Food Reintroduction

Treating a child with eosinophilic esophagitis (EoE) is a journey with both ups and downs. From allergy testing and endoscopies to trying food eliminations and elemental formula diets, the CHOC Eosinophilic Esophagitis Clinic team works with patients and their families to narrow down each child’s EoE triggers.

After an endoscopy shows that the eosinophils have gone away, our team works with the patient’s family to reintroduce foods. The foods are selected according to previous allergy testing, nutritional quality, the child and family’s preferences and the expertise of the team. Foods are slowly reintroduced one at a time beginning with those negative on testing and/or least likely to cause a reaction. During this time, it is important for caregivers to monitor the patient for allergic reactions or EoE symptoms. Symptoms are usually similar to those that led to the child’s initial diagnosis and can range from mild reflux and food impaction to cramping, vomiting and difficulty swallowing. If there is known or suspected risk associated with the food, the reintroduction may be done under the supervision of the child’s healthcare team.

After a few foods have been reintroduced, patients undergo another endoscopy to see if the eosinophils have returned, even if the patient does not have obvious EoE symptoms. If there are no eosinophils, the child can continue eating those “safe foods.” If the eosinophils have returned, those foods are again removed. The food reintroduction process continues until the EoE team is able to determine the food(s) causing the allergic reaction. Once the team figures out which foods cause the child’s EoE symptoms, those foods are permanently eliminated from the patient’s diet.
Has your child been on an elemental diet?

Learn more about the food reintroduction process for children who have been on an elemental diet.

Food reintroduction can be exciting and overwhelming for patients and their families.

The challenges of food reintroduction

After all of the hard work, it may come as a surprise to patients’ families that reintroducing foods into a child’s diet may not be the celebration of success they had imagined. Difficulty reintroducing foods into a child’s diet can happen for a number of reasons.

Negative feelings for food

Over time, it is not uncommon for children who have had EoE to develop negative feelings toward foods—especially when they realize how much better they feel with foods being partially or completely eliminated from their diets. Because it is difficult to pinpoint foods causing EoE immediately, we often eliminate foods with the purpose of reintroducing them later to see if there is a change in eosinophils. Children who have experienced the six-food elimination diet or a customized food elimination diet, may be nervous to incorporate food back into their diet that they were once told may harm them.
For children who have been through the diets and end up on the elemental formula diet, food reintroduction can be particularly difficult. Children who are used to consuming formula as nutrition often become so used to this way of life and feeling good without the need of foods that they may refuse the idea of eating regular foods all together.

Under or over sensitivity to tastes, smells or textures of foods

While on a restricted diet, a child’s sensitivity toward the textures, tastes and smells of foods can change. This sensory change is particularly true for children who have been on an elemental formula diet—whether they receive their nutrition by mouth or a feeding tube.

Elemental formula has a very distinct taste. Because it isn’t a taste that children particularly love, they often drink it while it is very cold, very quickly. Over time, they can become used to the formula’s taste and find it difficult to enjoy the tastes and smells of regular foods—even those they once enjoyed.

Tips for Parenting Difficult Feeders

Parenting a child who has difficulty feeding can be frustrating. Caregivers parenting difficult feeders, should always try to:

  • Make eating a family affair and encourage the entire family to have family-style meals.
  • Combine foods the child likes with those the child does not like to eat. A plate full of foods the child doesn’t like turn into a losing battle. Including foods the child likes will improve his or her attitude toward new foods or foods he or she doesn’t love.
  • Use small sensory shifts when introducing foods. Change one thing at a time (shape, color, taste, texture).
  • Follow routines with meals. Children thrive on routine and feel safe when they know what to expect.
  • Give the child time to imitate or comply. It may take the child a while to take a bite or swallow. Be patient and encourage even small successes when it comes to food introduction.

If a child is having difficulty accepting foods, our feeding specialists recommend the following:

Social modeling

Social modeling is demonstrating the right way to eat for the child. Parents should not only model the right way to eat but model good behaviors associated with eating. Meals should be eaten one-on-one with the child. The one-to-one ratio with no other distractions will make mealtime much less stressful for the child. The focus of the meal should be the food, not the child and the conversation should center on food. The child should stay at the table for the duration of the meal time, even if they are not eating and should never be punished for eating incorrectly or not at all.

Structured meal and snack times

Snacks and meals should be eaten in the same place according to the same time schedule every day. Meals should be limited to 30 minutes and snacks to 20 minutes. Children should be presented with three meals and two to three snacks each day. At each meal or snack, we recommend placing several foods on the table for exposure.

Predictable meal-time routines

  1. Warning  – Provide the child with a verbal warning such as, “We’ll be eating in ten minutes.”
  2. Sensory preparation – Bring the child into the kitchen to smell or see the food. Also consider providing the child with physical activities that can prepare him or her for the process of eating. Our specialist recommend activities including swinging, jumping, pushing or pulling toys, listening to calming music, running in circles, rocking in a rocking chair, or brushing his or her teeth with a vibrating toothbrush.
  3. Transition activity – Ask the child to set the table and wash his or her hands.
  4. Sit at the table – The child should go to the table with an empty plate. Part of the mealtime is a learning experience that includes talking about food and having the child allow food to be put on their plate. Consider making it a game, using fancy dishes for older children, providing a “learning plate” for younger children or dressing up for meals.
  5. Family-style serving – If the child prefers, allow him or her to dish out the food to him or herself and the adult.
  6. Eat – Remember the child needs to stay at the table for 20 to 30 minutes even if they are not eating. Make sure to keep the conversation light.
  7. Clean up routine – Ask the child to assist with the process of clearing off the table. It may be helpful for some children to throw one piece of every food into the trash.

Be aware of portion size, food size and food type

The amount or size of food can be overwhelming. Foods should be presented in manageable bites. Children should not be overwhelmed by too much food. We recommend one tablespoon of each food per year of age. To make the meal more pleasurable, offer one of the child’s “preferred foods” at every meal (if allowed).

Prevent Food Jags

A food jag is the same food prepared the same way every day or at every meal. Children will get tired of the same thing prepared the same way and can burn out on it permanently. It is important to offer any one particular food only every other day. If it is early in the child’s food reintroduction process, we recommend changing the foods the child does eat in this order:

  1. Change the shape
  2. Change the color
  3. Change the taste
  4. Change the texture

It often takes two to three weeks of changing on thing (i.e. shape or color) before the child is okay with it. The change should be large enough to be noticed but small enough that the child will still eat the food

The Facts About Difficult Eaters

It is tough to know how a child will react to foods being introduced into his or her diet. A child may happily accept one food while rejecting the other—or reject all foods entirely. It is important for caregivers to keep in mind these myths about food and eating while working with children who are difficult feeders.

  • If children are hungry enough, they will eat. They will not starve themselves. Not true.
  • Children only need to eat three times per day. Not true.
  • Eating is easy. Not true.
  • If a child is not eating, they are just acting. Not true.

Caregivers should keep these truths about food in mind while feeding their child:

  • Messy is good. Allow a child, especially very young children, to experience the food by seeing, touching, smelling and tasting the food.
  • Everyone has preferences and no one person likes all foods and food textures—including children.
  • Children should be praised for trying a food, even if they don’t love it because positive reinforcement yields positive behavior. Yelling and other negative behaviors showing the caregiver’s frustration will not encourage the child to eat more food.
  • The normal reaction to new tastes is rejection.
  • Children under age 8 need to be presented with and eat a new food 10 times before it’s a regular food.
  • Children over age 8 need to be presented with and eat a new food 15 times before it’s a regular food.

Knowing When It’s Time to Get Help with Difficult Feeders

For children who struggle with feeding, the speech therapists and occupational therapists at CHOC work to evaluate and create a treatment plan for each child that takes into consideration the child’s specific oral-motor, sensory, behavioral and developmental needs.

There are three main goals of feeding therapy:

  • Improve the child’s feeding skills.
  • Increase the amount of nutritional foods the child eats.
  • Make mealtimes enjoyable for both parent and child.

Caregivers should contact the child’s pediatrician if the child has:

  • Difficulty accepting new foods and/or textures.
  • Wet sounding vocal quality while eating. (If the child’s speech is “gurgly” it could be a sign of aspiration or “going down the wrong pipe.”)
  • Poor weight gain.
  • Coughing, choking or gagging during feeding.
  • Feeding periods longer than 30 to 40 minutes.
  • Lack of coordination when sucking and swallowing.
  • Food refusal or fear.
  • Negative behaviors during mealtimes.
  • Unusual/low muscle tone in mouth or face.

Many parents are surprised to know that there are many things our specialists can do to help a child who is struggling with eating:

Individualized feeding and/or swallowing therapy

  • A trained therapist works with each child one-on-one to follow a treatment plan based on an initial evaluation and the therapist’s recommendations. The therapist works closely with the patient’s family to encourage caregivers to do many of the same things taught by the therapists at home. As the child makes progress, he or she may be transitioned to a small feeding group to add the challenge of eating with peer interaction.

Increasing acceptance of new foods or textures

  • The therapist presents the child with preferred and non-preferred foods based on their sensory properties (i.e. look, smell, taste).

Modifications to position and posture for eating

  • The therapist will work with the child to ensure he or she is positioned properly in a chair for all meal times. Proper positioning will improve attention and concentration during meals.

Behavior modifications and management

  • The therapist educates each child’s family on how to increase desirable behaviors during meal times by ensuring that interactions between the caregiver and child are appropriate and understood by the child.

Referral to other professionals, such as a psychologist or dentist

  • A multidisciplinary approach is important to make sure that all the child’s needs are being addressed. If the child has an underlying condition contributing to their feeding difficulties that is not being addressed, progress with feeding will be limited.

Want to make an appointment for feeding or swallowing therapy?

Caregivers should request an authorization for a swallowing or feeding evaluation at CHOC from the child’s primary care physician, allergist or gastroenterology doctor or nurse practitioner. Once the Rehabilitation Department obtains the authorization, they will schedule the child for an evaluation based on their triage process-which looks at the medical acuity of the child. For more information, please call 714-509-4220.

The Team Approach

The Multidisciplinary Feeding Program at CHOC utilizes a team approach for treating children with complex feeding disorders. By combining the expertise of a variety of disciplines, we are able to provide patients with a truly unique experience and customized treatment plan that is specific to their goals and developmental needs. The inpatient treatment offered by the CHOC Multidisciplinary Feeding Program is designed to improve oral intake for children who are G-tube (feeding tube) dependent or are at risk of G-tube placement. Most patients have had feeding therapy on an outpatient basis with limited progress. Click here for more information about the Feeding Program at CHOC.