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Field Talk is a monthly blog post sharing the voices of early childhood providers who serve or have served military families of young children with disabilities (birth to 5 years old).  We hope you find it to be educational, personable, and encouraging.

This month we talked with Nicole Withrow PhD, MS, RDN.  Dr. Withrow is an Assistant Professor/Dietetic Internship Coordinator at the University of Northern Colorado and a Pediatric Clinical Registered Dietitian Nutritionist at Colorado Children’s Hospital.  This interview has been edited for length and clarity.

Describe your current role.
I am an Assistant Professor and Dietetic Internship Coordinator for the University of Northern Colorado. I develop and maintain courses for graduate and undergraduate students. Currently, I have 30 dietetic interns nationwide who are completing an accredited dietetic internship. The internship is accredited through the Academy of Nutrition and Dietetics and each intern must complete 1200 supervised practice hours. Along with teaching responsibilities and maintaining an internship, I am involved in conducting research in Autism Spectrum Disorders.

Recently, I created the Sensory Processing, Aberrant Mealtime, Motor, Inventory for Eating (SAMIE). It is a screening inventory for children with an Autism Spectrum Disorder and will be used in the community, hospitals, private practices, and residential facilities. I am currently in the copyright and publication process with this inventory and hope to have that completed within the next 3-6 months. In addition to my University position, I am a consultant for the Center for Discovery, a residential program in New York for individuals with disabilities, and a pediatric clinical dietitian at the Colorado Children’s Hospital for children with an Autism Spectrum Disorder.

What’s your favorite part of your current job?
I absolutely love having opportunities to wear several hats in the field of nutrition. I thrive when I am educating individuals and helping minimize the struggles of families and individuals due to a disability, specifically Autism Spectrum Disorders. I also enjoy conducting research.

What “insider” tips or advice do you have for service providers working with military families who have young children with disabilities?
I would suggest collaborating with the team of providers who are treating the child. I would say less is more when it comes to recommendations and if families are working with an Occupational Therapist, Speech and Language Pathologist and/or behavioral therapist they should work to make goals that complement each other’s specialty area.

If you could change or improve one thing for military families with young children with disabilities, what would it be?
I would like screening of problematic eating behaviors to occur earlier since they appear to be long-standing and without prior diagnosis and treatment they could have long-term health consequences.

What are some strategies or resources useful in supporting a family whose child has a limited repertoire of food?
One of the most important things to remember is that there can be numerous reasons a child prefers a limited variety of foods and understanding them, and treating them will help with increasing the variety of foods that a child will accept and consume. Reasons a child may struggle with accepting new foods are: sensory processing impairments, oral motor, core deficits of an ASD (rigidity/need for things to be the same), anxiety, gastrointestinal dysfunction and dental caries (cavities).

When introducing a new food, be mindful that it may take more than 10 exposures of a bite size of food before a child looks, licks, touches, or tastes the food item. Only serve a bite size so that he/she is not overwhelmed by the quantity and shuts down, immediately. If a child looks, licks, touches, tastes the food item, positively reinforce him/her with verbal praise. Then continue to offer the food and increase the quantity slowly.

Another tip is to introduce “like/similar” foods. For example, if a child likes McDonald’s chicken nuggets, purchase a bag of frozen nuggets and serve one every time you serve a McDonald’s chicken nugget. Also, pair language with food, “same but different.”

How do you balance nutritional needs given a child’s food tendencies and preferences? What strategies can a provider use to help a parent ensure their child’s nutritional needs are being met in such instances? (For example, a child who will only eat crunchy foods, or foods at a very hot temperature)
This is difficult since increasing a food repertoire takes time. I recommend a multivitamin in order to decrease risk of Vitamins C and D, and as well as iron deficiencies. If your child drinks juice, be mindful to purchase fortified juices (i.e., orange juice that has calcium and Vitamin D added to it). If your child only eats crunchy foods then you can bake foods, offer raw fruits/vegetables, or freeze fruits/vegetables – be creative! Again, if your child prefers only a few food items continue offering a new bite size food item with them.

What are some strategies that providers can use to help families introduce new foods that are outside of a child’s preference? For example, helping a family introduce new foods when their child will only eat a food of a particular color or texture.
Start with a food history and you may notice that at age 1-2 the child ate more foods. Bring those back into their diets, but only a bite size and with repeated exposures. If your child only eats a particular color/temperature/texture then start there and build in different types of foods, but a bite size. Research illustrates that if a child does not get help for food selectivity before the age of 8 then it is more difficult to treat and nutritional risk may become an issue. If a child will only eat chewy foods then offer a gummy vitamin, if they only eat crunchy foods then offer a Flintstone crunchy multivitamin, if they do not eat them right away offer the vitamin every day at breakfast, lunch or dinner. You may also want to add a calcium and Vitamin D supplement in a powder form called Dari Free. You can order it online through Vance’s Foods and it can be mixed into a food or beverage – it has no taste!

Could you please talk about food chaining and how to implement it?
Food chaining is a type of feeding/eating intervention that assists in expanding an individual’s food repertoire. This process builds upon a preferred food and based on the individual. One may also need to start with a similar color/texture/type, depending on the primary reason for food selectivity. For example: A child prefers McDonalds french fries, therefore start with those while also purchasing a bag of frozen shoestring fries. Prepare a couple of frozen shoestring fries and serve them with the preferred food. Once the child tolerates them, increase the quantity of the prepared frozen shoestring fries and reduce the McDonald’s fries. This process should be repeated by introducing another type of frozen fry (waffle/steak cut/curly/fresh potato wedges). Once the child is eating a variety of fries, the end goal is a baked potato. After the baked potato is well received, introduce a sweet potato.

Are there certain vitamins or minerals you have found that improve the symptoms of autism?
There is not a lot of evidence-based research to support many of the supplements that are currently being used to remediate symptoms of an ASD. However, more research is being done. Vitamin D is a fat-soluble vitamin that acts as a mild mood stabilizer and has a role in muscle function and the immune system. Vitamin D is also needed to assist in the absorption of calcium. I often recommend supplementing with this vitamin, especially if the child is on a gluten and casein free diet.

Another supplement I often recommend is a multivitamin, especially if an individual is food selective or a “picky eater” and has been for quite some time. Vitamin C deficiency (scurvy) has been diagnosed in individuals with developmental disabilities who have food selectivity. This can be avoided with a multivitamin while working on increasing the individual’s food repertoire.

Flavored cod liver oil is often used to aid in immune function and cognitive function, plus it has anti-inflammatory properties.

Are there any studies evaluating the effectiveness of special diets (i.e. gluten free, casein free, etc.)? Can you expand on or speak to them?
There are minimal double-blinded trials, the gold standard for gluten and casein free, so many of the results are anecdotal. There is one- 12-week double-blinded gluten free, casein free (GFCF) trial with a crossover at the conclusion of 6 weeks. n= 15 individuals w/ASD (ages 2-16)

Behavioral assessments were done at baseline, weeks 6 and 12, and urinary peptides screened at weeks 1, 3, 6, 9, 12. The results illustrated no significant differences. However, 9 of the15 parents reported that they would continue the GFCF diet (Elder, 2006).

However, even with limited research, the gluten and casein free diet is the most popular dietary intervention to treat individuals with ASD (Levy & Hyman, 2003). The diet is popular due to the belief in its safety, non invasiveness, healthiness, and the anecdotal reports of improvements in symptoms of children with ASD.

According to the Autism Research Institute’s recent survey of 2208 parents regarding the gluten and casein free diet, 65% of parents reported subjective improvements in children’s autism symptoms (decrease in self-stimulatory behaviors-flapping, rocking), maladaptive behaviors, GI improvements seen, and an increase in communication (use of words).

For parents who do choose a GFCF diet, it seems much harder to get adequate nutrition for the child. What do you suggest?”
It is not as difficult to consume an adequate diet on a GFCF today due to several fortified foods (i.e., breakfast cereals, juices, rice/soy milk, gf breads/waffles, etc). I would recommend adding a multivitamin and calcium supplement with a Vitamin D supplement if the child is food selective.

Another resource regarding feeding concerns and nutrition in children with autism spectrum disorders can be found in the Journal of Autism and Developmental Disorders [1].  This article was recently discussed here.

[1]  Sharp, W. G., Berry, R. C., Mccracken, C., Nuhu, N. N., Marvel, E., Saulnier, C. A., . . . Jaquess, D. L. (2013). Feeding Problems and Nutrient Intake in Children with Autism Spectrum Disorders: A Meta-analysis and Comprehensive Review of the Literature. Journal of Autism and Developmental Disorders,43(9), 2159-2173. doi:10.1007/s10803-013-1771-5