What Picky Eaters Really Don’t Eat?

Patient Presentation
A 2-year-old female came to clinic for her health supervision visit.
Her mother was concerned that over the past 2 months, she had started to refuse to eat many of the regular table foods that were eaten by the family. Specifically she was now refusing to eat anything that had a sauce or dressing on it including pasta, tacos, mashed potatoes with gravy, and even jelly on toast. She sometimes would eat it if it was presented “on the side” of the plate separate from the other foods. Her mother said that more often now she seemed to have one favorite food for a few days and then abruptly refused to eat it when served. Her mother said she was concerned about her not eating very much and so she would make her other preferred foods and would let her eat whenever she wanted to during the day. Her mother asked about any vitamins she could give her to help her appetite. The mother denied any emesis, diarrhea, loose stools, or obvious weight loss. “She’s never been very big, but she looks skinnier to me,” her mother said. Developmentally she was saying 1-3 word sentences, would scribble on the chalkboard in the room, would use a spoon and cup, and could run and jump. She got along well with her 3.5 year old brother and other children in her daycare class. The past medical history was non-contributory. The family history was negative for any gastrointestinal diseases. There was some generalized anxiety in the mother and other maternal relatives. The review of systems was otherwise negative.

The pertinent physical exam revealed a well-appearing female. Her weight was 10.6 kg (10% for age) which was only 200 grams up from her 18 month visit (= 10.4 kg, 25%). Her length was 82.5 cm (25%) and her head circumference was 47 cm (25-50%). The rest of her physical examination was normal.

The diagnosis of a healthy child with picky eating habits and declining weight percentiles was made. The pediatrician recommended that the child be offered 3 meals and 2-3 snacks during the day. Each meal should have at least 2 hours between the meals. The meals were to be served with the child sitting down to eat with appropriate plates, cups and utensils for the meal, trying to keep the meal a quiet and pleasant social time between the child and other family members. “Even if you are out and about, you can all sit down and enjoy a snack for a short time together,” he noted. He recommended that the child be offered the meal and then 1/2 way through the meal offer any beverage so the child wouldn’t fill up on only the liquid. “A serving should be the size of her palm or fist. She doesn’t need a lot, so don’t try to give her too much because then she might be overwhelmed with too much food on her plate,” he mentioned. “I also recommend using a big plate because then the food amount looks small. Just like anyone wants some choices in their foods, she can have them too but there are limits. Generally I recommend 2 choices for a snack. She can be offered the same meal that the rest of the family is having. If after 10-15 minutes she hasn’t eaten her meal, then you can just put it away. The food doesn’t come out again until the next meal or snacktime. Then you can re-serve the previous meal’s food if it is appropriate,” he also recommended. “I want to see her back in about a month to recheck on her weight and see how you all are doing”

The patient’s clinical course at one month showed her weight to be 10.95 kg (10-25%). Her mother reported that they had stopped letting her eat between her meals but weren’t always good about not offering her several choices of food when she refused to eat. They also weren’t as good about sitting down to eat a meal and her mother would feed her while in the car or stroller many times too. The pediatrician praised the mother for starting to make some changes and having appropriate weight gain over the month. He reiterated that she would learn healthy eating practices from the mother, and re-recommended taking a break to sit down for a meal and fewer food choices. During a sick visit ~10 weeks later, the child’s weight was now 11.5 kg (10-25%) and tracking. The mother said that they still didn’t sit down for all the meals but did for more than before, plus the child only got two choices for a snack. “Sometimes I still let her have a sandwich at dinner instead of what we are having,” she confided.

Discussion
Picky eating does not have one definition and is a broad term. In general, picky eaters are described as limiting the amount and types of food, and a refusal to eat novel foods.

Normal healthy children often will reject different types of food they have accepted before in their second year of life. They tend to place more value on food properties such as the color or texture. Feeding problems occur in 25-45% of normally developing children and in up to 80% of developmentally delayed children. Most of the problems are acute issues and resolve within a short time with reasonable guidance and interventions. Most children have resolution of picky eating behaviors by 6 years of age.

Parents and other caregivers can become quite stressed about the picky eating. They worry about the child’s health, as potentially picky eating can cause poor nutrition or the child to become underweight. They also are worried about behavioral or emotional problems such as tantrums, aggression, being oppositional, depression, anxiety and social withdrawal. Studies have been mixed regarding being a picky eater as a child and correlation with eating disorders as an adolescent or adult. Risk factors such as having unpleasant meals or conflicts around meals/eating, food avoidance, and eating slowly which do occur for some picky eaters, are the same risk factors for eating disorders.

Though most picky eaters will have resolution quite quickly, others will last longer but resolve within 1-2 years. Still others will be persistently picky with > 3 years duration of picky eating behaviors. One study was able to identify children who were more likely to be persistently picky eaters (>3 year duration) using a questionnaire with 3 key questions: “Is your child a picky eater? (Yes), does s/he have strong likes with regard to food? (Yes), and does your child accept new foods readily? (No)”

Learning Point
Using data from the 2008 Feeding Infants and Toddler’s Study of children up to 48 months, researchers in 2016 reported that picky eaters ate:

  • Lower amount of meats/protein including eggs
  • Lower amount of vegetables especially raw vegetables
  • Lower calories when eating mixed dishes (i.e. casserole, burrito, etc.)
  • Less of certain food textures such as mushy or slimy or highly textured requiring more chewing. Texture resistance was highly correlated with picky eating.

Fruit, grain, milk or other beverages, and sweet intake was not different for picky or non-picky eaters. Bitter taste also was not different between the groups. Other studies have also shown picky eaters tend to consume less fat.

Questions for Further Discussion
1. What recommendations do you offer to caretakers of picky eating toddlers?
2. What are your criteria for further medical or psychological evaluation or treatment for picky eaters?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Toddler Nutrition and Child Nutrition.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Toyama H, Agras WS. A test to identify persistent picky eaters. Eat Behav. 2016 Jul 15;23:66-69.

Machado BC, Dias P, Lima VS, Campos J, Gonçalves S. Prevalence and correlates of picky eating in preschool-aged children: A population-based study. Eat Behav. 2016 Aug;22:16-21.

van der Horst K, Deming DM, Lesniauskas R, Carr BT, Reidy KC. Picky eating: Associations with child eating characteristics and food intake. Appetite. 2016 Aug 1;103:286-93.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Can You Do About Tinnitus?

Patient Presentation
An 8-year-old male came to clinic approximately 4 weeks after having left otitis media. His mother was concerned because he had said several times over the past week that he had sounds in his ears. He described the sounds as “popping” or sometimes “crunchy” like rice cereal. He said it wasn’t high pitched but was like a voice tone; it wasn’t too loud or soft. The sounds lasted only a few seconds but he wasn’t sure if it was associated with jaw movement or yawning. He denied ear pain, sore throat, or vertigo. He had normal balance and mentation. “It just sounds kind of weird for a few seconds and then goes away,” he described. He was not bothered by the sounds and denied having any similar problems in the past. He denied any trauma but did use headphones when he was playing videogames. The past medical history showed some upper respiratory tract infections including 2 otitis media infections in the past. He had not head trauma in the past. The family history was negative for any ear, nose or throat problems.

The pertinent physical exam showed a healthy boy with normal vital signs and growth parameters in the 75-90%. HEENT showed some clear fluid behind the left tympanic membrane with bubbles within the fluid. The tympanic membrane was in a normal position with normal landmarks. His right ear was normal. He had some very mild clear rhinorrhea. Yawning or other jaw movements did not reproduce the sounds. Neurological examination was normal including tests for balance. The diagnosis of a resolving middle ear effusion was made. The pediatrician counseled that it was most likely that the sounds were caused by the eustachian tube opening and closing causing air to move into the middle ear as the effusion was resolving. He recommended monitoring the problem and keeping a symptom diary with a followup appointment in 4 weeks if the problem was not resolving and sooner if it was becoming more frequent, painful or was affecting his activities including sleep or balance. He did not return for the followup appointment.

Discussion
Tinnitus is derived from the Latin word tinnire which means to ring but in general practice it means any perceived sound that is not generated externally. It is a common problem in adults. In children it is described as being commonly overlooked as children do not spontaneously report it. It is felt that children may consider the sound normal, or are easily distracted and therefore forget about it. Children can accurately describe the sounds they hear and use words such as buzz, ring, hum, swish, whish, blow or beep. Spontaneously reported tinnitus is ~6.5% and increases to 34% when children are specifically questioned in one study. Prevalence has been reported in up to 36% of children with normal hearing and rises to up to 66% in children with hearing loss. Constant tinnitus (43%) is reported more commonly than intermittent tinnitus (31.5%) and bilateral (69%) is more common than unilateral (31%). Tinnitus that affects quality of life is not reported in studies but studies in adults show ~33% will report tinnitus but only 0.4-1% report it affecting their quality of life. Reported problems in children with tinnitus include sensory perception problems, emotional/psychological problems, headache, dizziness and vertigo, fatigue, and sleep problems.

One study found no association between childhood hearing disorders and adult tinnitus after adjusting for adult hearing thresholds. Another study of adolescents found a high prevalence of tinnitus in those who had significant exposures to high sounds volume for long periods of time such as attending nightclubs or parties, headphone use for music or using cellphone headsets in the ear.

Learning Point
The cause of tinnitus is unclear but it has been associated with otitis media, myoclonus of the muscles of the palate or middle ear, acoustic trauma, arteriovenous malformations, and intracranial hypertension. Evaluation by an audiologist and otolaryngologist may uncover ear pathology. Treatment includes amplification if there is a hearing loss, sound generators (e.g. child who has increased problems in a quiet environment could listen to music while studying), and counseling. Counseling can validate the problem, discuss the natural history, identify aggravating and mitigating factors and help develop coping skills to address the tinnitus.

Questions for Further Discussion
1. What are indications for an audiogram?
2. How common is congenital hearing loss?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Tinnitus

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Savastano M, Marioni G, de Filippis C. Tinnitus in children without hearing impairment. Int J Pediatr Otorhinolaryngol. 2009 Dec;73 Suppl 1:S13-5.

Shetye A, Kennedy V. Tinnitus in children: an uncommon symptom? Arch Dis Child. 2010 Aug;95(8):645-8.

Sanchez TG, Oliveira JC, Kii MA, Freire K, Cota J, Moraes FV. Tinnitus in adolescents: the start of the vulnerability of the auditory pathways. Codas. 2015 Jan-Feb;27(1):5-12.

Aarhus L, Engdahl B, Tambs K, Kvestad E, Hoffman HJ. Association Between Childhood Hearing Disorders and Tinnitus in Adulthood. JAMA Otolaryngol Head Neck Surg. 2015 Nov;141(11):983-9.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

How Common is Post Traumatic Stress Disorder in Children?

Patient Presentation
A pediatrician was talking with a colleague who asked, “Maybe you know the answer to this question? I was evaluating a teenager yesterday and the problem list had PTSD also listed as one of his problems. I could see that there were several notes for counseling. I had another patient within the last month who also had PTSD listed as a problem. I know that adults certainly can get PTSD, but how common is it in kids?” The pediatrician said she wasn’t exactly sure but that kids like adults can have many traumatic experiences in their life and that usually, with a supportive environment, the kids work through the problem. “We’re recognizing these problems more and more, even in young children, because of the stressful environments that many kids live in. Even a single event could cause PTSD but most don’t thankfully. Suicide is also an increasing problem in the teen population with stress and trauma certainly playing a part,” he said.

Discussion
Exposure to traumatic stress events including physical abuse, sexual abuse, violence, witnessing violence in the home or community, severe family dysfunction/psychopathology, natural disasters, severe accidents and/or their own or their caregivers’ life-threatening illness are not uncommon in children and adolescents.” It is estimated that up to 60% of teens age 16-18 have experienced at least 1 traumatic event.

Some children, teens and adults may experience transient psychological problems or distress which may cause physical complaints including pain, behavioral changes such as irritation or regression, sleep problems, etc.. Some children, teens and adults go on to experience more difficulties immediately after the event or later on.

Risk factors for having significant problems include multiple traumatic exposures, multiple trauma types (physical, emotional, sexual, etc.), trauma intensity, personal mental health problems, high risk social situations including poverty, isolation, delinquent peer affiliation, multiple out-of-home placements and family members with physical or mental illness including substance abuse. Resiliency helps to moderate the effects including having problem-solving skills, self control, positive interpersonal relationships, safe home and school environments, religious faith, success with school and peers, socioeconomic advantage, and being older when trauma occurred.

To review a case about resiliency to the effects of war click here.

To review a case about the effects of bullying click here.

To review a case about gun violence click here.

Learning Point
Post traumatic stress disorder (PTSD) is a psychological disorder in a group that also includes reactive attachment disorder, adjustment disorder, acute stress reaction and acute stress disorder. The DSM-5® has criteria for children > 7 years, teens and adults. There must be:

  • An exposure to a traumatic event by direct self-exposure, direct witnessing of the exposure, learning of the personal exposure by a close friend or relative, or exposure by repeated discussions of the exposure by others
  • Intrusive experiencing of the traumatic events such as intrusive thoughts or memories, nightmares, flashbacks, intense distress with reminders of the trauma, etc..
  • Avoiding of the stimuli that brings on the intrusive experiences such as avoiding people, places, conversations, etc..
  • Negative cognition and mood associated with the trauma such as believing the world is not safe, distorted blame of the events, detachment from interpersonal relationship, anhedonia or persistent negative emotions including fear, guilt or confusion, etc..
  • Arousal and reactivity alterations such as anger and aggression, self-harm, recklessness, easily startled, hypervigilance, problems falling asleep, etc..
  • Duration of symptoms must be at least 30 days
  • Causes clinical impairment in important areas of functioning or significant distress

There are other criteria for children < 7 years old, but they are similar.

“The reported overall lifetime prevalence of PTSD in the general youth population is 3-9%. Some studies show gender differences with 4% of males having PTSD and 7% of females. A meta-analysis showed a highly significant association between PTSD and suicidality and “…was associated with elevated levels [of] suicidality in adolescents in a wide range of circumstances.” Suicide is the 3rd leading cause of death in the U.S. so recognition of traumatic stress, PTSD and potential suicidality is important.

There are several traumatic screening tools that can be used and PTSD is considered highly treatable. Although treatment plans are individualized “…[c]ommon treatment elements include (1) psychoeducation about PTSD, (2) relaxation and coping skills, (3) affect monitoring and emotion regulation skills, (4) cognitive processing of reactions to trauma, (5) helping the child construct a therapeutic trauma narrative, (6) in vivo exposure to trauma reminders and practicing of coping skills, (7) conjoint parent-child sessions, and (8) monitoring and enhanced individual safety.”

Questions for Further Discussion
1. What mental health services are available in your community for PTSD?
2. What role does the media and social media play in traumatic stress?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Post Traumatic Stress Disorder

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Stoddard FJ Jr. Outcomes of traumatic exposure. Child Adolesc Psychiatr Clin N Am. 2014 Apr;23(2):243-56, viii.

Martinez W, Polo AJ, Zelic KJ. Symptom variation on the trauma symptom checklist for children: a within-scale meta-analytic review. J Trauma Stress. 2014 Dec;27(6):655-63.

Panagioti M, Gooding PA, Triantafyllou K, Tarrier N. Suicidality and posttraumatic stress disorder (PTSD) in adolescents: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2015 Apr;50(4):525-37.

Connor DF, Ford JD, Arnsten AF, Greene CA. An Update on Posttraumatic Stress Disorder in Children and Adolescents. Clin Pediatr (Phila). 2015 Jun;54(6):517-28.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

How is Swimmer’s Itch Diagnosed?

Patient Presentation
A 4-year-old male came to clinic with a pruritic rash for 24 hours. He had been swimming in the local freshwater lake over the weekend. His mother had tried calamine lotion and over-the-counter strength hydrocortisone cream but said that “he just can’t stop itching.” The rash started on his legs but soon involved the area where his swimsuit had been. She denied any new soap, lotions, sunscreens, insect repellents or other new products. They were frequent users of this lake which was known to have swimmer’s itch and she said, “he just lives in the lake when we are there.” The mother said that she was also starting to itch around her ankles that morning. The past medical history was non-contributory.

The pertinent physical exam showed a healthy male who was rubbing his legs and groin. His vital signs were normal with growth parameters in the 50-90%. The rash was 2-3 mm macules with most having a papular component but no vesicles. The lesions were grouped especially in flexural areas of the ankles, knees, groin and buttocks. He had some distinct excoriations and some generalized erythema of the groups but it was difficult to tell if there was real erythema or it was secondary to rubbing. The mother’s ankles did not have any distinct lesions but did have general erythema because of her rubbing them.

The diagnosis of swimmer’s itch was made. The pediatrician recommended using an antihistamine and prescription strength topical hydrocortisone to help with the pruritis. “This usually takes a few days to go away but I think the medicines should help him be more comfortable. Swimmer’s itch often gets worse with more exposure so I would try to keep away from the lake if you can and swim elsewhere. If you go there, it helps to wash off right away and change clothes, so the bugs that cause this have less chance to get into his skin,” the pediatrician advised.

Discussion
Cercarial Dermatitis (CD) is known by many names throughout the world, but is commonly known as swimmer’s itch. It is a water-borne, non-communicable infectious disease that is caused by the larval stage (cercariae) of parasitic schistosomatid flukes. The cercariae causes an allergic maculopapular skin rash in humans that is usually self-limited (usually 4-10 days) but can cause problems for up to 20 days.

CD parasites are considered an emerging disease because of the increased distribution of the problem across the globe. Different parasite species cause the problem. In a normal life cycle that occurs mainly in fresh water but also brackish water, schistosome eggs invade various species of aquatic snails that act as an intermediary hosts. Within the snails, the schistosome eggs develop into schistosome cercariae. The schistosome cercariae migrate from the snail back into the water. In the water the schistosome cercariae encounters birds or mammals which are their definitive host. The cercariae penetrate the skin of the bird or mammal and travel within the host to a definitive organ (which depends on the species) where they develop into schistosome flukes. The schistosome flukes produces eggs which leave the definitive host usually through the intestinal tract usually, but occasionally through the bladder and urinary system. The schistosome eggs then start the cycle all over.

The usual intended definitive hosts are avian, especially waterfowl. Many different varieties of aquatic snails act as the intermediary host and of the more than 100 different schistosome species, 70% can cause CD. One of the most common species which causes CD is Trichobilharzia. Humans are incompatible species and are simply affected bystanders.

CD occurs in the warm weather when snails and bathers have their height of activity. Slow moving water, water near the edge of the water body, and being in the exposed water for longer increases the risk of acquiring CD. Children, especially 5-9 year olds, who play near the water’s edge for long periods of time have increased risk. It also appears that the children’s skin is more sensitive. The risk can be decreased by swimming in places where definitive hosts are not present or are present in fewer numbers, swimming farther out from the water’s edge especially in faster moving water, not swimming for long periods of time, and washing off and changing clothes after the potential exposure. Environmental mitigation includes drug treatment of definitive hosts, drug treatment of snails or manual removal of snails from the water. Use of waders, impermeable gloves and other protective clothing is a must for some recreational or professional uses.

Learning Point
The cercariae penetrate into human skin. If it is the initial contact, the cercariae may not cause a rash but can cause allergic sensitization. With subsequent exposure, there can be a prickling feeling with entry of the cercariae and then the rash becomes extremely pruritic. With recontact, a small macular-papular rash (1-2 mm initially) centered around the entry point of the cercariae happens within 12-48 hours. The macules can remit or become larger and vesicles can form on top of the papules. There can be surrounding erythema of the rash area. Pustules can occur if there is bacterial superinfection and pigmented spots can persist after resolution of the papules. The rash usually resolves within 4-10 days but can last for up to 20 days. Acute systemic reactions such as generalized limb swelling, nausea, diarrhea and fever can occur with subsequent exposure. The diagnosis is usually clinical-based but if needed, the organism can be identified on skin biopsy. Criteria include contact with water, rash appearance within 12-48 hours of exposure, and lesions on the body only where the water was in contact. Treatment of the rash is usually with antihistamines and/or topical steroids. The differential diagnosis includes insect bites, contact dermatitis, bacterial dermatitis, and skin reactions to larval cnidarians such as sea anemones or thimble jellyfish (if in appropriate location).

Questions for Further Discussion
1. What other parasites affecting humans are water-bourne?
2. What do you recommend for summer safety?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Parasitic Diseases and Water Safety (Recreational).

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Cercarial Dermatitis or Cercariosis: What’s in a Name?
Morley NJ. Trends Parasitol. 2016 Feb;32(2):92-3.

Pinto HA. Cercarial Dermatitis’ and ‘Cercariosis’: Very Broad Terms.
Trends Parasitol. 2016 May;32(5):351-2.

Horak P, Mikes L, Lichtenbergova L, Skala V, Soldanova M, Brant SV. Avian schistosomes and outbreaks of cercarial dermatitis.
Clin Microbiol Rev. 2015 Jan;28(1):165-90.

Kolarova L, Horak P, Skírnisson K, Mareckova H, Doenhoff M.
Cercarial dermatitis, a neglected allergic disease.
Clin Rev Allergy Immunol. 2013 Aug;45(1):63-74.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital