If your child's growth rate is following the expected course, she's most likely in good health and does not have a serious feeding problem. But any change or interruption in her expected rate of growth may signal a more serious problem that needs medical attention. To be sure that your child is growing normally, it's very important to schedule regular checkups throughout his or her childhood.

An important part of the medical examination involves measuring the child's growth and comparing it to growth curves and weight averages. A growth curve is a chart which illustrates the average rate and amount of growth in children within different age groups.

If a child is not growing normally, this may be an indication that the child has a more serious problem that needs medical attention.

How Many Calories Do Children Need to Grow?

In order to maintain normal growth and good health, your child has two important needs: an adequate intake of calories, and a balanced diet that supplies a wide range of essential nutrients. Calories supply the energy needed for growth, and keep you from feeling hungry. The number of calories a child needs varies according to the child's size, growth rate and activity level. But in general, if you want to know how many calories your child needs, a good rule of thumb for children up to 5 years of age is to begin with a base of 1,000 calories and add 100 calories for each year of your child's age. For example, a 1-year-old would need approximately 1000 plus 100 calories for 1 year, or 1100 calories. A 2-year-old would need 1000 plus 200 calories for 2 years, or 1200 calories. With this simple equation, you can calculate the approximate number of calories your child needs in order to maintain normal growth.

Children need more food (and therefore more calories) during growth spurts, and less when growth tapers off. Specifically, a child's calorie needs continually and rapidly increase during the first year of life, when growth is very rapid. In fact, a healthy child's weight usually triples between birth and the end of the first year. But after the first year, a child's calorie needs begin to taper off and even decrease, as the growth rate starts slowing down. Over time, the caloric intake will begin to increase again, but at a slower rate until he enters another growth spurt, usually during adolescence.

Also, children often vary from day to day in the number of calories they consume. One day they may not eat much, and on the next they'll eat more than usual. This may seem worrisome and unusual behaviour to a parent. But over a long period of time, a child's caloric intake averages out to just the right amount needed for growth. This is a normal and natural way for children to eat. Again, as long as a youngster is growing normally, and isn't losing weight or getting fat, it's safe to assume that he's consuming the right amount of calories for his particular needs.

A balanced diet

Besides getting enough calories, it's also very important for your child to have a balanced diet which includes a variety of nutrient-rich foods from each of the 4 food groups shown in Health Canada's Food Guide. To ensure that your child is eating a balanced diet, offer some foods from each food group every day. And be sure to offer a wide range of foods from within each group, so that your child's diet has the variety needed to be nutritionally complete. Also, it's very important that fats not be limited in the diet of a child under age 2, because fats are essential for proper brain development and growth.

Consequences of Inadequate Nutrition

If your child isn't getting enough nutrients or calories in her diet, she may have some of the following symptoms:

• poor weight gain or weight loss pallor (or pale looking)
• fatigue or listlessness
• irritability
• or poor school performance (especially when the child skips breakfast)

In extreme cases, a child who isn't getting enough calories or nutrition in her diet may suffer from malnutrition or poor growth, also known as "failure to thrive". Fortunately, this is rare.

The medical and dietary assessment

If you think your child has a feeding problem, be sure to have him examined by a doctor. The doctor will screen the child for problems, to determine whether or not the eating problem has a medical cause. During the examination, the doctor will look at your child's medical and behavioural history. The doctor will also ask detailed questions about your child's diet. It's very important for you to give a full description of the child's diet, so that the doctor can determine if your child is lacking in nutritional or caloric intake. She will also give a full physical examination, measuring your child's growth and weight gain and comparing these to growth curves. She may take a blood test for anemia, as well as test for other conditions if the child appears to have symptoms of poor health. Once all the information has been gathered, the doctor can assess whether or not your child has a serious feeding problem.

Picky or fussy feeders fall into two categories, each of which needs to be treated differently:

• Those with poor or abnormal growth and weight gain, with or without nutritional deficiencies. These children are considered to have a serious feeding problem that needs to be adequately treated. Treatment may involve a team of specialists, including doctors, dietitians and psychologists, and may in some rare cases require hospitalization.
• And those with normal growth and no obvious nutritional deficiencies or imbalances. Fortunately, the large majority of children fall into this second category.

If the doctor has determined that your child is growing normally, and isn't ill or anemic, you can feel confident that your child's feeding behaviour isn't affecting his health. Your doctor may recommend that your approach focus on an individualized combination of practical measures and behavioural techniques designed for both you and your child. In the next few sections, we'll look at practical issues such as how to ensure that your child is eating enough, getting a balanced diet, and how to schedule meals.

Practical Feeding Tips

• Children need to eat frequently to sustain their high energy levels and keep their bodies growing. As a general rule, they should have 3 meals daily, and 2 well-spaced snacks.
• What's most important to the child's health and growth is not the quantity, but the quality of the food he eats. So be sure to put nutritious food in front of your child, without over-emphasizing portion sizes or how much he's eating.
• Because drinking too much liquid can lessen your child's appetite, limit liquid consumption to a total of 3 to 4 cups daily. This will help ensure that your child is hungry enough to eat solid foods. Also, limit liquid intake in the hour or two before meals.
• If you're concerned that your child isn't getting enough calories, avoid giving your child "light" or "low-fat" varieties of food, and offer whole milk instead of skim or 2%.

Ensuring a balanced diet

• Although likes and dislikes should be respected, young children should be encouraged to try at least a little of every food that is served. Introduce new foods one at a time, alongside familiar foods which your child likes.
• If your child strongly dislikes a particular food, don't serve it for a time. Instead, offer other foods that have a similar nutritional value. At some later date you may be able to serve the rejected food with better results.
• If your child will only eat one type of food, continue serving it along with other healthy alternatives in case she changes her mind or gets curious about other foods.
• You might also try creative ways of working rejected foods into other foods. For example, if your child refuses to drink milk, add it to oatmeal, puddings, or mashed potatoes.
• If the child won't eat vegetables, puree them and add them to the main dish or other dishes.
• If your child fills up on sugary foods, she's going to have trouble getting all of the nutrients her body needs. Satisfy your child's sweet tooth by serving foods that are naturally sweet but nutritious - like fruit - for dessert or snacks. Top pancakes or French toast with fruit, or all-fruit jams instead of syrup or sugar.
• If your child consumes a regular, balanced diet, he won't require multivitamin supplements. But in some cases, supplements may be recommended to make up for nutritional deficiencies. These should only be given in the recommended amount. This is because overconsumption or unnecessary consumption of certain supplements can be toxic for children - especially iron and vitamin A. For the same reason it's important to keep all supplements out of the reach of children, to prevent accidental overdose.

Snacks

• Snacks can be as important as regular meals in obtaining needed nutrients. Parents should think of a snack as an added opportunity to provide foods with nutritious value.
• Be sure to keep snack portions small, so that they satisfy your child's hunger, but don't fill him up too much to eat the next meal. Also, avoid giving snacks in the two hours before a meal.
• Don't allow your child to snack all day. Stick firmly to 3 meals and 2 snacks. If your child doesn't feel like eating much at one meal or snack, don't offer more food before the next scheduled feeding. This encourages a regular feeding schedule, and avoids power struggles over when to eat. If your child doesn't eat much at one meal, he or she will probably eat more at the next.

Practical Behavioural Tips

Since many feeding problems are behavioural in origin, they often improve over time as behaviour changes. In fact, food refusals and strong food preferences are a natural part of a child's development as their taste buds, emotions and bodies change. If your child is refusing to eat her meal or snack, try to remember that it's not a rejection of you as a parent. Most likely your child is simply not hungry, or is going through a normal and harmless phase.

It is important to avoid comparing one child to his or her siblings because each child's feeding behaviour is different. Although parents often worry that their children are not eating enough or properly, too much parental concern can actually aggravate eating problems in children. It's important for parents to handle frustrating situations with patience, a positive attitude, and firmness without being aggressive or emotional. Try to avoid power struggles: don't force-feed, plead, bribe your child, or make her feel guilty. These kinds of tactics will only worsen the problem.

Your own attitudes at mealtime can have a strong influence on your child's eating behaviour. If you often bring negative emotions or tension to the table, or if you're too forceful or critical about your child's eating, it can have a negative impact on your child's attitude towards mealtime and eating. You may also need to improve your own food choices and eating habits. In order to set a positive example, it's a good idea to have at least one meal a day in which all of the family, including parents, sits down to eat a healthy meal together.

Here are some additional tips for encouraging a reluctant child to eat:

• Try to present healthy foods in a positive light, so that they aren't associated with dullness or deprivation. Also, avoid placing foods into categories of "good" and "bad".
• Offer your child lots of opportunities to make her own food choices from a variety of balanced foods that you offer.
• Give small portions, so as not to overwhelm your child with too much food. It's better to allow your child to take seconds if she's still hungry.
• If your child will only eat food served a certain way, try to accommodate her requests. She may prefer her food to be a certain temperature or to have a certain texture. This is quite normal, and her tastes are likely to change with time.
• Try preparing and presenting rejected foods separately from other dishes. For example, if your child doesn't like carrots, don't put them on her plate or in the main dish. Instead, place them in a separate bowl on the table, and allow your child the choice of whether or not to have them.
• Try serving foods your child doesn't like in new, original ways. For example, if your child insists that she hates spaghetti, try serving bow-tie pasta instead. Also, cutting vegetables in fun shapes may turn previously rejected vegetables into food that's fun to eat.
• Children 5 and older can be involved in food preparation or shopping, which may increase their interest in eating.
• Make the mealtime table a relaxed and positive environment, free of family conflicts and tensions. Meals should be a time when the family can socialize together in a friendly atmosphere. Minimize distractions by turning the TV off, and removing toys from the dining area.
• If your young child finishes eating before everyone else, let him leave the table if he wants to. A young child that's forced to sit still at the table until everyone else is finished may begin to resent mealtimes and resist eating.
• Help your child work up an appetite through physical activities.

Visit www.drpaul.com to read more interesting articles from Dr Paul.