crucial time for babies, or rather, the future human being to establish a muscle mass and is also the most vulnerable pivot where you can actually have protein malnutrition.

Next question. We talked about protein. Now we're talking about fat. How many calories in breast milk come from fat?

Well, this one I didn't put in a “not sure”. You might have to guess if you're not sure. 10%, 20% 30%, 40%, 50% or 60%? Quite a wide range. Yeah. So surprising. Maybe you didn't realize 50% of calories from breast milk come from fat. And this is how it's calculated. The bulk of breast milk is water. 87% water followed by lactose which about 7% and fat is 4%.

Full fat is about 4%. And if you remember breast milk calories, 67 calories per 100ml. If you have four grams of fat, that is 36 calories. So just over 50% of calories come from fat. And these are some things that patients and parents may not actually be aware of. Now, when we talk about feeding versus eating, what is that difference?

Why do we say we feed the child versus the child is eating. Feeding really means the interaction between the caregiver and the child, the person who's feeding the child, and the child who's doing the eating. Whereas eating is when the child is eating by themselves or feeding themselves. And really eating is a social activity, right? So why is it so important to develop positive eating behaviors?

Because eating is how a child consumes appropriate nutrition, whether it's macro or micronutrients. And definitely not surprisingly, it's for physical growth as well as cognition. And as we heard from Peter this morning, and that the social interaction in a young child is so important. And there's nice studies to show that if there is increased parental pressure to eat, there's resistance from the child, with a decrease in the child's eating and weight gain.

And whether this is, you know, the chicken or the egg. Studies have shown that maternal pressure to eat at one year negatively predicts a child's weight at two years. Whether it’s the chicken or the egg, right? The child who doesn't eat very much, mum is more stressed, mum actually tries to force the child to eat.

And then this results in child eating even less. It's really important to figure out how to break that cycle. Now what are some of the common concerns? If you think back about the last few patients that mums have told you about why they were concerned about the child's eating, is it my child when trying new foods?

My child's a very picky eater, very fussy. My child needs to be entertained while they eat right. How many times you go out and you eat, and you see the device, the parents put the device in front of the child so that the child would eat. The parents had to entertain the kids when they're feeding them. My child wouldn’t sit still.

Walks around, plays. You know, and my child eat something on some days. And the favorite food one day, the next day, the child's not eating it. So, the parents are really frustrated. Now you put them into two big groups. It's quantity and quality of the food is eaten. And then the other way the other big group is the behavior around eating.

And that's important because when the patient comes to you and although the parent tells you, my child's not eating fussy eater, I've got difficulty feeding my child. Then really, the two big groups you need to ask in your history, right? Quality and quantity of food, this being eaten and the eating behaviors around eating. So, if you cover these two things, you probably covered most of it.

And I'm going to jump into two cases. And this is the first one, I'm not sure whether this child sounds vaguely familiar to what you might have seen in a clinic. Three-year-old boy parents are concerned he's not eating enough. Going out is now becoming a problem because he's very fussy and he eats only a few things.

Where they go really depends on what he would eat. He would not sit still. He wants to run around, play. They have to put an iPad to keep him engaged at the chair. And sometimes meals can last more than 60 minutes. Sounds, sounds vaguely familiar, like what you might have come across. So how would you assess him if you're sitting in your clinic?

And what other questions would you ask in the history? I'm going to give you 45 seconds to speak to the person on your left or right. This is you have a chance to talk now; how would you assess him and what questions would you ask in history? 45 seconds to talk about this. Okay, I'm going to bring that to a close.

If you have a chance to discuss, I'm not going to ask anyone to volunteer answer. So not to worry. When you take a history of a child who is said to be fussy eater, not keen eating, I will look at it from three broad areas. So, the first thing is the food, right? What is being offered?

How much? How often? Why did the parents consider him fussy? What would he eat? What would he not eat? And I think this is really important. Sometimes when you figure out what the child's eating or not eating, you think about it in terms of texture and consistency. Can you classify them? The child is actually rejecting the tougher tasting food, or is a child rejecting certain types of food?

The child eats only crispy stuff and does not eat the mushy stuff. Take a history of what is being rejected or what is being eaten. The other big thing to think about is the child. Is a child interested in eating right? What does the child do when the child's eating? Does a child sit at the table? Does the child need to be distracted?

Does the child have any symptoms when the child is eating, such as choking, gagging, vomiting, discomfort and of course, the last thing is sometimes we forget to do this, is to actually ask, what do the caregivers or the people feeding the child, what do they believe in? How do they react and respond to the child's behavior? Are these sensitive to the child's cues?

What is the feeding environment? Location? And we heard from Peter earlier, it’s really that interaction between the caregiver and the child. He said the child smiles, you smile back. And you have to repeat it a few times. And that's really so important because a lot of times when parents see the child, all they’re interested in is getting the food into the kid.

The plate has been finished, and the child has to finish eating without really saying ‘is the child's mouth empty?’ ‘Has a child actually swallowed the earlier spoon?’ Do you wait for the child to finish before you put the next spoon in? And if the child sort of leans back, do you chase the spoon or do you wait a while and say, okay, you know, why is the child turning away?

That responsiveness of the parent is so important in terms of feeding. Additional history - back to this three-year-old kid. He eats better in school, he goes to school and in school he can feed himself, and he does have a portion. He doesn't finish everything, but he does about half.

He doesn't have any past medical history, no other concerns. You know, systems review when you examine him, he's really active alert. He's not pale, physical exam is otherwise normal. Now, very important, every time you see a child in your clinic you must plot the height, weight and OSC. So, the growth of the child is really important. When parents say I'm concerned when my child not eating so much, remember to plot the growth.

I hope you can see the points on this. You can see the child's tracking just under the percentile for weight, and on height, the child actually has crossed a little bit. This is actually, I would say, a point for concern. So how would you approach someone where you think the weight is actually tailing off?

If that weight is tailing off, then you worry there's an imbalance between calorie intake and energy expenditure. You have to assess is the child actually eating enough calories? If the child is eating enough calories, then are there increased losses or increased metabolic demand? There must be some reason to explain why, despite eating enough, the child's not putting on weight.

If the child's not eating enough, then the question is, is the child not eating enough because the appetite is small? Is the child's appetite small because it's limited by pain and discomfort? A medical reason is limiting the child's appetite. Also, child eating less by choice because a bit fussy about the taste and textures. A concern. Or is the child unable to feed? So, this is one is really neurological.

It's the children with neurological dysfunction or abnormalities of structure of the upper airway and mouth that may have difficulty, but those would be obvious. The children have these problems, that would be obvious. As you approach a child, three-year-old child with fussy feeding, it is important do a nutritional assessment. There's some tailing in growth that tells you there’s inadequate calories.

There's a lack of mealtime structure. The child eats okay in school, but mom has a problem at home. So obviously there's some structure or behaviors around mealtimes. That is the issue here. Is there some indulgent parenting going on and the child has a small appetite. Even in school it's only half share, right? These are some of the things I would sort of think about when I see a child who's a little bit fussy and growth is not so good.

How can one increase a child's caloric intake? The first thing, of course, is to feed on a schedule that encourages hunger. The most common response of a parent with a child who's a small eater or fussy about eating is to keep feeding the child. One meal will last a whole hour and before 1 or 2 hours, they are up feeding the child again.

They're constantly feeding the child, and the child has no chance to actually get hungry. So, a quick question as a parent is ‘how do you know the child is hungry?’ If the parent says, I don't know, I never wait for the child to be hungry because I'm just feeding the child. Then you know, they're actually not feeding at the correct schedule.

So, you want to make sure that the child experiences hunger. And then you feed the child, then the child learns, “I've got this funny feeling when I eat, I feel much better”. Generally, we'll say two and a half to three hours - don't feed at an hourly schedule. Build the ‘anchor foods’ in the diet. The four main food groups - don't forget fat in a very young infant.

Remember, 50% of breast milk calories come from fat. A very common mistake parents do in the first year of life is you can basically cook food with no fat at all. If you boil it on the stove or do something, unless you're actively adding fat or using food as fattening it, they are actually eating a very low fat diet, if you're not careful.

And if the first weaning foods are actually root vegetables, vegetables, and fruit, there's almost no fat in those foods. And of course, if the child has a really small appetite while you're trying to build the good habits, you might need to use a high calorie supplement. And sometimes you see you either do it yourself at home, you can make your own smoothies, milkshakes, or you can do multivitamins and things like that.

Depending on what the child is eating and willing to eat, you might need to supplement for a short while. Now, what are some other good feeding habits? Again, feeding to encourage hunger roughly in small children, you're looking at 5 to 6 eating opportunities. Small children might need to eat 5 to 6 times a day. I would generally limit mealtimes to about 30 minutes because I tell parents your ROI, your return on your time investment, goes down.

They will tell you after 25-30 minutes, the child's really not eating very much. The more effort I put in doesn't translate to more eating. Tell them by 25-30 minutes you probably want to stop. So, that decreases stress for themselves and stress for their child. Avoid distractions; generally, I would say feed at the same place at the same time.

Highchair, sit at the same table, serve age-appropriate foods. Sometimes parents in their mind might give too tough foods for the kid to eat. The kid is really, you know, one year old, 14 months, they really cannot manage tough foods. Tolerate mess. You want them to self-feed. So, encourage self- feeding is really important.

But sometimes when kids feed themselves, the food goes all over the mouth, more on the floor than in the mouth. So, sometimes I tell parents from a practical perspective, put newspaper on the ground. Even though there's a mess around the table, what they need to do just put the newspaper together and throw it away so you don't have to clean the floor. And of course, consistently offer new foods.

Offer one new food every 3 or 4 days and that will actually increase exposure. We always say on the baby's plate or infant's plate, add food that you know they will eat, and always put on the side something new, so that the child can actually try something new. And even the child didn't eat it, it's all right, because the child will still be eating their regular foods.

Now, one really important thing about social interaction I want to emphasize here is eating is a social activity. How many of you, if you eat by yourself, will take out your own device?

Right! You will take out something. You're not just going to sit there and just stare into space. And the same thing with children. When children are eating, they really depend on the caregiver to interact with them. You're not going to be eating in silence. They will need interaction. And that's the social interaction is a great opportunity for parents to actually talk about food, talk about the taste, talk about colors, talk about why they're eating.

It's really important that that social activity occurs. Second case; 14-month infant who vomits and would eat has been to the clinic. Past history of reflux in the first six months of life. But the vomiting, not surprisingly, settled at about 7 to 8 months when solids were introduced. She had some gagging and vomiting with lumpy food, but was okay when it was finally pureed.

Currently, at 14 months, she drinks milk, loves milk, 240 ml of milk four times a day, drinks it really quickly in ten minutes. It’s gone. Parents offer her solids three times a day. She generally doesn't like to eat. She’ll shake her head and turn away. She might vomit and gag if she's given lumpy food. Otherwise, very well thrived. Putting weight on the 75th percentile.

And when you examine the child it’s a normal physical exam. What are some of the key issues here? I want to give a chance to talk about this, but just think in your head if this was the patient sitting in front of you, what are some of your key thoughts as to what's going on?

So, the child is growing really well. That tells you enough calories, and you're not surprised because milk is a good source of nutrition. But the child is drinking a huge amount of milk, and the calories are being drunk and not eaten. If the child turns away, this food refusal, it's a learned behavior. So, is it a learned behavior - the child associates pain with eating?

Or is it because the child has been given textures that the child cannot deal with? And therefore, when the child sees something that they cannot eat, they just turn away? Kids are smart. If you see something that is going to cause you pain in discomfort, you're not going to do it. If you see something that you know 100%, you're not going to be able to eat.

You're not going to let your parents put it in your mouth. They are really very smart. So, you need to be careful about that, and vomiting and gagging. Is reflux still a problem here? What is triggering the vomiting. Is it primary problem or is it secondary. Because the child's gag. So, the child can’t swallow a piece of meat, gags and then vomits.

So, the history taking is really important. What is causing the child to vomit? Is it they gag and then vomiting? The child never gags the child wouldn't be. Vomiting is really important to make sure you got your history correct. So as a broad principle I always tell parents; less than one year old you drink your calories, more than two years old, you must be eating your calories.

And in between you need to make that transition. And this why weaning and getting solids is so important to kids. You start them on solids, the first few months of eating really is for practice, tastes, learning that new skills - not really for calories. But after that, beyond one year of age, you really need to be eating more and more calories from the food.

This was some data which we picked up from our feeding clinic, and it was actually, to be honest, new knowledge for me. I didn't realize that there was this issue. We looked at our patients who were otherwise well, but labelled as “picky eaters”. We had about 150 children. Just over half of them were males, and the median age was 26 months.

So just over two years of age. And what was really surprising to me was that 40% of them had underlying delayed feeding skills and/or sensory issues. Okay, so quite a large number of delayed feeding skills, and I think at least in the Singapore context, the delayed feeding skills were because the children had some difficulty with the lumpy textures, and they were gagging.

And parents went back to smooth textures because they were eating the smooth textures well, without gagging. But because they kept giving them the smooth textures, the kids never really learned how to deal with lumps, and they continued to gag and reject the solids. So, the delayed feeding skills were actually because parents were afraid of the gagging at the mealtime.

Now, when would you suspect a sensory issue? We did have a subset of children who had sensory issues that resulted in their feeding refusal or their picky eating. I think when they have selective feeding from the point of eating only a small range of food. If they eat less than 15 different foods, then they are severely selective.

If in your history they're refusing foods based on taste, texture, smell, or appearance, that means they smell the food and they don't want it. Or if they become visibly anxious when you show them something they don't want to eat. I mean, they look at it and then they start going away, or they get anxious. So differential diagnosis when you have selective eating is - are you dealing with a sensory issue or you're dealing with chewing skill deficit?

And some tips I would ask if you're worried about sensory issues. You ask in the history ‘is the child sensitive to touch, light and sound?’. And one thing which I find a good question to ask is ‘do they like to play with sand?’ ‘Do they like to get their hands dirty?’ ‘Are they okay with it?’ A second question to ask is when you put on a T shirt for the kid, ‘are they unhappy if it's rough?’

If sometimes they've got a pattern on it and they don't like it, they like the shirt of a certain texture. That gives you an idea that there are underlying sensory issues. Sometimes you have sensory issues in an otherwise well child, sometimes you have sensory issues in children who might have autism or are on the spectrum.

And sometimes I find that feeding difficulties are actually the first presentation of kids with behavioral issues. So, what are some of the clues when you take a history from your patients? Prolonged mealtimes, disruptive mealtimes that are stressful, the parents have to distract the kids - song and dance before the kid will eat – or, if there's prolonged reliance on breast or bottle feeding.

If milk is the main source of calories beyond 12 months of age, you might have a problem. So, you need to be careful. Okay, so my key take home messages is the importance of developing positive mealtime behaviors. Because nutrition is a key for normal growth and development in children. And you need to pay attention to not just what is eaten, but also how it's eaten.

And these are strategies to promote positive mealtime behaviors. You’re never too early to start early. The minute you start weaning - the parents are weaning the children - you actually encourage them to feed on a schedule. Limit mealtimes, eat in the same place all the time. The minute the child is developmentally able to reach out and puts it in their mouth.

Encourage self-feeding, consistently offer new foods. It is important to interact with the child, and parents are role models. I always tell parents; do you eat the vegetables? If the parents says no, I don't eat vegetables, then I'm not surprised the child's not eating them. The parents have to actually role model the behaviors they want for their children.

Thank you.