Michael Smith, MD (Host): Meaningful medicine is a Novant Health podcast bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. Today I'm sitting down with Dr. Amari Howard and we're going to be talking about picky eaters.

I love that. But before we get started, Dr. Howard, I always like to ask my guests, you're in gastroenterology. How did you choose that specialty? How did that become your passion?

Dr. Amari Howard: I've always sort of been interested in medicine. When I was in medical school is when I first got my introduction to gastroenterology and I thought I was actually going to do adult medicine. But then I had my pediatric rotation and I was like, I mean, I fell in love with all the babies and I love seeing a variety of ages.

I love seeing infants to toddlers to school age children to teenagers. So every day is different. And with gastroenterology, I really love the pathology that's with gastro. So I love inflammatory bowel disease or EOE, constipation; constipation is probably one of my favorite topics to kind of talk to parents about.

So I like just seeing the variety among the age groups, but also in pathology as well.

Host: Before we jump into the topic today, which is about the picky eaters, I know a lot of parents are listening to this podcast. And so I think it's fair to say that many of them get very confused about when they should be concerned about certain gastrointestinal symptoms. You, you just threw out a whole bunch, you love constipation, all that kind of stuff.

If it's a stomachache, if it's constipation, diarrhea,when does a parent need to be concerned and seek help?

Dr. Amari Howard: That's a very good question because a lot of the symptoms of different gastrointestinal disorders all overlap. You have vomiting, you have belly pain, you can have diarrhea. I think if the symptoms are prolonged, meaning over a 72 to 96 hour period for vomiting and diarrhea, that certainly needs to be further investigated.

If kids are having symptoms of belly pain two to three times a week for months on then. If their appetite's a little bit off, they're not eating as much, or if they're losing weight, those are certainly symptoms that would seek further evaluation.

Host: This is almost kind of a personal question, but I know a lot of other parents are wondering this too, it's specifically about stomach aches. My son, when he was a kid, it was like every day was a stomach ache. My belly hurts. My belly aches. All that kind of stuff. You know, given all the different over the counter medications that are out there today, what is safe to give for those aches and pains in the stomach?

Dr. Amari Howard: That's a very good question, and there's a lot of medications that are available over the counter, so I think it sort of more so depends on symptoms. So if it's a stomach ache and kids are not pooping very well, certainly MiraLax is a medication that's over the counter that is safe to give. You can start with half a capful to one capful and that's a very titratable medication.

If it's a lot of discomfort, I usually don't love using Tylenol or ibuprofen very often. A couple of doses here and there should not be harmful, but too much Tylenol can affect the liver. Too much ibuprofen can cause ulcers in the stomach. So there's really no pain medication that a gastroenterologist really loves.

Any of these medications in moderate amounts should be okay for a couple days. But again, if they're needing it more often than not, that begs the question of why are those symptoms occurring? And that needs to be further investigated.

Host: Perfect. I love that answer. So let's get into the picky eaters. Boy, oh boy. This is a tough one. There's a lot of kids out there. My son wasn't so much of a picky eater, but he had friends that all they wanted to eat was like one food thing every meal, every day, whether it was a peanut butter jelly sandwich or whatever. I mean, really picky stuff. Why does that happen with kids? And when does that kind of become concerning?

Dr. Amari Howard: I think kids are, they just, it's hard to say why exactly it happens. There's certainly some patients who have issues with textures that can sometimes come into play, or sensory issues that leads them to be more picky over another kiddo. Sometimes they're just their favorite foods that kind of come into play.

I think when pickiness becomes of concern is when kiddos are not gaining weight very well. If they're just so specific in what they're eating; they're not getting the nutrients that they need, their vitamins, their nutrition, or it alters their growth. And sometimes it does become a little bit more worrisome when kids are noticing that they're having a hard time eating certain foods.

So some kiddos become selective because they have a hard time swallowing specific textures or it hurts for them to swallow. So that's one of the conditions that come into play is a condition known as eosinophilic esophagitis that we see a lot of symptoms develop around picky eaters because it hurts for them to eat.

So some kiddos they learn to stay away from those foods because it bothers them. And it usually starts in young toddlerhood when they aren't able to communicate that it bothers them to eat. So they sort of just refrain from it instead of including it into their diet.

Host: And then they naturally go with the food that doesn't bother them. And then now you think they're a picky eater, right, when it's really that other food is hurting them.

Dr. Amari Howard: Exactly. So, those are some of the things to kind of investigate if it takes, some of the questions that we ask in clinic is does it take a long time for your kiddo to eat? Usually a standard meal is probably up to 20 to 30 minutes, but some patients, I had a patient who was taking two hours at lunch.

 And the people at school were complaining that, you know what, he's just a really extremely slow eater. Or if they have to use a lot of liquid when they're eating their foods to kind of wash things down because they feel like things are kind of getting stuck.

Or if they're school-aged or older and they're having to cut their food into very small, tiny pieces just to get it down, those are some of the questions that we kind of ask families in our picky eaters to see if there's any underlying pathology to that.

Host: You brought up the idea of maybe not getting enough nutrients throughout the day, obviously the vitamins, the minerals, those are all so important. What do you do about that then? If you have child who because of maybe pain or whatever it is, is not eating a more, maybe, complete meal; what do you do? As a parent how do I make sure they're getting all those nutrients?

Dr. Amari Howard: Well, yeah, that's a very stressful situation for sure. I think first and foremost, being on a multivitamin helps significantly, especially when kids are, I try to of course encourage, I want them to be able to eat their minerals and their vitamins and such. So getting, uh, variety of a diet.

But of course, that's hard for some picky eaters. So for sure, being on a multivitamin, I think sometimes helps. I love for kiddos to more so eat their calories instead of drinking it. But sometimes we do rely on complete nutritional shakes, which they do drink that. Also offers the extra calories, but also the vitamin and minerals that they do need to grow.

Host: Outside of some of the more inflammatory conditions that are causing some kids pain maybe when they eat, what about kids who just, you've ruled out a lot of things. They just seem to be a little picky right now. Maybe it's sensitive stomach. Maybe they get stomach aches real quick, like my son did.

How do you help them, especially at school? Do you have any recommendations for like a good lunch to pack?

Dr. Amari Howard: So I think not sticking with the same things over and over and actually just continuing to offer a variety of foods actually helps. Because maybe they don't take it on the first or second try, but maybe it's the third time that they do take it. So, and I also don't encourage parents that kind of force things on. I want them to kind of try it in their own time. But just continuing, and not giving up actually over time, they do usually tend to take things. And sometimes, some kiddos, we do refer them to a feeding therapist just to encourage them to eat a variety of different foods.

They usually start with very small bites, and they kind of over time, increase the amount of bites and different things that they're taking as well. So sometimes we do work with another skilled feeding therapist to help in our really extremely picky eaters.

Host: Let's talk a little bit about the timeframe here. A lot of parents want to know, is my kid always going to be like this? Are they always going to be that picky eater? When are things going to get better? And I know that's a hard question because it can be very individualized, correct? But can you give us some guideline on what to expect if a parent has a picky eater and how long that usually lasts.

Dr. Amari Howard: So I will certainly say I think when kiddos are infants to toddlers, they readily take a lot more foods, as compared to later toddlerhood to early school-age children. And by usually by late school age, meaning like 10 to 12, and even older, their diet's a little bit better. But I would certainly say the late toddlerhood to around age three to school age kids, five to seven is probably the trickiest time, or the pickiest time, and they usually open up a little bit more when they become a little bit older.

Host: Yeah, that was kind of my son, with his picky eating and his stomach aches and stuff. It was tough around five, six, seven, those years. I don't remember it being like a specific day, but it was almost like all of a sudden it did kind of stop. And next thing you know it, he's eaten me out of, out of my word. I mean, I, he was eating the whole fridge in one day. I mean, it just like off. Right? So there is hope for parents out there. does in most cases get better, right? That's the end of the day. Let's move into what you said you love to talk about. And that's constipation. First of all, why is that one of your top symptoms or issues you like to deal with?

Dr. Amari Howard: Because we see it so often, it's kind of been one of my topics that I've just become very interested in because it just, it hits so many people. Again, at different ages, stages, we see it in infants, we see it in, when we transition to milk, a lot of dietary kind of reasons that contributes to constipation.

And it's one of the things that also usually gets better with time. So I love when a kiddo comes in and they're not having a hard time pooping anymore. The smile that comes onto their face, they're not having any more belly pain. I get a lot of satisfaction out of treating constipation at times.

Host: So, when you look at a child and you know, I guess it depends on the age, right? You got infants, you got toddlers, you got school-age kids, but in general, what are some of the things you're thinking about when a child is presenting with constipation? Like, what are some of like the top two or three things you're always going to work through?

Dr. Amari Howard: In terms of, you mean like a differential?

Host: Yeah, yeah, like what are you thinking? Like, are you telling the parent that this might be and how you want to approach it?

Dr. Amari Howard: Sure, so constipation is one of those things where a lot of the time, it's what we call functional constipation, meaning there's no underlying inflammation or mass or organic reason that a kiddos is having a hard time pooping. A lot of it could be behavioral if a patient had a hard time pooping and their poops are hard; they don't want to necessarily pass something that's going to hurt. So some kids kind of withhold because, you know what? I don't want to be in pain when I'm trying to poop. So a lot of it could be behavioral. A lot of it could be related to diet, especially again, that toddlerhood age, where they're extremely picky, they're not getting enough fiber, they're not getting enough exposures to fruit and vegetables, they're not drinking enough water. Those kids are usually very active, so I don't have any concerns about their activity levels, but all of those are kind of contributing to constipation.

 And more so to the functional constipation, but there are sometimes some underlying reasons for constipation. If there's a thyroid issue, things like celiac disease, electrolyte abnormalities, if there's any underlying weakness of the muscles or poor muscle tone, that could also be contributing to constipation as well.

So when we go through a visit, those are all the things that we're going to be kind of exploring. And I'll be asking all the way back to someone's birth history. Even back to asking parents about that passage of that black, sticky poop known as meconium. Those are all things that we ask for to kind of hone in or kind of narrow down our differential kind of thinking about the causes of constipation.

Host: Fortunately for most kids, it's a functional type situation. Often will clear up, but you know, as a parent, in the middle of the night when your child is crying and screaming because they can't go to the bathroom and they really want to go to the bathroom and all that kind of stuff. What are some of the things that they can do?

Amari Howard, MD: I think if they're really, really uncomfortable and they have not passed any stool in several days, they usually go to that kind of produces immediate relief, it's usually an enema or a suppository, which is a rectal form of medication, which most kids don't like to do, but it is a very effective form of medicine.

On the other hand, other medications that are over the counter like Miralax or even Ex-Lax which is a stimulant medicine, that also seems to help as well, but not necessarily right in the moment. That's going to take some time for it to be effective.

Host: This has been a fabulous conversation. I want to thank you for coming on and joining me today. Is there anything else you would like to share about gastroenterology and kids that we didn't talk about?

Amari Howard, MD: I mean, I love gastroenterology, but if there's anyone who has any questions about this field, I'm happy to talk more about it. I do like that, again, like I see a variety of different conditions. I do like that I'm also in the endoscopy suite. So, kiddos who are having a lot of vomiting or tummy pain, that's one of the modalities we have to kind of explore other etiologies. So sometimes I do a camera study called an endoscopy.

 So I'm there as well. I'm also talking with, interacting with our radiologists, our surgeons, our pathologists on a regular basis as well. I do love the multidisciplinary nature of gastroenterology that we all work together to take care of an individual or a single patient. So I love my job. I love what I do on an everyday basis.

And, I always want parents to know that during our time, they can ask any and all questions. No question is stupid or too small. Definitely want them to be able to leave feeling that they got, they were heard and questions answered.

Host: Again, Dr. Howard, thank you so much for joining me today. To find a physician, you can visit NovantHealth.org. For more health and wellness information from our experts, you can visit HealthyHeadlines.org. I'm Dr. Mike. Thanks for listening.