Introduce self and topic. Make connection between this presentation and other recent trainings (like other modules in this series. Or, discuss relevance of topic by mentioning any recent news stories related to childhood obesity and/or issues of feeding young children). Today’s presentation is about a very important – and sensitive – topic. As families and health professionals become more concerned about problems of childhood overweight, more attention is being focused on the feeding of young children – and on their patterns of growth. While attention to healthy feeding and healthy growth can be positive and supportive of parents, caregivers and children, it also has the potential to create problems rather than prevent them. POSSIBLE DISCUSSION: Ask staff what news stories they may have seen recently – or what questions they would like to have addressed during the session.
Healthy Feeding WIC’s Job WIC’s job is to get children started right. Since about 50 percent of infants born in the US have some contact with a WIC program, all of us have an important role to play in helping families with this important issue. When discussing the issue of weight in childhood, it is always important to emphasize GROWTH PATTERNS rather than a specific weight at one point in time. Health care providers – and parents – need to realize that weight and height at any one point are not inherently “good” or “bad.” A single growth point tells us only how the child's size compares to that of other children. As savvy health care providers know, it is crucial to &quot; track before you panic !&quot; What is important is to observe growth over time – and to compare a child’s pattern of growth to norms and standards that are considered to be healthy. As WIC staff, we are in a powerful position to do enormous good for parents and children. By being in the right place at the right time with the right information, we can help families establish healthy feeding relationships – and help children get a healthy start on a healthy weight for a lifetime.
Levels of Intervention with Feeding In any health care setting, there are different levels of intervention. Different types of problems require different levels of intervention – and involve different types of health care providers. WIC is a primary prevention and intervention program. Families who require secondary and tertiary intervention for more serious feeding problems will need an appropriate referral for clinical care. Families who are receiving clinical care may also be participating in WIC – and can continue to benefit from education and support during their WIC visits. POSSIBLE DISCUSSION: Ask staff to identify specific individuals/places they might refer a WIC client for secondary or tertiary care about overweight concerns.
As a primary intervention program, the role of WIC is to provide education and information for parents and other caregivers. In this role, WIC staff can offer: Support for developing healthy feeding relationships between parents, other caregivers, and children Anticipatory guidance for what adults can expect from their children during various stages of feeding Explanations of normal growth – and interpretation of growth measurements Encouragement for age-appropriate physical activity – and education on ways that parents can play with their children
It is important for WIC staff to understand what a healthy pattern of growth is. WIC staff also need to be able to explain growth measurements and patterns to parents (or other caregivers) in terms that they can understand.
The foundation for any discussion of growth patterns is the fact that: Children are excellent regulators and tend to grow in accordance with their genetics. Since each child has a unique set of genes, this means that they will also have a unique pattern of growth.
Healthy Feeding Children tend to grow predictably. In these infant growth charts, we see a child who is growing right along the 50th percentile in terms of both weight for age and length for age. Consistent growth, whether it is high, low or in the middle, is likely to be normal growth. However, growth divergence may or may not be normal.
As we all know, predictable, healthy growth is not a perfect system. Things can get off track in a variety of circumstance, like: When parents and children do not have a healthy feeding relationship and when children lead sedentary lives. When children are not given much control over how much they eat – and so begin to lose their ability to self-regulate their eating. For example, when well-intentioned adults make them clean their plates or eat “just a few more bites.” When the food and beverages offered to children are high in calories, fat and sugar – and low in nutrient value. The most important role of WIC is prevention – to keep the system “on track” by educating and supporting parents in healthy feeding and active lifestyles. WIC can also provide primary intervention – when the system is beginning to get off track – by educating parents about healthy habits and providing early problem-solving strategies.
The goal of growth assessment – taking accurate measurements and plotting them accurately on growth charts – is to determine whether a child’s pattern of growth is healthy and normal. When a child’s growth seems to diverge – or move away from -- an existing pattern, the goal is to determine whether the divergence is normal, healthy growth or whether there is a problem that requires some level of intervention. The goal of growth assessment is see if the “system” is working – or whether things may be getting “off track.”
Slow divergence over time is likely to be normal. In this slide, we see the two-year-old child at the 95th percentile weight for age. Over the next several years, his weight gradually diverges downward to the 75th percentile and then the 50th percentile. This pattern is most likely a healthy pattern of growth – perhaps as the child grows predictably toward his genetic potential.
Rapid growth divergence may also be normal and healthy. This girl diverged from the 3rd percentile to the 95th percentile weight-for-length between one month and 18 months. She was a twin and seemingly, she had some catching-up to do in terms of her growth. Notice that after her “catch-up” growth spurt, her weight-for-length stabilized around the 75th percentile. An important question for WIC staff is: How can we tell the difference between the child whose weight is diverging normally and the one diverging abnormally?
In terms of growth patterns, rapid divergence over a relatively short time is likely not to be normal. To illustrate, let's look at this girl’s weight-for-age chart. Her rapidly divergent growth was alarming by any standards. After growing consistently along the 75th percentile until she was 15 months old, her weight suddenly took off from the curve, rapidly crossing several percentiles. Growth patterns like these raise several questions for WIC staff: How do we determine what is happening in a situation like this? How do we provide the parents/caregivers with the appropriate level of care? What can WIC staff provide in terms of primary care? Do they need a referral for additional help?
Talking to parents about their children’s growth is an extremely sensitive issue. Parents want to be good parents – and they want to feed their children properly. Parents may feel embarrassed, defensive, or even angry if your questions make them feel like they are doing a bad job of feeding and caring for their children. Rather than just telling parents what is wrong with their child’s growth (and what they should be doing better), it is more effective to first find out how they view the situation. If they are able to bring up their concerns and questions, they will be more likely to be receptive to your suggestions for possible changes. POSSIBLE DISCUSSION: Ask staff to share their reactions to these questions: What other questions might be important to ask? What other ways have they found to discuss these important questions with parents?
Healthy Feeding Asking the right questions and providing primary education is critically important – because interfering with a child’s feeding pattern may have serious consequences. If, for example, parent’s are told (or believe themselves) that their child is overweight, they may try to keep the child from eating too much. If they think that their child is underweight, they may try forcing them to eat.
The critical questions then are: What is interfering? What is a normal, healthy feeding relationship between children and their caregivers? When might a feeding relationship cause problems? It is also important to realize that parents may not see their actions as interfering. In fact, they may view their actions as the job of the parent – they may believe that parents have to tell their children what and how much to eat.
Division of responsibility Optimum feeding for healthy growth depends on establishing and maintaining a division of responsibility between parent and child. This division of responsibility is evidence-based – and is outlined in detail by feeding expert Ellyn Satter in her books and materials. It has also been supported by several researchers, including Susan Johnson in Denver, Leanne Birch in Pennsylvania, Jean Skinner in Tennessee, Jennifer Fischer in Houston, and many others. The evidence is clear: Optimum feeding supports food acceptance, food regulation, and healthy growth. In infancy, the division of responsibility is simple. The parent gets to choose what – breast milk or formula. The child determines everything else: How much, how often, how rapidly. As the child gets older, the division of responsibility changes. The parent gradually takes on the when and where of feeding in addition to the what. However, the child remains responsible for how much she/he eats of what the parent has offered. Indeed, the child determines whether she/he eats at all.
Crossing the division of responsibility The consequences of crossing this division of responsibility can have a serious impact on children’s eating and on their growth. When a child’s food intake is restricted, they become food-preoccupied and they are prone to overeat when they get the chance. Several studies have shown that restricted feeding tends to make children fatter. Food restriction gets the system “off track” – since children are unable to effectively self-regulate with internal cues of hunger and satisfaction. Research also show that parents who restrict their own food intake tend to raise fatter children. This may be because they directly restrict their children’s intake – or because the whole family becomes food-preoccupied and tends to overeat. Pressuring children to eat – or to eat specific foods – also backfires. When children are forced to eat certain foods, they become less interested in them. This means that pressuring children to eat vegetables tends to make them like vegetables less – not more.
When some researchers recently talked to parents about feeding relationships, they discovered that the adults understood and accepted their role (to decide WHAT, WHEN, and WHERE). However, the parents did not believe that their children could decide WHETHER and HOW MUCH to eat. The adults did not trust that children would eat the right amounts unless they told them how much to eat. In other words, parents saw that it was their responsibility to interfere in a child’s eating. POSSIBLE DISCUSSION: Ask staff to share their own experiences in this area. Do they think that parents have more trouble with the child’s role in a healthy feeding relationship? How have they been able to reassure parents that their child can make healthful decisions about whether and how much to eat?
It is reassuring for parents to know that when they do a good job with feeding, their child will do a good job with eating. Part of a parent’s job is to trust that children will eat well. You can help parents learn to trust children’s eating by sharing these facts as appropriate: Children will eat. Even sick babies have the drive to eat and to survive. Children know how much they need to eat. From birth, they are good at listening to their internal cues and regulating their food intake. A child will stop in the middle of a bowl of ice cream if she/he has had enough and is satisfied. (Many adults have lost touch with these natural abilities.) Children will grow predictably – based on their genetics. A child might be large, small or in between, but growth will be predictable. Children will eat a variety of food – If they are OFFERED a variety . Over time, step by step, children will learn new eating skills and “grow up” with their eating, just like they mature in other ways.
The WIC Program’s role is primary intervention – and this is where we can really make a difference. Talking and problem-solving at a WIC visit is primary intervention. Reading a book or brochure about feeding is also primary intervention. Some parents can make changes in their interaction with their child based on primary intervention; some cannot. Parents and caregivers who are able to change can: accurately self evaluate. They can apply what they are told, or read about, to themselves and their situation. see the situation from the child’s point of view. For example, they could see how restricting a child’s food intake would make them voracious – and might lead to overeating. recognize their own issues (like trying to lose weight or to control their own eating) and set them aside. follow through with change, even when it gets hard. These parents consistently set limits – even if their child whines or complains about it.
A healthy eater It may be hard for parents, especially first-time parents, to know exactly how a child behaves when he is a “healthy eater.” It may be even harder for parents (or caregivers) who are not “healthy eaters” themselves to judge what healthy eating looks like. Adults may also lack confidence in their own abilities to establish a healthy feeding relationship. This may be particularly true if they are receiving contrary advice from other family members or caregivers. Since myths about feeding young children are commonplace, you can play a very important role in helping parents understand “what is a healthy eater?”
Healthy eaters (children and adults) can be defined in several ways. A healthy eater: eats from internal cues – of hunger and satisfaction. A healthy, normal eater will sometimes eat a bit more – and sometimes eat a bit less. In general, however, their eating is driven by internal cues – rather than external rules (like finishing everything on your plate). enjoys a variety of foods from different food groups. This does not mean they love to eat everything; we naturally have a preference for some flavors and textures over others. It is normal for children to go through phases with foods (food “jags”) – when they seem to eat only a few items exclusively and then switch to others. experiments with new foods. Children are naturally “neo-phobic” (suspicious of new foods and beverages). With repeated exposure, healthy eaters will gradually learn to enjoy new items. Healthy eating (combined with regular physical activity) is one of the most important ways to insure that children grow healthfully – and that adults achieve and maintain healthy weights.
Raising a healthy eater During the first few years of life, healthy eating varies with the age and developmental stage of the child. One of the things that parents, especially new parents, need most is guidance on the different ages and stages of healthy eating. This is exactly what the WIC program can provide as primary prevention and intervention care.
This simple grid outlines three basic stages of eating from birth to 5 years – and indicates the parental/caregiver responsibilities and children’s abilities at the different ages. POSSIBLE DISCUSSION: Review grid – and ask the audience to share an experience or example of the most difficult challenges in feeding at the different stages.
According to child feeding experts, optimum feeding for the newborn is based on information coming from the child. Rather than trying to stick to a schedule or restrict food to a certain amount, newborns must be allowed to eat as much or as little they want.
Healthy Feeding Infant feeding times are not just about nourishment – they are also important times for parents and children to bond. One way in which breast-feeding builds the bond between mother and infant is that it allows the mother to learn to recognize her baby’s cues and messages. In many ways, infants and children have the capacity to show us what they are ready for and what they can do for themselves at different ages. We just need to watch and “listen” carefully.
Division of responsibility During infancy, the division of responsibility is simple: The parent gets to choose the what—breast or formula. The child determines everything else: How much, how often, how rapidly, at each level of skill. The parents’ job is still very important. It is to calm and organize the infant – and to feed in a smooth and continuous fashion paying attention to the baby’s cues.
Developing a healthy feeding relationship is a complex task – especially in today’s fast food world. This is especially true when a child is moving from breastfeeding (or formula) to solid foods – a time of major transition for both babies and the adults who feed them.
Communication and feeding skills The communication between the infant and parents is very important for feeding. Parents need assistance in listening to the nonverbal ways that children let us know about the skills they have mastered and what they are trying to learn to do next. If adults ignore messages for too long, they may miss the window for introducing infants to new things – like solid foods. Or if they try to make the infant learn things before they are ready, they may make it very hard for the child to learn healthy habits about food and eating. Babies are ready to transition to solid food when: They can sit up and if they are stable while sitting. They have the necessary fine and gross motor skills, like the whole hand grasp and the pincer grasp, to get the food from table to mouth. Coincidentally, about the time that children need the nutrients in solid foods, these motor skills begin to emerge. Isn’t it wonderful that as our needs change, our skills for the complex task of eating change as well?
Division of responsibility During this transition, there are lots of feeding decisions for parents to make: WHEN means establishing routines for meals and snacks. This may be hard for parents, especially young parents, who did not grow up eating regularly themselves. WHAT means making decisions about the safety, health, and acceptability of foods and beverages. Parents have to decide if it is OK for their toddler to have things like hot dogs and soft drinks. WHERE means creating kid-friendly places to eat at home (age- appropriate furniture, dishes, utensils, cups, etc) – and deciding where and how often to eat away from home (like at fast food restaurants). WIC’s role in primary prevention is crucial at this time – to support parents in making healthy decisions and to help insure that things stay “on track” for healthy growth.
How children learn about food Children have their own ways of learning about food. How they choose to learn about eating depends on their age and their developmental stage. One of the most frustrating and challenging times for parents in feeding their children is during the time that their child is 18 months to 5 years of age. During this period, children are gaining skills in muscle coordination and movement – and they are learning how to master their environment and be independent from their parents. During the “terrible twos” children like to say “no”, “me”, and “mine!” These verbal accomplishments demonstrate the pre-schoolers focus – she/he is the center of her/his universe. The preschooler’s task is to learn what she/he can do and what the limits on her/his world are. Therefore, she/he is constantly pushing the boundaries and will generally push until he consistently meets a firm “NO!” from an adult.
Many times, a young child will exert independence in the eating realm. Mealtime can become a battleground unless the child is given sufficient opportunity for mastering her/his “eating universe.” A preschooler may do battle by refusing to eat foods that she previously liked or by becoming much more resistant to trying new foods. A very helpful message for parents is that this is normal behavior for children of this age and they don’t need to become overly concerned unless the child’s growth is “getting off track.”
Division of responsibility Children have relatively simple feeding needs during the preschool years. However, it may not be so simple for parents – especially if they are under lots of stress or have never had role models for a healthy feeding relationship themselves. Preschoolers do best with eating when they: Have regular meal and snack times, rather than constant grazing. Enjoy family meals in a calm environment with few distractions. Are offered a variety of different foods to choose from, some familiar and some new. Are not pressured or forced to eat certain foods or specific amounts of foods. Have the chance to develop age-appropriate eating skills, like serving food onto their plates, pouring milk into their cups, choosing food at the grocery store, and helping to prepare meals and snack foods.
Talking to parents about growth and feeding As we discussed at the beginning of this presentation, talking to parents about their children’s growth and feeding is a sensitive issue. WIC’s role in primary prevention and intervention is to provide parents with the support and information they need – to raise healthy, happy children. If we carefully consider what parents want and how best to have conversations with them, we will be able to do this job more effectively (and we will probably also enjoy it more!). Every time we talk with a parent, we have the opportunity to learn about the parent’s relationship with his or her child – and to build a positive relationship with the parent.
What parents want In order to see you as a source of information and support, parents need to feel that you are on their side – and that you understand that they are trying to do a good job. With this goal in mind, it is absolutely critical to remember the four key desires of parents: To have happy, smart kids. To be seen as experts on the subject of their own kids. To be seen as acting in their kids’ best interests. To make parenting as easy as possible.
It is also important to approach issues in a positive way – so the parent does not feel blamed or defensive about their ability to be a good parent. Open-ended questions put the parent in control of the conversation – and allow them to express their concerns. Most parents do have questions and concerns – they just need to feel comfortable enough to express them. POSSIBLE DISCUSSION: Brainstorm other open-ended questions that staff can use to make clients feel comfortable and accepted during a WIC visit.
Client and staff division of responsibility It may be difficult for some families to make changes – even if they are healthy and important to make. Some clients will only be able to take “baby steps” for change – and others may not be able to make any change at all. Just like it is important for adults to trust that children can decide how much to eat, it is important for WIC staff to trust that parents can determine how much change they are able to make. We can share the benefits of change. We can help clients identify the possible “baby steps” toward change – and brainstorm ways to overcome their obstacles to change. We cannot force people to change – or to comply with our recommendations. Most importantly, we can develop a positive relationship with our clients – so that they can see us as a resource when they are ready to make some changes.
Client and staff division of responsibility A healthy feeding relationship is based on a division of responsibilities between parent and child. In a similar way, a supportive relationship between WIC client and WIC staff is based on different roles and responsibilities. The responsibility of staff is to provide information and to support positive parenting choices. It is the parent’s responsibility to decide whether to change – and how much change makes sense for them.
WIC’s job is to teach parents about healthy feeding relationships with their children from birth and to help them accept their children’s natural body sizes. WIC can help and support parents in developing healthy lifestyles so their children can grow into bodies that are right for them. As we talked about earlier, eating is a complex task that requires many organs and systems. This means that feeding children well is also a complex task. As we help WIC families with their children’s eating and learning, and help them listen to the messages their children are giving them, we can help build healthier, stronger children, families, and communities.
Healthy Feeding for a Healthy Weight
Healthy Feeding for a Healthy Weight <ul><li>WIC’s job is to help families and children get a healthy start on a healthy weight. </li></ul><ul><li>Emphasize healthy growth, not healthy weight </li></ul>
Levels of Intervention with Feeding <ul><li>Primary </li></ul><ul><ul><li>Education, early problem-solving </li></ul></ul><ul><li>Secondary </li></ul><ul><ul><li>Detailed evaluation and treatment </li></ul></ul><ul><li>Tertiary </li></ul><ul><ul><li>Detailed evaluation and treatment of complex problems with other specialists (i.e. MD, therapist, etc.) </li></ul></ul>
WIC Primary Intervention: Education and early problem-solving <ul><li>Support a healthy feeding relationship. </li></ul><ul><li>Teach stage-related feeding. </li></ul><ul><li>Explain normal growth. </li></ul><ul><li>Encourage age-appropriate active play. </li></ul><ul><li>Promote other healthy behaviors. </li></ul>
Slow growth divergence over time is likely to be normal. <ul><li>Weight for age 2–20 years </li></ul>
Rapid growth divergence may be normal. <ul><li>Weight for length 0–18 months </li></ul>
Rapid growth divergence may not be normal. <ul><li>Weight for age 0-36 months </li></ul>
Asking the Right Questions <ul><li>How is feeding going with your child? </li></ul><ul><li>How do you feel about the meals and snacks that your child usually eats? </li></ul><ul><li>Is there anything about mealtime that you would like to be different? </li></ul><ul><li>How do you feel about your child’s size and shape? How do feel about her growth pattern? </li></ul><ul><li>Do you, or anyone else, have any concerns or questions about how your child is growing? </li></ul>
<ul><li>Interfering with feeding may lead to weight gain and/or other feeding problems. </li></ul>
Division of Responsibility <ul><li>Adults are responsible for what is presented, when and where it is presented. </li></ul><ul><li>Children are responsible for whether to eat and how much to eat. </li></ul>
Division of Responsibility <ul><li>Crossing the division of responsibility can lead to problems. </li></ul><ul><li>Restricting food scares children and makes them overeat when they can. </li></ul><ul><li>Pressuring children to eat makes them less interested in those foods. </li></ul>
Division of Responsibility <ul><li>Research reveals: </li></ul><ul><ul><li>Caregivers understand and accept the adult’s role in feeding. </li></ul></ul><ul><ul><li>Caregivers have more trouble with the child’s role in feeding. </li></ul></ul><ul><ul><li>Adults need reassurance to trust a child’s ability to self-regulate. </li></ul></ul>
Division of Responsibility <ul><li>Research reveals: </li></ul><ul><ul><li>Children will eat. </li></ul></ul><ul><ul><li>They know how much to eat. </li></ul></ul><ul><ul><li>They will grow predictably. </li></ul></ul><ul><ul><li>They will eat a variety of foods. </li></ul></ul><ul><ul><li>Their eating skills mature with age. </li></ul></ul>
Division of Responsibility <ul><li>Parents who can utilize primary intervention are able to: </li></ul><ul><ul><li>Self-evaluate. </li></ul></ul><ul><ul><li>Accept the child’s point of view. </li></ul></ul><ul><ul><li>Set aside agendas. </li></ul></ul><ul><ul><li>Incorporate advice. </li></ul></ul>
<ul><li>Knows hunger/ fullness </li></ul><ul><li>Self-feed </li></ul><ul><li>Self-serve </li></ul><ul><li>Conversation </li></ul><ul><li>Routines for eating </li></ul><ul><li>Variety and experience </li></ul><ul><li>Utensils </li></ul><ul><li>Opportunities for mastery </li></ul><ul><li>Eating with child </li></ul>Early childhood 2–5 years <ul><li>Knows hunger/ fullness </li></ul><ul><li>Self-feeding begins </li></ul><ul><li>Limited verbal communication </li></ul><ul><li>Routines for eating </li></ul><ul><li>Variety and experience </li></ul><ul><li>Utensils & physical structure </li></ul><ul><li>Opportunities for mastery </li></ul>Toddlers 9–24 months <ul><li>Knows hunger/ fullness </li></ul><ul><li>Attend to cues </li></ul><ul><li>Offer appropriate food </li></ul><ul><li>Feed child </li></ul><ul><li>Child centered routine </li></ul>Infants Birth–9 months Child Abilities Parent Job Age
The Newborn Bonding with baby for a lifetime of healthy eating
The Newborn <ul><li>Establish feeding relationship. </li></ul><ul><li>Feed based on baby’s cues. </li></ul><ul><li>Accept baby’s growth patterns. </li></ul><ul><li>Trust different feeding patterns. </li></ul>
The Toddler Making the transition to solid foods
The Toddler <ul><li>Establish a regular routine. </li></ul><ul><li>Choose “safe” foods. </li></ul><ul><li>Offer different foods to enjoy. </li></ul><ul><li>Let child decide how much or how little to eat. </li></ul>
The Preschooler Accept drive to “do it myself”
The Preschooler <ul><li>Eat together as a family. </li></ul><ul><li>Offer a variety of foods. </li></ul><ul><li>Avoid pressure to eat. </li></ul><ul><li>Allow child to “experiment” with food and eating. </li></ul>
What Parents Want <ul><li>To have happy, smart kids </li></ul><ul><li>To be seen as experts on the subject of their own kids </li></ul><ul><li>To be seen as acting in their kids’ best interest </li></ul><ul><li>To make parenting as easy as possible </li></ul>
It’s Not What You Say…As Much As How You Say It <ul><li>Instead of … </li></ul><ul><ul><li>You have to quit feeding him so much! </li></ul></ul><ul><ul><li>Your child has to get more exercise now! </li></ul></ul><ul><ul><li>Your child is getting severely overweight. </li></ul></ul><ul><li>Parent is on the defensive – with no choices. </li></ul><ul><li>What about … </li></ul><ul><ul><li>What fruits and veggies does your family enjoy? </li></ul></ul><ul><ul><li>How often do you get to play at the park? </li></ul></ul><ul><ul><li>How do you feel about how your child is growing? </li></ul></ul><ul><li>Parent is able to express his/her concerns. </li></ul>
Suggest the Right Amount of Change <ul><li>Consider the barriers and the benefits to change. </li></ul><ul><li>Trust the client to determine how much change they think they can do. </li></ul><ul><li>Be ready to accept no change since this may open a door for future change. </li></ul>
Roles and Responsibilities <ul><li>Your job is to provide information and support positive choices. </li></ul><ul><li>The client’s job is to decide whether to change and how much change to make. </li></ul>