At the Table with Brittany Shapiro

Welcome to At The Table with Sarah and Julie. At The Table is a podcast by two pediatric registered dieticians and moms who love food and wine. We cover a wide range of topics with our goal to provide you with evidence-based insights but also to be a hub of true expert voices in the food and nutrition field. In this episode of At The Table, we sat down with Brittany Shapiro, a registered dietician and pediatric expert. Brittany has extensive experience working in the field of pediatric nutrition. She received her degree in dietetics from the University of Maryland and went on to complete her dietetic internship at the National Institutes of Health. Brittany worked as a pediatric dietician at Children's National Medical Center in Washington, DC for over eight years. She started her private practice, Capital Pediatric Nutrition in 2017 and sees patients across the DC metro area. Her specialties include infant feeding, picky eating, weight concerns, GI issues and food allergies among others. In our conversation with Brittany, she provides us with expert advice on navigating selective eaters and creative ways to have them at the table. We learned so much from her and can't wait to share this with you. So with no further ado, here's Brittany Shapiro. Brittany, thank you for being at the table with Sarah and Julie. It's been a while since we've talked and worked together but I love that this is full circle and that the three of us have worked at Children's together and go back to those times. But yeah, we wanted to talk about your practice and what you're up to. Yeah, yeah. So as you guys have heard, my background was at Children's National with both of you. So I was working at the hospital for I think eight years and then I was working both in the inpatient side in the GI and neurology areas. But then the second half of my time there, I was working as part of a multidisciplinary feeding program. So I was working with psychology and occupational therapy and speech therapy, working with kids that you know have different problems with eating. And so that kind of was really a nice avenue to starting my own practice. And so I have a private practice called Capital Pediatric Nutrition. And in that practice, I work with all different babies through teenagers. So lots of different areas helping babies, introducing solids and giving support for parents, working through navigating food allergies, a lot of GI problems like celiac disease or irritable bowel syndrome or Crohn's disease. And then a lot of just general picky eating with toddlers or school-aged children or even teens. And weight concerns if the doctors are worried about any kind of growth issues. And just general nutrition for families as well. So I get to see lots of areas and it's never dull. It's wonderful. You have such a wide range of expertise. What would you say is your most common infant feeding question that you get? Yes. So when it comes to infants, I definitely get a lot of questions when I'm talking about introducing solids, about whether we should be doing the purees and conventional feeding practices or if we should be doing the baby-led weeding, which a lot of people are seeing on social media as a big push. I really like to remind parents that it doesn't have to be whole-forth one or the other. A lot of times people feel shame about giving a puree to their child and I actually remind parents that that's the conventional, often typical way of feeding children. And so there's nothing to be worried about. I think the key with any type of texture we're giving children is just to make sure that they're engaged in the feeding session. So we're not shoving purees into their mouth while they're turning their head, but we're really either giving the baby a spoon that has purees and letting them bring it to their mouth or we're waiting for the child to open their mouth and lean forward and be excited to eat the purees off of our spoon. So any different feeding method can work as long as the child participating in the session. So that's probably the main question, I guess. And so for those cases when baby may be less excited about participating, what are your tips for those scenarios? So just always to keep in mind that babies are very new eaters. So for the first six months they've been working on figuring out how to take milk or formula or breast milk and so that really shows not every feeding session needs to be perfect. They don't need to take a specific amount. So it's all just practicing the skill and over time as they get closer to one, it's going to be starting to serve as a big source of nutrition for them. So if the session is not going well, the baby's turning their head, they're crying, they're just not happy and it removes them from their high chair, that's totally fine. We can try seeing if they want to, you know, calm down a little bit and then put them back in or see if they want to eat on someone's lap, if that makes it over better. But yes, nothing to worry about. Try again later that day or the next day. Would you say that repetition does continue to do the same with introduction? I feel sometimes there might be some thought process of, oh well, if you take them out of the high chair or you hold them in your lap, it's going to give them a different idea and they're going to get used to it. I think in general, we just want to keep everything really positive at the table and so whatever it takes, we want to even engage them just with spoons or toys in the high chair at first while they're figuring out how to actually enjoy sitting in the high chair and then we can kind of build. But yeah, over the first week or month, you'll see if the baby really learns, oh I sit in the high chair and that's where I get to eat, right? But at the beginning, they just don't understand that. So I was telling you all that I started pureed with my six-month-old this weekend and the sessions have lasted about three minutes total and it usually ends with him being upset and wanting to get out of it there and we end it. And so it's definitely a learning curve and we'll get there but at the beginning, there's some rocky moments. Yeah, I think setting those expectations is so important because new parents, I don't think know what to expect with starting solids. Even as a dietician, my firstborn, I did have sort of expectations that she would take off relatively quickly with solids and that wasn't necessarily the case. So you said it's a new skill, they're not going to go from drinking milk to all of a sudden eating large portions of food obviously. I think setting those expectations for parents and knowing what is normal. Definitely and I always love the question parents are like, well what should the first food be, right? And I always remind them, well the first food is probably not really going to get consumed anyways and so don't put too much thought into it, right? We're not going to make this whole fancy gourmet thing and then it doesn't even get really touched much. So give them a food that's convenient or something that's culturally appealing to you all. Don't put a high expectation that they're going to consume much. So we want to talk to you about selective eaters, you know, picky eaters and what is the pattern? So what advice do you provide families to navigate selective eaters? Yeah, so I mean definitely there's a higher propensity to have some selective or picky eating tendencies with kids that either have some kind of oral motor problems where they don't have a lot of strength, they're probably chewing, that can lead to some picky eating tendencies. A lot of kids with sensory problems, maybe they don't like certain textures, they don't like touching things or getting them messy, that can definitely contribute. And then a lot of just general feelings of anxiety in life can often translate into the table and eating. But either way, we handle it the same way. We want to really support kids to be as flexible eaters as possible and so I think that comes with just the idea of providing a huge menu variety. As a parent, I'm a big proponent of the Ellen Satter division of responsibility and feeding. So this idea being that the parents job is to put the food down to come up with the menu and to give regular meals and snacks and it is totally up to the child if they're going to eat and how much they're going to eat. So we're not dictating the amount and we're not going back and getting alternative food or sticking to the menu that we're offering to the child. So I think if we can keep that structure, if we can keep the variety, not having the same breakfast every morning but maybe three or four in the rotation, the same thing for a lunch and dinner, I think that really starts the child on a good foot to help manage some of that picky eating. And when you do have a more selective eater, who again were as parents, our role is to help choose what is going to be on the menu, are you usually telling parents to offer a couple of the foods that the kid don't like that we know that they generally accept and then adding in those maybe less common foods as a more exposure food, is that generally your... Yes, absolutely. So we want to build trust at the table and if we put down all foods that are very dairy or non preferred to that child, there's no way that they're going to want to even engage or sit there for five seconds. So building that trust, cutting down a food that the child's comfortable eating alongside small amounts of some newer food, I think it's key, but whatever that safe food or preferred food is, we should really try to vary up that preferred food as much as possible. So if it's chicken nuggets, different grains, if it's cereal, all different flavors. So really switching it up in that way. That's interesting. That's not something I actually thought about, of making sure that you don't use variety but within that same source essentially, not safe. Exactly. And I remind parents, even if the chicken nuggets that we're switching up the brand doesn't offer a different type of nutrition or say one is organic and the other isn't and that's making us feel shameful, that's actually really productive in the sense that teaching a child to be flexible when it comes to the look of the food. Some is more crunchy, some is softer, right? Some might be based in actual whole chicken breast, whereas others are more ground chicken based. So it's really teaching a lot of flexibility that can translate into nutrient variety over time. I love that. I love this flexible eater. I don't know if I've heard that as commonly used and I really like that. Yeah. And you brought up a really good point about textures and oral development. I've noticed that there are some kids that are so much more sensitive to temperature and texture. What are some tips to navigate that? Because it might not always be obvious. It might not be an extreme sensitivity, there might be some subtle hints to it. Definitely. So I think in general, a lot of kids age three and four or younger still have a hard time managing very chewy textures, right? So why won't my two-year-old eat steak, right? Well, they might like the flavor, but it's still a lot of work, right? So there's a lot of texture preferences, but a lot of it's also kind of within the realm of normal. Either way, we should try to lean into it and use this idea of food chaining. So this idea is with food chaining, we're using their preferred flavors or textures but building on it. So if they really like crunchy textures, which is very common because it's kind of very predictable and we get that feedback of the crunch, it's familiar. So a lot of those crunchy crackers or snack foods, how can we get some more variety? So could we lean into some maybe freeze-dried fruits and vegetables as a way to get the food groups for fruits and vegetables? Or maybe some crunchy chickpeas or something to get some protein, right? So just kind of leaning into the preferred texture, but using that to get the variety. I really like that. Even as dietitians, we know all that, we have all the resources and the expertise, but it's still a frustrating moment when your child is refusing that food. Kind of similar to that concept of food chaining, we talk about the steps to eating. So before we even actually eat a food and consume it and go back for it, there's a lot of precursor steps. Seeing the food across the table or seeing it in front of us or smelling the food or maybe licking it or putting it in our mouth and spitting it out, right? These are all really productive precursor steps to actually going back for more. So putting the food down and getting the child just used to seeing it is really productive. With my three-year-old, I can assure you he doesn't touch a vegetable and we don't put them on his plate and sometimes if I forget, he'll be like, mom, you forgot to give me the broccoli. So they come around to it, they get it, but if we don't put it there, that's going to be a big barrier. That's part of the process. He's gotten used to it. It's the routine. So what process do you use to determine when something more complicated is going on? Are there screening tools or other processes that you use to help determine when there is more distorting? Yeah, great question. Definitely. So in general, when we want to know, okay, is it just preferences or selective eating versus problem feeding, we call it, we do have some criteria. So if growth is impacting their ability to get the right nutrition because they're so limited, that's one part to know, like, okay, they probably need more help. Whether they're growing too fast because they're relying on foods that are really dense in calories or they're growing too slowly because, you know, maybe they're grazing all the time or they're filling up on foods that are very low calorie options. So that's one area. The other being the variety of the food group. So we talk about if there's less than 10 foods in a category needing less than 10 proteins, less than 10 grains, or less than 10 fruits or vegetables, that can also be a sign that they might need some more support. I do always remind parents that the same vitamins are in fruits that are in vegetables. And so if we are rejecting all the vegetables but we're eating 20 different fruits, we're still able to meet all of our vitamin needs. So that's really reassuring and it takes a longer time sometimes to like vegetables, so keep working at it. But either way, if we feel like our child is very limited in the way that it's impacting their growth or their nutrient variety in their food groups, I definitely would seek out some help either from a registered dietitian or also from a feeding therapist, which would be an occupational therapist or a speech therapist who specializes in feeding. Usually it's the collaborative approach between both people that actually is really helpful, the dietitian and the feeding therapist. Perfect. So what should parents be looking for with selective eaters in terms of growth? Yeah, I definitely see a lot of children growing on the lower end of the curve. A lot of times I'll see kids that are kind of always kind of small, but then because of that, they tend to have a smaller stomach size and they tend to have lower appetites in general. And so a lot of parents have this expectation of, oh, why aren't they finishing their meals compared to their sibling or compared to the other kids in their class? But they might actually be okay. They might just be growing at a lower area on the growth curve, but still maintaining their established growth curve. So maybe they're always at the fifth percentile and always just eat a little bit less, but it's not a problem if they keep growing along that way. It's only a problem when we see kids that are much higher on the growth curve and then they're falling off. Or maybe they were much lower and then they're going off really fast. And for some families, sometimes it's hard to navigate the growth curve. What are some good ways to really understanding what those percentiles mean? So a couple different things. I think that there are different percentiles going from zero to 100. And the purpose of that is not to say that every child's supposed to grow at the 50th percentile in the middle, right? That's not actually the goal. The goal is for the child to pick a percentile and then maintain that one, right? So whether that's third percentile or 85th percentile, you know, it can be anywhere along that curve. It doesn't change for some fluctuations, right? If a child was last year at the 25th and now is at the 12th, actually that could be okay, right? And they can kind of bounce up and down within a small range. It's just if they were at the 50th, then they were at the 25th, then the 10th, we're starting to wonder, oh, why are they consistently dropping, right? So I think having a very detailed conversation with the pediatrician is important. We don't want to look at just one percentile. We need the trends, right? So I think that's really helpful. And then if there's any concern, going to a dietician and getting their interpretation because sometimes we're missing out on that big picture. And what is your opinion on the use of nutrition supplements such as Pediature or the variety of supplements that are available these days into those who maybe are more selective eaters or particularly if their growth is a concern, how do you most appropriately use those? Yeah, so those supplements, Pediature, Boost, or things like that, we use those definitely in some of those kids that need help with growing. They're maybe falling off the growth curve, not able to get in enough nutrition with food, but we use them very strategically. So I have a lot of kids that are relying heavily on milk or these shakes like Pediature and sometimes we see that they fill up their bellies and then they're not hungry for the food, which is really where we want the main volume of nutrients to come from, especially over time. So we have been strategically meaning that we put them down at meals and snacks together with the food, not before or after, you know, right there together with the food. And we really control the volume. So I would never want a child to drink a full cup of that at the meal, I would definitely control it like two ounces, four ounces, somewhere around there. And then we can serve it multiple times a day right there with the other foods or before bed. But we're just very strategic about it so that it can supplement what they're taking from the meal in terms of the solid food, but not replace it. I think that's an important thing. Yeah, especially supplement, it's not a replacement, which I feel sometimes it does take the form of a meal. How about multivitamins? Is it more selective eaters or do you recommend that in general for most kids? Yeah, good question. So I definitely don't think it's hard, but oftentimes it just covers our base in case we're worried that something's missing in the diet. I will say that a lot of things don't need them. If they're able to eat better, more different proteins, vegetables and grains, they're probably good and they can be expensive and add up for sure. So if there's a lot of inconsistencies, our kid only eats apples for one week and then they stop and then they only eat oranges. There's a lot of inconsistencies, lack of predictability in terms of what they're going to eat. I think it's never a bad idea. That way, when looking at the multivitamins, I just recommend finding one that has a nice comprehensive list of vitamins. So some of them are marketed as a multivitamin, but they really only have a couple on the list. So making sure they have things like calcium. If they're not into eating proteins, animal proteins, considering getting one with iron for sure, then a lot of times kids benefit from some vitamin D as well. So just making sure it's a nice comprehensive list of multivitamins or vitamins in that supplement, but otherwise, yeah, it's never a bad thing. So I have a follow-up question to that because I get the question a lot in my practice as a dietician about protein intake with a lot of our kids and even especially with selective eaters. A lot of the pediatricians or physicians that I work with are constantly concerned about protein. Do you agree with that concern or do you think because we have that rule of if they're eating at least 10 different foods, they're getting that nutrient? Yeah, I definitely find that there's a lot more concerns about protein among families or providers. And then sometimes when I meet with the families themselves, I have less of a concern. I always remind families that the actual protein needs in kids is often a lot lower than we think that they need. So usually they really are able to meet their protein needs. But I think the key is just the variety that they're not only accepting protein from milk and cheese, but there's some iron protein foods and some zinc protein foods in their diet. And so it's really just about the variety, but they don't really need to be taking a specific serving size of protein at all their meals. Usually we're looking at the average in terms of the day or the week rather than just the meal to meal. It's just making sure that they're getting all the nutrients from getting a variety of different sources. Especially with toddlers, there's a lot of inconsistencies in terms of their hunger, right? So we have these babies that are ravenous taking everything and then really in toddlers, the rate of growth is slowing down and that translates to a lower appetite at baseline as well. So we have these expectations that are set really high of they're going to eat all the chicken and rice and potatoes. They're going to eat everything. And then that doesn't happen in toddlers. And sometimes they'll just eat the fruit. A lot of times they'll just eat one of the foods that's a meal that's put down. We put down three to four foods, but they might just choose one or two and that's really their choice. And that's okay. It doesn't have to be even from breakfast, lunch and dinner. A lot of toddlers will flat load and so they eat a lot of breakfast. So maybe serving a heavier protein breakfast that when they have the appetite for it and then dinner time, keep the expectations low. Perfect segue into talking a little bit more about that hierarchy. Again, you spoke about our role as parents and then the children's role of deciding how much or whether to eat. What is your take on intuitive eating in children and how best to promote that as caregivers? Yeah, that's great. Mindful eating, this big child really learning how much to eat in terms of how their stomach is feeling and then connecting the feeling in their stomach to their brain and then dictating if they should eat more or stop eating, right? I think a lot of times when there's a lot of pressure at the table or if the parent has an idea in their head about how much volume they want their child to eat, sometimes they're doing that job for them. They're like, well, you must take three more bites. Well, what if the child's not hungry for three more bites? What if their belly is really full? Then we're actually surpassing their ability to listen to their own hunger cues and we're doing it for them. And that's a lifelong skill that I think is really important. A lot of adults don't even have that skill of listening and they lead to their hunger and fullness cues. So we want to really practice that from early on. And I think just the best way is put down the food and then talk about something else at the table. We don't need to talk about the amount, don't need to talk about if the food is gross or not gross. We just put it down and then we have a conversation about the day or about anything else and just try to make the table a place where the child wants to be and to stay so that they have the chance to really listen to how much their body needs while they're there. That's great. So just keeping it super positive and keeping that pressure off the child. Yeah, I also get a lot of questions about, especially kids that are growing on the higher end of the growth curve, what is a good portion size? When should I cut them off? What if they want second or third? Definitely, I think it's important to give your child a lot of opportunities to have seconds and thirds so that they understand what it feels like for their belly to feel too full and so that they can connect that with, okay, in the future maybe I won't, right? Or maybe I'll stop right before I'm starting to feel sick, right? And so that's a skill that I think we should put in the child's hands a lot of times. All the time I think it's okay to say, everyone gets two scoops of pasta today, but I want to make sure we have extra to put in your lunch tomorrow. So we're gonna just stop here and feel free to eat the other foods on your plate. Or we're all just getting one piece of cake today so we can enjoy another day. Or we only have one pint of raspberries, so we're gonna split it into quarters and raspberries are expensive, right? So these are all very reasonable things to explain to a child and it doesn't have to be about, oh, that's not good for you to eat more or that's unhealthy. It's more about these other things. I love that super rational approach and I feel like it teaches a lot of different skillsets navigating the portion size and other ways to approach it. Because kids love to snack. Kids want the sweets and I feel sometimes our adult mentality can get in the way of saying, don't have that cookie or don't have that sweet because we know, we know what these nutrients are of that. But how do you navigate? Totally. The idea of when a child says the word snack, they think about it as an easy and preferred food and a meal as a challenging and non-preferred food, right? So this idea of neutralizing meals and snacks so that we can enjoy both of them, right? It's not that snacks are the only time of day where it's going to be enjoyable to eat, right? And I think that's how a lot of toddlers or younger school-aged children start to feel, especially when we're very restrictive at meat and snacks. They're very unrestricted, right? So I think this first thing is a very strict schedule where we have times of the day for eating meals and snacks and times of the day where the kitchen closes down. A lot of times the kids are just eating snacks all day all over the house and so that's why it's the easiest thing for them. Trying to bring all the food to the table as much as possible and then when the meal or the snack is over, we move on and do something else. So that's one. I think the other thing is thinking of snacks more as like mini meal opportunities so they can offer just as great nutrition as the meals themselves. So that can be like, okay, if they're having snack or put it with some kind of protein or fat to make it more of a mini meal like some cheese or if they're, I don't know, having some apples, put it with the peanut butter just to kind of round out that snack and make it more satiating like a mini meal so that they feel satisfied. There's more than just one food and it's gonna be kind of similar to a meal. The other really, really helpful thing that I think families enjoy hearing is trying to bring some of the snack food to the meal to kind of neutralize them. So if dinner is all we keen on, right, then roast the potatoes and the child doesn't enjoy those grains. Trying to bring some other familiar grains like popcorn or crackers or chips, right, to the dinner table and kind of neutralize the snack in that way and get the buy-in of the dinner and they're really convenient and easy. So it's making it not that we're putting up snacks high on the pedestal but it's more of everything is food and it's all convenient meals and snacks. I love that. I think those are super helpful strategies. So we're going to segue a little bit and we wanted to talk about allergies and food intolerances. I know especially with introducing foods, what is some advice that you provide families to introduce some of these allergens and navigating those intolerances? Yeah, so we definitely are getting more and more research about how early introduction of the allergy foods to babies leads to less incidence of reactions. And so they're the top allergies being dairy, soy, wheat, fish and seafood, nuts and tree nuts and sesame and eggs. So just making sure that we introduce these foods in the first few months of starting solids and then have a continued exposure to them is also key. So it's not like, oh they had cashews once and at six months and they were fine but making sure, first of all, they probably had a nibble on it at that age and so wasn't much volume but just making sure that they're continued to be exposed for that from time to time. I have a lot of kids that come to me and they have reactions to eggs and milk and soy. What do we give? A lot of it is making sure that while we're avoiding the food that they're allergic to, we're still able to get them proper nutrition. And so what are some alternatives? How do we make sure that they're getting a varied type of diet without those allergen foods? And I think that's really needed to work with the dieticians to help navigate. And then the other piece of it is a lot of parents will start to diagnose these intolerances, right? Oh, my kid doesn't do great when they have too much dairy or things like that. And I think the key is if we are going to be avoiding those, really making sure that we have a good reason to do it and that's absolutely necessary because if we stay away from certain foods or food groups altogether, that's really limiting the types of nutrients that our child's exposed to which can have a big impact on their growth and their nutrient intake. So making sure that there's a certain amount of dairy they can handle and that we shouldn't be encouraging that amount. But overall, working with the providers, the whole team to say, okay, if we're avoiding these foods, is it really necessary? Is there a time we want to challenge and retry it down the road so we're not avoiding it for longer than necessary? I think that's all really important. And I know we talked about this a little bit, but what are some of the more common micronutrient deficiencies or even macronutrient deficiencies that you do see, maybe especially in those groups that have allergies or have special diets? Iron is very common, whether it's in the picky eaters or maybe a soviet or vegetarian diet or with the allergies. Definitely making sure that we are checking iron levels around that 12 to 18 month visit and then supplementing if we need to while we're working out increasing the iron in the diet. The same with calcium. There's a lot of non-dairy sources of calcium we can focus on as well. And then we're starting to see zinc be another one that's a common nutrient in a lot of animal protein foods. And you know sometimes that B12, if they're falling more of a vegan type of diet and then vitamin D, that one is tough to get enough of. So I'd love to keep an eye on that and supplement it with a vitamin if we need to. So we talked about the families. We know that kids copy behavior. With some good advice for families to be able to work through the table and dinner time with them. Yeah, definitely. I see really commonly actually a lot of spectrum that the older kid is worried on the really high end of the growth curve and the younger one is on the lower end. And I would say just to add on to this growth discussion, so much of it is genetic. We have to come to terms with it and really show acceptance of their body so that they can obviously be accepting of it over time as well. So yeah, definitely a lot of different growth patterns and set of nutrient needs or preferences around the table. And so making sure that everyone has a preferred feed. We can do a little bit of individualizing when it comes to growth problems. So if one child is not growing well, then then you should still stay the same for the whole family. But maybe that child gets a little bit of added fat. Maybe their rice has olive oil on it or a mascarpone does have butter or something like that. And the same with the drinks. Maybe one kid is getting a 2% milk and the other kid is getting a PediaSure. So those are ways that we can individualize it. But when it comes to the menu, I think here modeling is really important. So keeping the table positive but using kind of that modeling. The same at school. Asking your kid, oh what did other kids have for lunch today? What looks good? What would you want to put in your lunchbox with somebody else? Well Brittany, this was so insightful. Thank you so much for joining us. This has been really great. Remind us, Capital Pediatric Nutrition. Capital Pediatric Nutrition, that's right. Yeah, so just helping the families across DC, Maryland and Virginia. You know, babies through teenagers. So yeah, if anyone needs support, feel free to reach out. Wonderful. Well, thank you Brittany. Thanks for having me. Nice to meet you. Bye. Thank you so much for joining us at the table. Be sure to follow us on Instagram as well as on Spotify, Apple or wherever you get your podcasts. We are Sarah and Julie. Talk to you next time at the table.