The day her son ate a hot dog for the first time, Erin Mandras couldn't believe her eyes.
Just a few weeks earlier, 2-year-old Austin would eat only three foods — bananas, sweet potatoes and avocados. Meals had become a time of angst for the Pikesville family. Austin would vomit or spit out any other foods. Or he would cry and push his bowl away or demand to get out of his high chair. His parents didn't know what to do.
Austin Mandras suffered from a feeding disorder — a condition afflicting at least one in four children that prevents them from eating enough or at all. The disorders can mean that children don't get enough nutrients to grow and develop.
More attention has been brought to the issue in recent years amid a growing understanding about underlying causes, including allergies and autism, and the medical community has become better at treating it.
Mount Washington Pediatric Hospital hosted a conference on the issue this month that included a session on the effect on families.
"For parents, it can be frustrating and frightening," said Dr. Richard Katz, chief medical officer and vice president of medical affairs at Mount Washington Pediatric Hospital and associate professor at the Johns Hopkins University School of Medicine. "This becomes the whole life of these families, just to feed their children."
In the worst cases, children end up on feeding tubes that deliver nutrients directly to their bodies. It may take months before parents figure out what is going on. They might think they are just dealing with picky eaters, and doctors might not give the correct diagnosis.
"It was exhausting," Erin Mandras said. "I was constantly trying to find something that he would eat."
At 131/2 months, Austin suffered an extreme reaction to eggs — projectile vomiting close to a dozen times — that provided a clue to what was happening to him. The family doctor ordered a round of tests and found that Austin suffered from extreme allergies to wheat, eggs and other foods that caused severe inflammation and irritation in his esophagus.
It hurt Austin to eat, but the boy was too young to communicate this to his parents. Because he had little experience with eating, he probably didn't even know or understand what he was feeling.
"It was like I had been poisoning my child for nearly 14 months," his mother said.
Many families like the Mandrases deal quietly with the fact that their children are living with such an unsettling and intrusive ailment, fearing that relatives and friends may look at it as a parenting issue rather than a medical problem. People have suggested to some parents that perhaps they could cook the food a different way or change bottles.
Several factors can lead to feeding problems, including developmental disorders that make it hard to swallow, chew or hold down food. Children with autism often deal with sensory issues and might be bothered by certain textures. Maybe they only can eat pureed or other smooth-textured foods.
Traumatic events also can lead to the disorders, such as when a child has choked on food or had a bad allergic reaction and is leery it could happen again. Some food allergy reactions may so bad that children just don't want to eat anymore.
"Kids will go to great lengths to avoid food," said Dr. Peter Girolami, director of the Pediatric Feeding Disorders Program at the Kennedy Krieger Institute. "They will spit it out, cough, choke. They will tell stories about their tummies hurting or hide food."
There are signs parents can watch for to detect such feeding problems, such as gagging and frequent spitting or coughing. The child also may suffer from frequent bouts of pneumonia or respiratory infections, or have trouble with acid reflux, or food coming back up the esophagus.
Even with all these symptoms, detecting a feeding problem is not always easy. Doctors and speech therapists will watch a child's body movements while they eat, examining posture and behavior. They also can do more intrusive swallow tests using an X-ray machine or lighted scope through the nose to look for weaknesses.
Often the underlying medical problem has to be addressed before feeding. If it is a subtle food allergy causing an irritable esophagus, Benadryl or some other allergy medicine can be given before the child starts eating regular meals. The same could be true with severe cases of reflux, with the child needing an acid-reducing medicine.
Food then must be introduced slowly back into the children's lives. In some cases, children have never eaten real food and must learn basic things, such as chewing and swallowing.
"If you have a child that has not been chewing for two or three years, you have to work on strengthening the tongue movement and muscles needed to swallow and chew," said Patti Bailey, a speech pathology therapist at Greater Baltimore Medical Center in Towson.
Kennedy Krieger and Mount Washington Pediatric have intensive programs to help treat chkildren with such disorders. Medical staff from many disciplines work with the kids, including psychologists, dietitians, speech therapists, pediatricians and gastroenterologists.
At Mount Washington Pediatric recently, mothers sat in a room and watched on computer screens as their children worked with staff on feeding in other rooms. Therapists spoonfed children who pushed the food away in some instances and took bites in others. The therapists used positive reinforcement, such as verbal praise or clapping, when a child, who will participate in the program for several weeks, ate well. Others used toys or books to distract the child as they fed them.
Some children may start with just a small crumb placed on their tooth — to help avoid a gag reflex. Therapists will gradually work them up toward accepting more food over time. Children may be given sticks to chew on before actual food to help prepare their mouths for eating.
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Once Austin Mandras was treated for his allergies, it wasn't long before he began eating. Doctors at Mount Washington Pediatric were able to get him to eat a hot dog, much to his mother's delight.
He recently sat in his high chair at home and heartily ate a lunch of turkey bologna, avocado and vegetable chips. Now, Austin can eat a wide variety of foods in every texture.
"More," he said, as he cleaned his plate of the vegetable chips.
"What do you say?" asked his mother.
"Please," he responded as she pulled out a pinch of chips that he then ate with a grin.