What should I feed my child with GERD?

You should read this document if:

• Your child’s “food list” contains a handful of items such as apple juice, crackers and chicken nuggets.
• Your child strictly adheres to the White Diet or the Prison Diet-rice, mashed potatoes, chicken and saltines, etc.
• You worry about food intake all of the time.
• You show signs of waitress syndrome-you cook special meals for your child and spend hours in the kitchen.
• You follow your child around the house with a spoon, bowl and cup.
• Your purse, diaper bag and mini van all contain a food pantry stocked with snack foods and drinks.
• You keep a diary of intake.
• You call grandma when your child eats 3 bites of food in a meal.
• You feel angry and defeated daily about feeding.
• It seems like you work much too hard to get your child to eat compared to others.

Parents of gerdlings always ask PAGER staff and volunteers the same question, What should I feed my child with GERD? Whether you are feeding an infant or adolescent, raising your first child or your 6th, your first child with acid reflux or your second, it can still seem frustrating and confusing to figure out the best way to approach feeding. There are a multitude of reasons why eating is so difficult.


Why is it so difficult for my child to eat?

• Eating = pain. Caused by poorly managed GERD.
• Eating = memory of pain. The pain is gone but it left a lasting impression.
• Food allergies
• Food intolerances.
• Sensory problems such as sensitivity to sensation in or around the mouth.
• Oral Motor Problems such as poor suck, swallow, high or low muscle tone.
• Several or all of the above.

Previous parenting experience, professional credentials and parenting books may not be very helpful. As parents, we often feel terribly defeated when we put forth so much effort and get so little in return. The problem is compounded when we receive advice from others. Probably their techniques work very well in other situations with other kids. We try every suggestion and fail yet again. It is exhausting and it can make it difficult to keep trying. Many parents get angry at well-meaning people who have offered suggestions and advice. It is easy to feel angry toward our children as well. Sometimes we feel a need to “punish” them for “ behaving” so poorly. Other parents do their best to hide their anger, retreating into the bathroom after another frustrating feeding session to cry quietly.

Parents, especially moms feel a great burden of responsibility to get in a bite here, an extra calorie there in a never-ending battle to nourish an underweight child. We sometimes get a great deal of pressure as well “If weight gain doesn’t improve, we will need to consider n-g tube/g-tube/surgical procedure." This is the stuff nightmares are made of.

Feeding a child should not cause parents to break out in a sweat, cry, and get angry or depressed. Our children would like to eat and derive pleasure from the experience but their hurting stomachs won’t allow them. As parents, we need to combine information, creativity and gut instincts to find a solution that works. Remember that each child is different and your journey to feeding success may be full of twists and turns. It can take a lot of time and effort and many dead ends before finding the right path. Seek assistance when you are feeling overwhelmed and realize that feeding your child with GERD may be one of the most challenging tasks you will ever undertake.

The Basics

Just about every pamphlet and book on GERD will advise avoiding high acid and high fat foods to reduce or eliminate symptoms of reflux. Since most of the literature is written for adults, it also goes on to recommend losing weight and reducing alcohol consumption. End of story. We are all on our own from here. One mom said in mock surprise-No wonder my toddler has so much trouble with her reflux! No more beer and wine for you young lady!

High Acid Foods

Foods high in acid include tomatoes, citrus and many fruits and fruit juices. These foods may burn an irritated esophagus and stomach and cause pain and heartburn. Many children with GERD report that they don’t like orange juice. Often this is an indication that the acid is causing discomfort and the child is avoiding a reflux trigger. Jenna decided that she would rather drink water after trying every juice and beverage on the grocery store shelf. All juices were too acidic for her.

A trial period without high acid foods may be indicated. Some children are able to reduce or eliminate medication by avoiding foods high in acid. If a child seems to tolerate one or more of these foods without difficulty or craves a high acid food, don’t sweat it. Peter’s mom tried to stop him from putting ketchup on his food. Eliminating the ketchup didn’t affect his symptoms but it did make his food taste awful, reducing his intake. Needless to say, he is back to using his favorite condiment. It is always a balancing act to provide balanced nutrition when a child avoids a food or food group. Be sure to ask your doctor for advice.

High acid foods

  • Tomatoes, ketchup, tomato sauce, tomato juice
  • Oranges, orange juice
  • Lemons, lemon juice, lemonade
  • Other citrus fruits-grapefruit, tangerines, clementines.
  • Coffee
  • Tea
  • Fruit juices-apple, peach, pear and many commercial juices.
  • Vinegar, oil and vinegar salad dressing

High Fat Foods

Fried foods, potato chips and bologna are all examples of high fat foods. Foods high in fat may be difficult to digest and stay in the stomach too long causing an over production of acid. The typical American diet is full of fats and calories intended to make the food we eat more appealing. Be sure to read labels carefully and look for low fat alternatives. See box.

High Fat
  • Bologna
  • Beef
  • Cookies
  • Potato Chips
  • Gold Fish Crackers
  • French Fries
  • Ice Cream
  • Donut
  • Milk Shake
  • Whole Milk
  • Fried chicken
  • Gravy

Low Fat
  • low fat ham or turkey breast
  • lean beef
  • Graham Cracker
  • Baked chips, rice cakes
  • Low fat crackers
  • Baked or mashed potato
  • Ice pop or snow cone
  • Bagel
  • Fruit Smoothie
  • Non fat milk
  • Broiled or baked chicken
  • Broth


A word about Fast Food

While a typical fast food meal is known to offer an abundance of fat, calories, salt and sugar, it is hard to find an All-American kid who doesn’t want an occasional fast food meal.

Rebecca, age 9 loves getting a Kids Meal at Mc Donald’s or Burger King once in a while. She usually eats about of the meal and discards the rest. It is too much food and she knows a full meal will make her sick. She even indulges in a soda, known to cause loud belching. After of a serving of soda, she switches to juice or water. Love those self serve beverage dispensers! She feels like a normal kid and eats without stressing her sensitive stomach.


Spicy Foods

It may be important to avoid certain spicy foods for a while to see if symptoms improve. Some children may be able to tolerate a nibble here or there while others will need to strictly avoid certain foods/spices. It can be tricky to find substitutes for some foods, especially ethnic foods and holiday foods. Pizza, Mexican food and holiday favorites all taste delicious but can lead to pain and discomfort for a child with gerd.

Spicy Foods
  • Garlic
  • Onions
  • Peppers
  • Chili powder
  • Peppermint
  • Chocolate


Eating Out

Eating out can be a pleasure or a nightmare. Restaurant food tends to be high in fat with large portions and may harbor hidden ingredients that can cause discomfort. Many restaurants can modify their selections by omitting ingredients and sauces that may be difficult to digest. Some parents find it is easier to feed their child home and just eat one item or share from your plate at the restaurant.
On the other hand, eating out may offer a more relaxed atmosphere for an eating adventure. A careful eater may decide to try a new food and expand his/her repertoire of acceptable foods.

Hints for eating out
  • Communicate your concerns to the waitstaff.
  • Call ahead and find out what is on the menu.
  • Take home dessert to avoid the temptation to over eat a large entree
  • Ask the waitstaff for meal suggestions.

Avoid Spicy Foods
  • Pizza with everything
  • Nachos with cheese and chilies
  • Potato chips with dip
  • Thai Spicy
  • Garlic Toast
  • Spaghetti with meatballs
  • Mashed Potatoes and gravy
  • French fries

Choose Milder Food
  • White pizza-cheese only
  • Veggies or pretzels dipped in Low fat dressing
  • Stir fry chicken with rice
  • Plain Italian bread
  • Plain pasta
  • Mashed potatoes, hold the gravy
  • baked potato
  • Chips with plain cheese sauce


Difficult to Digest Foods

A variety of fruits and vegetables may be difficult for your child to digest. It is likely that your child is a careful eater and already has made the decision to avoid some of these foods. Keep in mind that every child is different and you should not restrict a child from eating these foods if they are tolerated.

Vegetables
  • Broccoli
  • Cabbage
  • Brussel Sprouts
  • Cauliflower
  • Corn
  • Cucumber
  • Turnips
  • Rhubarb
  • Kale

Fruits
  • Apples
  • Banana
  • Figs
  • Coconut

Beverages
  • Milk
  • Coffee
  • Tea
  • Carbonated Beverages
  • Caffeinated drinks

Starches
  • Beans
  • Oats
  • Tofu
  • Barley


Easy to Digest Foods

So far we have discussed the abundant foods that should be avoided. So, is there anything left that is “safe’ to eat?

There are some foods that may be easier for your child to digest. Carbohydrates are burned more rapidly than proteins and high fat foods. This may explain why many of our gerdlings are carb junkies. Mashed potatoes, rice, bread, crackers and cereal. Gerdlings think these foods are delicious for any meal! Moms call this diet the White Diet or the Prison Diet. It has to be bland, white and available in massive quantities for every meal. While this diet may be deficient in nutrition, it is the ultimate comfort food diet. It just feels right for our kids. Some parents have found that adding a liquid nutritional supplement can provide the calories, protein and vitamins missing from the White Diet. Pediasure, Ensure, Peptamin Jr and Carnation Instant Breakfast are examples of nutritional supplements. Some parents also give their toddler or child a multivitamin to offset a poorly balanced diet.

Minerva found that her daughter Maloree needed a nutritional beverage when she was a toddler. Maloree was too old for baby formula but hadn’t started eating or drinking enough to gain weight adequately. Minerva gave her daughter 3 cans of Pediasure per day and let her explore table foods. She gradually decreased the number of cans of Pediasure per day as she was able to eat more food. Now at age 2 she is able to tolerate milk and eats a growing variety of table foods and her mom rarely uses the Pediasure anymore.

Clear liquids and foods are also easy to digest. Broth, soup and jello are well known examples.

Food Intolerances

Many children with GERD are intolerant to one or more foods. A food intolerance can cause pain, gas, belching, bloating and discomfort in the absence of a true allergic reaction (where there is a chemical change in the body ).

Lactose intolerance is a commonly known food intolerance. The digestive enzyme Lactose, found in cow’s milk cannot be broken down or digested by some people. A child or adult who doesn’t like milk or avoids dairy products may be lactose intolerant. It is important to keep in mind that lactose intolerance varies in severity from mild to severe so some dairy products may be tolerated. Kate, age 7 loves having a bowl of ice cream after school but wouldn’t dream of drinking a glass of milk. If she has two or more servings of dairy products per day, she tends to get bloated. Lactose intolerance and GERD are a common combination so a high level of suspicion is warranted when a child seems to avoid dairy products. Diagnosis is made by eliminating dairy products from the diet or taking a breath hydrogen lactose intolerance test. Treatment may include reducing or eliminating dairy products containing lactose from the diet or substituting lactose free milk or soymilk. There are also pills and liquid drops to break down the digestive enzyme available over the counter.

Other food intolerances include Wheat /Gluten Intolerance (Celiac Disease) and Fructose intolerance.

Sometimes a food just doesn’t seem to be tolerated and we cannot figure out why. Everyone has a food that they don’t enjoy eating. Remember George Bush and broccoli? While a food intolerance doesn’t cause a allergic reaction such as a rash, our bodies get a strong signal to avoid the food. Children with GERD seem to have a HUGE list of food they avoid or seem to be intolerant to. For some infants and children, all food gets washed in acid and is pretty unappealing. For others, their brains/stomachs just won’t accept the food.

Rebecca’s Peanut Story

By age 3, Rebecca already knew that she needed to avoid all nuts. If someone handed her a treat such as a piece of candy or a cookie, she always asked her mother if it contained nuts before she put it to her lips. At Halloween, she dumped her loot bag on the table and separated out all of the candy containing nuts before she would eat one piece. One year, she decided she couldn’t bear to give away all of the candy containing nuts. She kept it all and nibbled on a few pieced containing nuts. A day or two later, she presented the nut ladened candy to her mom and said in disgust, “Here, I don’t need this any more.” It became a family joke- There was Rebecca at the Easter Egg Hunt, only picking up candy that was nut free. Rebecca could never verbalize what it felt like when she ate nuts. However, her strict self-selection seemed to indicate that she felt some pain or discomfort.

Her mother became alarmed when Rebecca became hoarse and began wheezing after ingesting a pistachio nut. Rebecca was evaluated by a pediatric food allergy specialist and Rast Testing (blood test) and skin allergy testing were both negative for any kind of nut allergy. The physician shook his head in disbelief and said, I guess Rebecca REALLY doesn’t like nuts!” While there is no test for “peanut intolerance” and it is highly unusual, avoidance of this offending food from her diet has helped her digestion greatly.

Children who seem to avoid certain foods or food groups should be evaluated by a physician to rule out allergies. If it is determined that a child is intolerant to a food or food group, avoidance of the food may be necessary. A physician or nutritionist may be consulted to evaluate your child’s diet and determine “safe” foods to substitute.

Food allergies

Food allergies are defined as immune system reactions to foods. The most common food allergies include: dairy, wheat, soy, egg, nuts and fish.

Diagnosis is made by skin testing, a blood test an elimination diet or a combination. Symptoms of a food allergy may include nausea, vomiting, diarrhea, hives and breathing problems. Food allergies usually cause a quick reaction within a few minutes of ingesting a food. However, it may take a few days or weeks of abstinence from an allergy causing food for symptoms to abate completely. A child with a tree pollen allergy may have difficulty tolerating certain fruits (peaches, apples), berries (strawberries) and melons (cantaloupe, watermelon). Cooked fruits such as applesauce or peach pie may be tolerated and allow a child to continue eating fruit. Be sure to ask your doctor for clear instructions. Some children with food allergies need to have strict avoidance of foods without exceptions since some foods can cause life-threatening anaphylaxis.

There is growing evidence that food allergies have a genetic component. If one or both parents have a history of food allergies, their child may be affected too. There is also evidence that babies at risk for food allergies due to family history should not be exposed to certain foods too early. Some physicians advocate avoidance of peanuts and dairy products during the last trimester of pregnancy for at risk infants. Some newborns are given a dairy free, predigested formula from birth. Breastfeeding moms may need to avoid dairy, nuts, soy or other foods. Again, consult with a physician, nutritionist, or lactation specialist for advice.

Formulating a Plan

You may need to
  • Consult with your doctor
  • Rule out pain/manage pain
  • Rule out food intolerances and allergies
  • Discuss nutrition and the need for supplements

It may be necessary to work with your child’s doctor to develop a plan to eliminate a food or food group

Elimination Diet
  • Spicy foods
  • High fat foods
  • Dairy/lactose
  • Soy
  • Other

Nutrition
  • Vitamins/mineral supplements
  • Supplemental nutrition drinks
  • Substitute foods with nutritionally equivalent foods

Eat Carefully
  • Cook food from scratch rather than pre-packaged food to control hidden ingredients
  • Eat small meals.
  • Discourage your child from being a member of the Clean Plate Club. Rather, encourage him to select a small portion of a variety of foods and come back for more.
  • Offer frequent meals during the day. Perhaps a sandwich at 11 am and another sandwich at 2 PM is better than a whole sandwich at noon.
  • Offer foods and drinks separately. Eat a small meal. With an hour or two and then have a drink.
  • Provide healthy choices-avoid the snack aisle and fill your house with nutritious, healthy foods.

But My Child Only Wants Cheerios and Apple Juice!

Perhaps your child has decided that the best diet of all is the Elimination Diet-all foods are off limits except for Cheerios and Apple Juice! There are many reasons why a child restricts his/her diet and it will take some detective work to sort it out. Children with severe nutritional issues or food aversion may need a consultation with a feeding team or feeding clinic.

Here are some general ideas to consider:
  • Increase Variety of flavors: Try to get your child to accept a similar food to the food he already eats. For instance, if your child only eats Cheerios, see if he will eat Apple Cinnamon Cheerios or another round cereal.
  • Mix favorite foods with a new, similar food. Mix Cheerios with Fruit Loops
  • Go Slowly. Try something new when you have the best chance of success. For instance, when the moons are in alignment, your child is well rested, healthy, etc.
  • Accept regression and loud protests. This isn’t going to be easy.
  • Substitute one type of food (pretzel stick) for an equivalent food (pretzel twist)
  • Substitute a similar shape/textured food for another-saltine for a wheat thin.
  • Repetition-Keep offering foods over and over. A new food may be on his plate for 6 or more meals before he will even consider touching it, much less eating it.
  • Role Model: She may need to see mom and dad eat a new food first.


Attitudes
  • Check your emotions at the kitchen door. Leave your anger, frustration and exhaustion out of the feeding experience.
  • Let someone else feed your child to get a break and break the cycle.
  • Have fun during meals-talk, smile, look her in the eye and tell her you are proud of her and know this will work.

Ages and Stages

There are different feeding issues from infancy to adolescence. Be sure to consider normal developmental stages for eating. While a child with a chronic illness such as GERD may exhibit delayed, divergent eating patterns, there may be some stages that are universal for all kids.

Infants
  • Delay introduction of solids
  • Breast feeding-try an elimination diet
  • Formula Feeding-soy, lactose free, predigested may be needed
  • Soy and dairy may be a problem
  • Safer first foods-rice cereal, potatoes, carrots
  • Don’t try to finish the jar of baby food.

Children
  • Rule out allergies
  • Rule out intolerances
  • Consider the need for vitamins, nutritional supplements
  • Check attitudes and emotions

Adolescent:
Same as children plus...
  • Give teens control
  • Let them: keep a food diary, select foods from the safe list, make decisions, suffer consequences and learn to “read” their stomach.


Conclusion

Feeding issues can seem enormous when you are in the middle of the day to day drudgery. It may seem like there is no hope for things to get better. An infant/toddler with overwhelming feeding issues will probably improve over time.

Rebecca’s mom kept a log of her intake for 2-3 days every other month. When she looked back on the entries, she realized that Rebecca has increased her intake of protein and fluids. It wasn’t a lot but it was progress.

When Rebecca was 2 years old, she ate 8-10 foods. Now at age 9, she eats a variety of foods, too numerous to mention. Her mother doesn’t need to carry a big purse anymore to transport Rebecca’s mobile kitchen nor does she play waitress at every meal. Eating is just a part of the day and not the central focus.


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