Toddlers, children and food

Terrible twos

Anyone who has had toddlers will tell you that every day can be an adventure. Suddenly their once compliant child is full of energy, able to run around, start to talk and their personalities start to develop. This can be fun, but it can also mean you go into daily battles over what they’re wearing, sitting still in a pram and what they eat.

When there is a whole world to explore, boxes to play with, questions to ask, food often becomes a low priority for toddlers.

Because food and nutrition are vital for anyone with cystic fibrosis (CF), a toddler refusing to eat can pose a real problem. Remember most toddlers go through this phase and you’re not the only parent dealing with this situation, even though for your child with CF there are greater health risks.

As hard as it may be, try not show anxiety and frustration about your child’s refusal to eat; they’ll work out they can control you by not eating, which will make the situation worse in the long run.

Below you will find explanations for this behaviour, some tips to overcome it, and the importance of food for toddlers and children with CF.

Why doesn’t my child eat well anymore?

Toddlers grow at a slower rate than babies, so they generally need less food. Growth and weight gain are not regular and a child may gain a lot of weight one month, but not grow much. The following month they may grow a few centimetres but not gain much weight.

Your toddler with CF will need more food than other toddlers, and their weight and growth may even more irregular.

Food fads

Toddlers often develop a passion for one or two foods, fortunately it’s usually it’s only a passing phase. If your CF toddler’s latest fad is a low energy food like salad or fruit, try to add extra energy cream to fruit or mayonnaise to salad.

When your child starts refusing certain foods, try and find alternatives that are similar e.g. try cheese instead of milk, or fruit juice instead or fruit or vegetables.

Be creative and make food fun; children can be tempted with foods made into shapes or faces, or drinks that have fancy straws. Something new like a picnic or helping prepare the food for the meal or snack can also help to stimulate interest. Remember all these things have a strong novelty for children, just try to swap ideas around so the novelty doesn’t wear off.

Dealing with challenging food behaviour

Don’t let meal times become a battle ground, bribes and forcing the child to eat won’t work.

If your toddler refuses to eat, don’t make a fuss, but give plenty of praise and encouragement when they do. Many toddlers manage better with frequent snacks rather than 3 meals per day – but they must be of high energy value.
Set reasonable limits around eating behaviour; demanding they join the rest of the family at the table for dinner is one thing, but in the end they will determine how much they eat
Don’t let them fill up on lollies and juice and then offer a meal or high energy nutritious snacks later
Be persistent and consistent with giving enzymes
Toddler’s are often very tired at the end of the day and small serves of easy to eat foods will probably be easier
Try the occasional milkshake or smoothie your child is too tired to eat
If the weather has been hot and your child has been very active check that they have had enough salt and fluids during the day, as this can be another cause of food refusal and tiredness

Salt supplementation

People with CF need extra salt in their diet because they lose larger amounts of salt in their sweat.
This is especially important in hot weather, during periods of illness and after being active.

Signs of salt deficiency

Increased thirst
Loss of appetite
Poor growth
Dehydration
Headaches
Dizziness
Cramps
Fatigue

Things to remember

Salt supplementation is recommended during summer. Younger children may prefer salt powder while older children and teenagers may take salt tablets. Fluid intake is also important.
Add table salts to food. There is no need to cook with salt for the whole family, encourage the child with CF to use a salt shaker at the table, get them their own special one if that helps
Vigorous physical activity means more sweating and therefore a needs for more salt and fluid. Salt tablets plus fluids or electrolyte containing drinks are good idea. Try adding a salt tablet or two to a cup of soft drink for a quick rehydration drink. There’s a recipe for a homemade sports drink below
If your child is sick, especially with a fever, they will need extra salt
If you live in a humid or tropical climate, pay extra attention to your child’s salt intake

How much salt is needed?

The following table is only a general guide. Your CF doctor or dietician will be able to help with a more tailored answer for your child.

	Salt (mg)	Salt (tsp)
Infants	500-1000 mg/ day	¼ – ½ tsp
Children	4000 mg/ day	2 tsp
Adolescents	6000 mg/ day	3 tsp

Homemade sports drink

Makes 2 cups

250 ml juice

250 ml water

½ tsp salt

Combine juice, water and salt and mix with a fork to dissolve the salt. Refrigerate and use within 24 hours. Best served cold.

Primary schoolers

Ideally by the time your child starts school they will have an understanding of cystic fibrosis, and as they grow it’s important to encourage them to take more responsibility for their health. This will help them become independent and cope when you’re not around to help.

Teaching your child why they need enzymes and high energy food is important to help them cope with the moments they feel different at school. Taking tablets and eating different, and more food than other children can be embarrassing, especially when other children might tell them it’s unhealthy. Remember to also teach your child how many enzymes to take and how to do it.

It’s also important the school knows about your child’s special dietary needs, especially in the importance of their enzymes and salt. Your CF Clinical Nurse Consultant (CNC) can help with this.

Sometimes children go through stages where they are not eating much at school. If this happens, afternoon tea becomes very important. Use high energy milk shakes, sandwiches, cereals, biscuits and cheese, yoghurts and custards.

Breakfast

You’ve probably heard it before: breakfast is the most important meal of the day. It’s especially true for people with CF.

If your child is unwell, and has been swallowing secretions all night, they may not feel like breakfast first thing in the morning, but might feel more like eating after physio.

Breakfast is an important meal, not only because it has been a long time since dinner or bed time snack, but it also contributes significantly to the total nutrient intake. Usually breakfast is the meal that most people skip.

Lack of time and lack of interest in eating breakfast foods are common reasons to skip breakfast. If it’s lack of time, at least try to make a smoothie and something else the night before that your child can have in the car, and if they don’t like breakfast food, feed them something else they will eat.

High calorie breakfast

Cereals served with full cream milk, sugar and dried fruit ( especially sultanas)
Sweetened muesli served with evaporated milk and yoghurt
Baked beans or canned spaghetti served on thick buttered toast
Scrambled cheesy eggs on thick buttered toast
Porridge served with cream and sugar
Thick peanut butter, honey or banana sandwiches
Bacon with poached egg and fried tomato
Milk shakes or smoothies

Packed Lunches

A packed lunch should contain the same nutritional value as a cooked meal.

Sandwich suggestions

Thickly buttered white, brown, or wholegrain bread with one of the following toppings:
ham with cheese and tomato
roast beef with tomato
mashed sardines with lemon juice and grated cheese
grated apple (mixed in lemon juice to stop it going brown) with honey and raisins
tuna chopped with tomato and mayonnaise
scrambled egg with mayonnaise or chopped fried bacon
corned beef and chutney
cream cheese with chopped walnuts and raisins
chopped chicken with mayonnaise
chicken with cheese and avocado
chopped hard boiled eggs blended with butter and grated cheese
Nutella with chopped walnuts and raisins
avocado and salad
baked beans or spaghetti

As well as a sandwich, pack some of the following:

cakes, biscuits or slices
dried fruit or nuts
cheese sticks or slices
cold meats, twiggy sticks
yoghurt
flavoured milk
fruit
fruit juice

Dinner

Just like breakfast and lunch the evening meal makes a very important contribution to the total nutrient intake.
These ideas are high energy, but also high fat, so more enzymes will be needed:

fry meats such as sausages, chops and steak
serve a large meat serve (covering at least ¼ of the plate)
leave the skin on chicken when cooking
add gravy or savoury butters to meats. Try crumbed meats such as schnitzels
add white sauce or cheese sauce to vegetables
serve butter or margarine with pasta and vegetables
stir oil through cooked rice
sprinkle grated cheese on vegetables
add mayonnaise or salad dressings to salads
try fried rice and stir fried vegetables
add sour cream to potatoes
eat dessert every night

It’s important to remember that this diet isn’t healthy for people without CF. This means cooking an entire meal that satisfies everyone in the family’s needs might need a little bit preparation.

Get your child/ren involved in the cooking process to help cater for everyone, as well as to teach them what goes into their food and why it’s important.

Food tips from Rebekah Davison

Gastrostomies

For some people with CF meeting their extra energy requirements through food alone is hard. This means they need another form of nutrition to keep them growing and at a healthy weight like a naso-gastric tube or gastrostomy.

A gastronomy is a tube placed directly into the stomach and is used to supply a liquid high energy formula in addition to what is eaten. The tube is surgically positioned through the abdominal wall, and while it may not be permanent, it is usually used long term.

The high energy liquid is usually supplied overnight while the person sleeps. The formula can be dripped in slowly or regulated by a feeding pump. Enzymes are usually taken before going to sleep, and again in the morning.

People fed via a gastrostomy tube overnight often don’t feel hungry when they wake up. Morning tea is often the first meal of the day. It usually takes around three months for the appetite to readjust.
Your CF dietician can give you more information on gastrostomy feeds and feeding equipment.