Changing your child's meal

Dear Dr. Donya,

I'm very grateful for your prompt reply. Since then I tried my best to change my son's meals. However, he has a very poor appetite. He prefers sucking rather than chewing. He often vomits although it is only a few spoonfuls of porridge (with meat and vegetables). A friend suggested giving him back the food he vomits. Is this wise? I look forward to your valuable advice. Thank you for your attention.

Best regards,

-- Kim C.

Dear Kim,

Thank you for writing again.

I do understand how you feel, Kim. It will take time, patience and understanding to change his behavior and appetite. The truth is children are different, some seem to be born with big appetites even when they are sick or unhappy. Others have picky appetites or their appetites are easily affected by their health and spirits. But every child is born with enough appetite to keep them healthy and gaining weight at the proper rate. Hence, do not compare one child to another because they are different. Children have an instinct to be balky if pushed too hard and to get disgusted by foods they have had unpleasant experiences with. So, it is important to remember that children have a remarkable system to know how much food and which types of food they need for normal growth and development. It is extremely rare for the child to develop serious malnutrition, vitamin deficiency or infectious disease because of picky eating habits.

Your son has a poor appetite, prefers sucking to chewing and vomits after a few spoons of pureed foods. Generally, after six months of age, most of the babies begin lumpy or chopped food and if a baby goes much beyond that time, eating nothing but pureed things, it will be harder and harder to make the change to solid foods.

So in your son's condition, you may want to start over again by making mashed up lumps of cooked vegetables or fruit and a piece of bread or toast. Remember, the change has to be gradual, don't push too much and allow him to pick up food and feed himself. It is only necessary he gets used to eating some lumps each day so you do not have to make all the food lumpy. Meats should continue to be ground or minced fine because most children don't like chunks of meat that they can't chew up easily. I recommend to offer the foods he likes best so when he sees it he really wants to eat it and avoid all the foods he dislikes for a few months.

Substitute foods will also help him maintain his nutrition. For example, if he dislikes vegetables you can give him fruits which have many of the same minerals, vitamins and fibers. Whole grains also have some proteins and many of the vitamins and minerals found in vegetables. The key is "to keep mealtime relaxed and fun".

If you are concerned about his nutrition, a multivitamin supplement can be used. Try the foods he likes most for a couple of months and add some new foods but not the ones he hates. Serve small portions, less than he will eat, not more as this will encourage him to think "this is not enough". This attitude benefits his appetite and makes him eager for food and gets him to eat as much as he wants. What makes him vomit is having food pushed into his mouth. So two steps can help, first is to encourage him to feed himself completely and go unusually slow in making changes to his food. If necessary, continue on pureed foods until he has lost all fear of eating and is really enjoying it.

You may have heard the advice for poor eating children to "put the food in front of the child, say nothing, take it away in 45 minutes, give nothing else until the next meal".

This only works when the parent is not fussy or worrying about the child's eating. But the truth is the parents have feeling too, the feelings get stronger as the poor appetite is more chronic. The most obvious feeling is "anxiety", "frustration" and sometimes "anger". All these feeling are uncomfortable and they make parents find it is hard to relax as long as the child is eating poorly. The best thing to do is try hard not to talk about this eating. You have to practice, practice and practice then you will be able to stop thinking about it which will relieve this pressure and he can begin to pay attention to his own appetite again.

Remember this will take time and effort but children have a remarkable mechanism to maintain their nutrition. My advice is be patience, relax and make eating a fun time for him. In time it will work out. Good luck

-- Dr. Donya

Dear Dr. Betancourt,

Thank you very much for reading my letter. Hopefully you can help answer a problem that my daughter has. My daughter is now three years and five months old. Approximately three months after her BCG vaccination (age three weeks years old), on her neck, appeared a little enlargement (diameter about an half cm). If she gets influenza or some other illness in her head and throat, then there is an enlargement of her neck lymph node. I have consulted her pediatrician but they are unable to give a clear answer.

Question: What is the enlargement? Are there any dangers associated with this swelling? What is the treatment?

Looking forward to the answers of my questions, I thank you very much for kind attention and help.

Sincerely yours,

-- Y

Dear reader,

BCG is the vaccine for tuberculosis. It is a live vaccine prepared from the tuberculosis (bacteria) to prevent severe and life threatening effects of TB. Its side-effects are very uncommon (1 percent to 2 percent), such as lymphadenopathy (enlarged lymph node) or abscess (pus forming infection) at injected site or at the lymph node (suppurative lymphadenitis).

However, it is true that swelling of lymph node is one of the side-effects of BCG. But it usually happens at the armpit area and the site of injection. Enlarged cervical (neck) lymph nodes can be symptoms and signs of tuberculosis but is more common from a variety of child infections (ear infection, sore throat, tonsillitis, impacted tooth) or more serious diseases like AIDS, leukemia or lymphoma.

Lymph nodes, normally cannot be palpated (felt). If you can feel it, it would be considered an "enlargement". In medical practice, cervical lymph node enlargement is more common from upper respiratory infection so if the lymph node is bigger than one centimeter or more than one lymph node of 0.5 centimeter is present then it would be a concern.

In your daughter's case, she has 0.5-centimeter neck lymph node enlargement and she is doing fine, there is nothing to be concerned about. But if that lymph node is getting bigger or it is painful or she has other symptoms such as fever, poor appetite, not gaining weight, fatigue, cough or has had contact with a person who has active tuberculosis, you should take her to see her doctor again. And if your doctor suspects that she has tuberculosis, the doctor may do a skin test or chest X-ray.

The treatment for your daughter right now is "observation". If that lymph node is enlarged from recurrent upper respiratory infection, this gland will get smaller as she gets older. So to recap, I recommend you keep an eye on your daughter, and watch to see that she continues to have a good appetite, gains weight, doesn't have fatigue or cough and hasn't had contact with anyone with active TB. Thanks for writing.

-- Dr. Donya