Student doesn't eat and I'm the person to fix it!

[JerseyTomatoMDCrab]

Here's some background on the student in question:

He started back here at school in December in the 2nd grade. Prior to that, he was home schooled by his mother who wanted him at home so she could get a handle on his myriad of conditions: severe anxiety, ADHD, OCD. Once she felt his issues were under control, she re-enrolled him back at school. He is a daily med taker with several allergies so I know him pretty well. Mom is a nice woman, a little overbearing but I can't say I blame her with this child who has so much going on. She's very good about keeping me informed with what's going on with the student.

So, mom comes to me last week and says she is concerned about little darling's eating habits. He is a skinny guy and the stimulant meds certainly don't help with weight gain. She informs me that he has serious "food aversions" and she has a hard time getting caloric and nutrient dense foods into him. He's allergic to peanuts and shellfish and very picky about textures, temperatures, etc. She asked me if, when Darling comes to get his medication every afternoon, I could help educate him on nutrition, the importance of adequate diet, etc. He's very honest about what he ate that day so that afternoon I started asking him about what he packed vs. what he actually ate. I started trying to educate him on the importance of good nutrition. He's got a very scientific mind so I started comparing his body to a machine, explaining that the body needs fuel to run and function, things like that. He also is OBSESSED with stickers so I told him we could keep a card in the office and for every day that he eats his entire lunch, he gets a sticker and we can display his sticker card on the wall. He was totally into the idea but... he has yet to earn a sticker! He has an excuse for not eating his lunch every day. I've sent home some suggestions to mom regarding preparing the food so it's desirable at lunchtime (how to keep bread from getting soggy, yogurts that aren't too runny, keeping cold things cold) but nothing has worked so far.

Mom tells me what this kid will eat and it's horrifying. Cinnamon buns for breakfast every day? I get they are high in calories but that's just scary.

Does anyone have any advice? I can't think of anything else to do but you know, my magic wand is supposed to repair everything.

I've never even heard of a well child having "food aversions" I just always called them picky. Any information would be great!

[pistolchick]

Pediasure, pediasure, pediasure! It's a great supplement.

Also, I have a patient on the spectrum (also showing signs of anxiety/OCD although doc says she is too young for a formal diagnosis on those particular fronts) who hates pediasure and many textures/flavors to the point of forcing themselves to vomit afterward (and also has violent episodes when anyone tries to open her mouth), so I blend up yogurt, fruit-flavored babyfood, oatmeal powder and whole milk. Other times I will blend up whole-wheat pasta, chicken or beef, vegetable baby food, and spaghetti sauce to create something tastes like spaghetti sauce but goes down like tomato soup. Often I'll add a bit of oil or melted butter to add additional calories and fat (as well as sneak in liquid vitamins). I don't permit her to eat sweets/sugar/too much white stuff, because that can cause unhealthy food addiction and worsen her behavior (since when has sugaring a kid up ever helped their ADHD, aspergers or other conditions?).

We also worked extensively with PT, OT, and speech to stimulate, exercise, and reduce sensitivity orally. Sometimes it was rubbing textured objects over the gums to help acclimate to new sensations, other times it was just stretching the jaw muscles. Our ultimate goal was to acclimate her to new textures/sensations without attaching food to it to prevent oral aversion and future feeding problems.

As time moves on, we have been able to slowly introduce new flavors by pureeing them into her usual meals without adding strange or new textures. Success has slow and incremental, but consistent.

Of course, all this is done ONLY in conjunction with a GI/nutritionist, and I perform these functions as a private duty nurse, not as a school nurse (I needed orders to give her pureed food). You perform a different role, so it may not be helpful to you. But if I were in your shoes, I would be referring Mom out to someone with the training and expertise to help her make informed decisions. Let her know you are willing to help her abide by the treatment of a GI/nutritionist/dietician/OT/ST, but it is her responsibility to do so.

Some hospitals have "feeding clinics" where kids with difficulty eating can attend daily over the course of weeks or months to help them transition to new food, so you might be able to point Mom in that direction, especially since your patient is pretty high-functioning.

None of this may be helpful to you, OP, but I thought I'd share my experiences and the remedies nonetheless! Good luck to you, and I'm so happy to see a school nurse so invested in the welfare of her patient when she doesn't have to be.

This is all fascinating. Thank you for sharing.

[OldDude]

These are all interesting and positive suggestions of which I agree with when it is recognized that a child's dietary behavior is consistently different from the "herd." I do not agree the child should be taken off the medications that make him functional at school and facilitate his ability to learn and develop socially. I see this often and it saddens me that it takes so long for the involved parties to recognize that intervention is necessary...in some manner.

I'll guess this child is quite intelligent, possibly gifted and talented material. I was going to add something here but I was distracted (imagine that) and can't remember what it was.

Anyway, back to your initial post, Jersey; I want to remind you that you've done all you can other than continued encouragement and support.

[linda1959]

I haven't had time to read all the replies, but here is my experience both from a professional and personal standpoint. Kids with these kinds of food issues are extremely challenging. The medications can cause havoc with appetite, and then you throw in the neurological issues. If they are not hungry, they are not hungry, and no amount of education or rewards will make them want to eat.

My best recommendation is a nutritionist if the family insurance will cover it, or they can afford it. They can look at where he falls on the weight and height scale, can assess what the child is actually taking in nutritionally, and can suggest/recommend appropriate ways to increase nutrition/caloric numbers for maximum use without having the kids eat volumes. They can help with avenues that others may not think can work. (ie. many parents/nurses shy aware from cereal because they think it is too much sugar, but I learned that a nutritionally fortified cereal with low sugar can be an acceptable food for some of these kids.)

I have suggested this to parents of my students, and had to do this with my own kids, who were well below the fifth percentile at one point and showing rib bones, and those visits with a pediatric nutritionist were a lifesaver.

[NutmeggeRN, BSN]

I haven't had time to read all the replies, but here is my experience both from a professional and personal standpoint. Kids with these kinds of food issues are extremely challenging. The medications can cause havoc with appetite, and then you throw in the neurological issues. If they are not hungry, they are not hungry, and no amount of education or rewards will make them want to eat.

My best recommendation is a nutritionist if the family insurance will cover it, or they can afford it. They can look at where he falls on the weight and height scale, can assess what the child is actually taking in nutritionally, and can suggest/recommend appropriate ways to increase nutrition/caloric numbers for maximum use without having the kids eat volumes. They can help with avenues that others may not think can work. (ie. many parents/nurses shy aware from cereal because they think it is too much sugar, but I learned that a nutritionally fortified cereal with low sugar can be an acceptable food for some of these kids.)

I have suggested this to parents of my students, and had to do this with my own kids, who were well below the fifth percentile at one point and showing rib bones, and those visits with a pediatric nutritionist were a lifesaver.

Possibly the school food service director can help? Ours used to be an RD.

[Spidey's mom, ADN, BSN, RN]

Mom has no interest in taking him off medications. He was a student here before being taken out for homeschooling. I didn't work here but according to his first grade teacher, the principal and the documentation from the previous nurse, his conditions were 100x worse before he was on medications. Like, he was so anxious about a math test that he ran out of the room and was hiding in a closet, school was put on lock down for 45 minutes and he had to go home. He's functioning very well at present (other than his appetite) and doing excellent in school. Now, i'm not saying that medications are the answer to his issues but these were the examples cited when I asked why he was medicated and if reducing his dosages would be an option.

Trust me, if I could choose not to medicate some of my students I absolutely would. Unfortunately that's not my call to make.

Some research shows we are pushing our young kids too much, too soon. If the child was "100X" worse before meds, maybe he had too much expectation on his plate for a young boy; especially a boy. Boys are less able to sit still and do workbook-style classroom activities. Kindergarten used to be the time when kids learned things by play. Now, they sit at desks and are expected not to act normal - fidgety, talkative, etc.

I'm truly bothered by the trend to medicate kids for what is most likely normal behavior or behavior that shows the kiddo is being asked to do too much for his/her age.

I'm in the middle of a discussion with a group of parents who are invested in that Baby Wise book by the Ezzo's and trying to rigidly schedule a baby's life so it lessens the impact on the parents lives. I think parents nowadays are unrealistic about what it means to have a child and raise a child. So, let's medicate any behavior that might just make our lives more difficult. But that's another story.

[MrNurse(x2), ADN]

Some research shows we are pushing our young kids too much, too soon. If the child was "100X" worse before meds, maybe he had too much expectation on his plate for a young boy; especially a boy. Boys are less able to sit still and do workbook-style classroom activities. Kindergarten used to be the time when kids learned things by play. Now, they sit at desks and are expected not to act normal - fidgety, talkative, etc.

I'm truly bothered by the trend to medicate kids for what is most likely normal behavior or behavior that shows the kiddo is being asked to do too much for his/her age.

.

We would not tell a type 1 DM kid to not eat any fats, carbs or sugars. The fact that a stimulant is given to calm down should drive home the viability of med management. My school is modeled after the Ron Clark Academy, very non traditional, and it would be downright cruel to not medicate my foster kid. The few times he has missed a dose was painful to watch. As an aside, want to watch a motivated teachers eyes light up? Mention the Ron Clark Academy.

[Farawyn]

I myself cannot do textures. I LOVE the taste of oranges, grapes, strawberries, yogurt. But the feel of them in my mouth makes me gag.

I love strawberries. This makes me sad.

The only thing gaggable is tripe, or other organ meat, but I think it's more psychological than physical. That being said, I will still try anything, once.

[Spidey's mom, ADN, BSN, RN]

We would not tell a type 1 DM kid to not eat any fats, carbs or sugars. The fact that a stimulant is given to calm down should drive home the viability of med management. My school is modeled after the Ron Clark Academy, very non traditional, and it would be downright cruel to not medicate my foster kid. The few times he has missed a dose was painful to watch. As an aside, want to watch a motivated teachers eyes light up? Mention the Ron Clark Academy.

I'm not saying that a true diagnosis of ADHD or any other mental health issue shouldn't be medicated.

I'm saying that many educators and parents are going overboard in saying a kid who is simply unable to sit still for very long needs to be medicated.

There is a trend nowadays to medicate kids instead of help them learn. The percentage of kids on meds has increased greatly.

As to the diet of Type 1 Diabetics, why would you not tell a child who has Type 1 about a healthy diet for diabetics?

[proudschoolnurse]

Sounds like the physician who is writing the scripts needs to be involved, especially if the child is not eating. Does the child see a psychologist or outside counselor or therapist. Sounds like a team meeting to communicate and collaborate is overdue. I applaud you and your efforts to educate the child- shows the world school nurses can and DO more than put band aids on boo-boos. It is frustrating when a parent expects the school to fix in 7- 8 hours what they can't in the other 16.

[JerseyTomatoMDCrab, BSN]

You guys are great. Thanks for all the advice and support.

My plan is to call mom at the end of each week with a summation of how things are going. We just started this on Thursday. Since spring break starts tomorrow (hallelujah) I will give her a call today with my suggestions.

[sbc12406]

When I was a kid I had a huge phobia of choking/being allergic to foods. It got so bad that I was only limiting myself to a small selection of foods and then I would barely eat them. I feel like if it was something like this though he'd express that's what he's nervous about.

[MrNurse(x2), ADN]

As to the diet of Type 1 Diabetics, why would you not tell a child who has Type 1 about a healthy diet for diabetics?[/quote

I stated that wrong, I should have said to avoid all fats, carbs and sugars, which is impossible, and forgo meds. I'll edit it. I agree that some kids are medicated that don't need it and expectations of parents are to make them little adults, see my post about over-medication a few back. My limited exposure here shows me that the non-medicated kids outnumber the inappropriately medicated kids. I probably would have had to be medicated the way they teach kids today.