Lisa: So an SOS feeding therapist, it’s somebody who works with extreme picky eatings. So that’s not the common guard and sort of fussy eater, but it’s the extremely fussy eater who are on a very narrow repertoire of foods. And I worked in the food industry as a food scientist for 15 years and decided to become a naturopath and a nutritionist about five or six years ago. And I really wanted to work with children. So I had really, you know, high hopes of changing the world. And I had these children that came to see me and I tried to put them on these therapeutic diets. And I quickly realized that I was so out of my depth with what they were eating and what I wanted them to actually start to eat. So I needed to have another tool in my toolbox. And I came across SOS feeding therapy, and it was just perfect because it’s a child-centered approach to fussy eaters. So it’s not a matter of, you know, if your child is hungry, they will eat and you just leave them sitting there long enough and they will eat. It’s the opposite of that. It’s a really child-centered approach to fussy eating and it just resonated so much with my philosophy of parenting. So I did the training several years ago and became a feeding therapist.

Andrew: Gotcha. Okay. So, you know, the first things that spring to mind are things like, you know, picker when we suspect a nutritional deficiency. There’s also obviously, the neurobehavioral issues that kids face. And I’ve spoken to a few of these kids about this or a similar issue. Some of them sort of said, you know, “When I got off my white diet and onto the good foods, everything changed and I’m so thankful,” blah, blah, blah. But I get that this is this group. Not necessarily all of them.

Lisa: Yeah.

Andrew: Because I certainly remember challenges with my youngest child. So where do we start with…Well, let’s take… let’s go through extremely fussy eating first, I guess. We are not talking about just a little bit of, “No, I don’t want that potato.” Tell me how bad this gets for kids.

Lisa: Yeah. So with the fussy eaters, they’ll still eat, you know, more than 30 different foods. With extremely fussy or extremely picky eaters, they will eat less than 20 foods. And by food, I mean one food would be Hundreds & Thousands Tiny Teddys. Another food would be Sour Cream Pringles. So they’ve narrowed down to specific brands, specific flavor in the brands and there’ll be less than 20 of those foods. And I’ve seen children where they’re down to five of those foods. So, you know, the Sour Cream & Onion Pringles, the Hundreds & Thousands Tiny Teddys and maybe three other foods and that’s it, that’s their repertoire. And the problem is that when a child has say 20 foods in their repertoire and they’re an extremely picky eater, they will jag on those foods. So they’ll eat those foods for breakfast, lunch, and dinner over and over and over again. And then one day they’ll stop eating those foods. And for a normal fussy eater, they’ll stop eating two weeks later. They’ll be like, “Yeah, I’ll have that food again. That’s fine.” But with the extreme situation, they’ll never eat that food again.

So if they eat the Hundreds & Thousands of Tiny Teddys every day, one day they’ll wake up and they won’t eat them again. So you might have started with 20 foods in the repertoire, now you’re down to 19. And that’s how you end up with the child that just eats donuts and 7 Up because they’ve jagged on all the foods they’ve eaten to the point where there’s only a handful of foods left. They’ll also not be able to sit at the table with the food. So they…you know, a child who’s just a normal fussy eater, the person beside them can be eating carrots and they’ll be okay, as long as they don’t have to eat the carrots. But with the extreme fussy eater, they’ll have to leave the room. So when they’re 7, 8, 9-year-old, they’ll be sitting in their bedroom, on their own eating their bowl of pasta whilst the rest of the family is at the table eating their normal family foods. So that’s sort of examples of how extreme it can get.

Andrew: Right. So these smacks of sensory overload here, are these extreme, fussy eating children, are they always children that have got a neurodevelopmental issue?

Lisa: No, they’re not. But I mean, I think it’s an estimate between 60% and 90% of children on the autism spectrum have got severe food restriction issues. So the majority of children with autism will have some of these issues, but I certainly in my caseload, I see lots of neurotypical children as well. And they might have sensory challenges, they might have anxiety, but the anxiety has built over time due to, you know, the fussy eating. And the avoidance of those foods has led to the anxiety escalating.

Andrew: Right. Okay. So there we go into anxiety and psychological issues, OCD, and often these are caused by some trauma in the child’s life. So is a large part of your therapy to do with counseling and how sensitive do you have to be with signals or cues that there may be things like abuse going on, something like that?

Lisa: Not so much abuse, but certainly choking. So if a child has had a choking incident, then they will have a fear of food as a result. So then you have to ask, well, “Why did they have a choking incident or multiple choking incidents?” And that comes down to their oral motor skills. So if a child has not developed oral motor skills, normally in that normal course of development from going from purees to mash foods to family foods, if something went wrong there and they didn’t learn to chew properly, then they might have choking incidents and then they’ll avoid food. So yeah, that sort of thing can definitely play a role. Which is why, you know, you start with a full assessment of the child.

So their posture, their muscle tone, their oral motor skills, their speech, all those things. Obviously, I will refer to occupational therapists and speech therapists for those thorough assessments, but you can get a good idea from watching a child eat. And looking at the list of foods that they eat, you can understand, can they just not do a rotary chew, which is why they can only eat chicken nuggets. So it’s, you have to look at all those underlying reasons why they have become a fussy eater because children don’t become a fussy eater just as a behavioral thing. So there’s usually an underlying reason which has led them down that path.

Andrew: Yeah. I wanted to sort of backtrack a bit and try and cover some comments that people might be thinking when they’re listening to this. And that is, “Oh, well, if you don’t have the bad food in the house, they can’t eat it.” We’ve been through this with my youngest. So he actually had this quite restrictive, high sugar. And I remember arguments with my wife about, “Don’t buy it,” dah, dah, dah. Liam has turned around like you wouldn’t believe. He eats the most healthy out of all of us. He is the fittest out of all of us. He does this like SIS mentality to training. When you think you’re at your limit, you’re actually at 30% and he keeps going. So this extremely intelligent mind, you know, philosopher. And he actually thanked Lee, my wife, and he said, “Mom, thank you so much for not just restricting me in those foods. I knew sort of what I was doing. I knew it wasn’t good, but it was right for me at that time.” Now, I can’t say obviously, that that’s everybody’s behavior, but it was just really interesting that he actually thanked Lee for not being draconian with the food because it might have even embedded a deeper sort of phobia or a deeper rigidity with that food. Is that what happens?

Lisa: Yeah, absolutely. And there’s about 5% of children will starve themselves. So, you know, you can’t just say, “Well, this is the food, eat it.” Or, “That’s it.” Because there’s 5% of children will be hospitalized and will starve themselves as a result. So that’s not a great thing to do. And when the children are having that really restrictive, just the white sugary foods, the first thing you do is to expand their range of white sugary foods. So the child that comes to me eating the, a Hundreds & Thousands Tiny Teddys, the first bit of homework that that family gets is to buy the variety pack of Tiny Teddys. So they’re having the Chocolate Tiny Teddy and they’re having the normal Tiny Teddy.

So it’s still high sugary food. It’s not like naturopathic food or anything, but it’s nudging their sensory system. So if you overwhelm a child’s sensory system with food, they will retreat, they will run away, they will go to their room, they will gag and vomit. So you never want to do that. But you just have to nudge their sensory system very, very slightly. And that small change of going from one flavor of Tiny Teddys to all the flavors of Tiny Teddys, it’s actually a really big step for those children. And they can make really good progress with that sort of approach of just expanding their repertoire of, you know, the white sugary foods.

Andrew: Right. And another thought that went through my mind was some of those behaviors smacks of anorexia nervosa, but they’re not because they’ll eat what they want to. So it’s not anorexia nervosa either, is it?

Lisa: No, because it’s not body image-driven. And that’s with the… I’m not sure if you’ve heard of a diagnosis called ARFID, Avoidant/Restrictive Food Intake Disorder, which it was a new diagnosis, not very new, probably seven or eight years ago, but it’s classified as an eating disorder and therefore, the treatment is as an eating disorder like bulimia or anorexia nervosa, but very often that sort of very restrictive eating, it develops because of the underlying skills deficit or sensory issues that you mentioned. And so if you don’t address those, you can’t address the extreme picky eating. So it is the way we look at feeding disorders. It is very different to looking at something like an eating disorder.

Andrew: Gotcha. Okay. And also what you were talking about this, introducing still white sugary foods, but introducing just a slight variance on that and gaining their acceptance of that food. So that smacks again of desensitization, like with a phobia. Is that what we’re dealing with?

Lisa: Yeah. Absolutely. So the SOS approach, like it covers, you know, the mealtime routines and the postural stability at the dinner table, but the big focus of feeding therapy is systematic desensitization to food. So having the competing, you know, the challenge plus the relaxation. So with kids and feeding therapy, the relaxation part is the play. So we play with food, but it works in the same way. If you had somebody who had a phobia of a snake, the first step would be in the room beside another room with a snake in a box in the room. And then the next time, you know, you might open the curtain between you and the snake in the box in the other room. And by week 20 you might have the snake on your hands.

It’s very much like that. We start off with the piece of sweet potato is at the opposite end of the room and the child can just about tolerate that. And then as the weeks go on, they get closer. We’re juggling with the sweet potato, they’re going home clutching the sweet potato. And then eventually they will eat the sweet potato. But it’s not flooding. So you’re not shoving the sweet potato in their face. They’re developing the comfort with the food to actually want to eat it themselves because they’ve been systematically desensitized to it.

Andrew: Gotcha. Okay. Forgive me. Going back again, you were talking about when you are assessing kids and you were looking at their posture, and that reminded me of something that Dr. Elisa Song taught me about pandas. About this very quick onset you know, a slumping posture, a lack of strength in their handwriting. So their handwriting goes very spidery. So when you are talking about these assessments that you do, does this have any linking to like an infectious origin at all? Or is it purely a behavioural type thing?

Lisa: It certainly can. Even…no, it usually has some physiological starting point. And pandas would present in a very sudden picture. You know, so a child that eats a normal wide range of food. And then in the course of a few days stops eating all of those. But then you have other kids who just will get a sore throat because they’ve got a really poor immune system. They’ll get a sore throat every few months and stop eating. So you can do all the systematic desensitization in the world, but unless you can address the reason why they keep getting the sore throat, then you know, you won’t make progress. So you always have to look at everything that’s going on with their body as a whole. And the posture, children especially a lot of children on the autism spectrum have hypertonia and they can’t sit upright. So those are the kids that won’t sit at the dinner table to eat because they can’t sit at the dinner table. So you have to actually make sure that they’re sitting in a really like straight-up position, really cushions beside them, a box under their feet, everything. So they actually, their body can eat, because if they’re slumped in the chair, you know, they can’t actually eat.

Andrew: Yeah. Wow. There’s so much that goes into this. I was gonna ask as well with regards to eating at the table, how important is that family mealtime, rather than, as you said, sometimes they just eat their food in their bedroom alone. How important is it to reintegrate them into the family for success?

Lisa: It’s absolutely critical. Eating with your family is a learning experience. Children learn to eat by watching other people eat. So even if the child is eating dinner at 5:00 and the parents are eating at 8:00, they’re missing the opportunity to see their parents, even to see how their parents chew food, the repertoire of food their parents are eating. So the first absolutely number one step for any child fussy eater is to get at least one parent eating with that child every single time that they’re eating. So, you know, not lunch because they’re at school, but breakfast and dinner at the table, even if the child is eating chicken nuggets and that’s it, the parent is beside them eating like regular family food. They’re getting exposed to that food continually. And I mean family mealtimes, it’s better for the children’s vocabulary, their performance at school, everything, but it’s 100% critical to reduce fussy eating.

Andrew: Gotcha. And you also mentioned speech therapy previously. How…Now, what’s the way to ask this? What would be the split of those kids that don’t have speech issues compared to those who do have speech issues in the group of kids who are extreme fussy eaters?

Lisa: I don’t know what the exact split would be, but because the majority or a lot of the children who come to see me have autism spectrum disorder, once you get diagnosed with autism, you go to see a speech therapist and you go to see an occupational therapist that’s kind of the road that is travelled. So they’re already working on that. But certainly, if a child comes to see me with extreme, fussy eating and you can tell that they’re not able to articulate properly, then I will get them sent off to a speech therapist or to someone to assess a tongue-tie or something like that, which will interfere with your speech and with your eating.

Andrew: Right. Gotcha.

Lisa: Tongue tip lateralization. So the ability to move your tongue from side to side can show up in a speech deficit, but also you can’t actually move the food onto your molars to chew it. So yeah, I don’t know what percentage would have speech issues, but it’s that whole like oral motor what’s going on in your mouth definitely needs a full assessment for you to progress.

Andrew: Wow. It’s so much more involved than what I originally thought. Like this is the minutiae. I can’t say it. Minutiae.

Lisa: Minutiae.

Andrew: So what…Forgive me there. What about results, Lisa? Like how quickly, how long does it take to get results and how long do the results last? Are they lifetime? Do you have to keep re-educating kids? Do they fall back into bad habits?

Lisa: So that’s a great question because of course it’s never, you know, SOS feeding therapy is the only way to go. Like it’s not a case of that. So if for instance, a child was so limited in their eating that they were going to have to get a G-tube inserted, I would not recommend SOS feeding therapy because it’s too slow. If they’re about to get a G-tube inserted, then they probably need to do a different type of therapy. With SOS feeding therapy, you start to see the results after about seven sessions.

So in sessions one to seven, you are really just getting the child comfortable with food. And after about session seven, they’ll start to actually, you know, taste the food. You might have to get to session 13 or 14 before they’re eating substantial amounts of the food. But the benefit is once they have gone through that process and they’re eating the food, they will not regress again unless they’re allowed to food jag. Whereas the quicker methods will get quicker results. But the minute the reward system is removed, the child will fall back into old habits and start to eat the old food. So SOS, feeding therapy relies on the child getting so comfortable with the food that they want to eat the food. And then as long as they don’t food jag, so that’s like burn out on foods, they won’t regress down the track and it’s… it will be a lifelong success.

Andrew: Right. Okay. So I’ve gotta learn that thing, food jag is like just binging.

Lisa: Food jag is just when the child burns out on the food or will just eat the same food, breakfast, lunch, and dinner. So one of the things I get all parents to do is to make sure that they don’t repeat the same food for 48 hours. And if you think a child has 3 meals and 2 to 3 snacks every day, if they’re only eating 5 foods, they obviously cannot go 48 hours without repeating the food. So say one of their foods is cucumber, which for some reason, a lot of my fussy eaters, the one vegetable they eat is cucumber. Then you have to present the cucumber differently every time you serve it within that 48 hours. So you might have it when you have it at breakfast time, it’s cut in sticks. When you have it at dinner time, it’s cut in circles. The next day it’s peeled and cut into sticks. So you just have to change the food slightly so that the exact same food isn’t repeated more than once every 48 hours.

Andrew: Right. This is mind-blowing, I’ve gotta say. Like this is going to the nth degree with food, but like it does remind me of things like things that I like, you know. It’s like, you know when I see I’ll pick up and eat a raw carrot, no problems. But I’d prefer sticks of carrots rather than circles of carrots. And I don’t have an eating disorder.

Lisa: Yeah.

Andrew: Maybe overeating. But it’s really interesting how we do prefer foods to be in certain presentations. And that’s for people who don’t have an issue with food, let alone people who do. I’ve gotta say, Lisa, this is quite amazing how in-depth you go to assess a child, firstly, with their issue, you’ve gotta have the patience of a saint because the changes that you’re advocating are quite slow. And if we are talking about white sugary foods in a neurodevelopmental issue…. sorry, in a child with a neurodevelopmental issue, then it’s not just about the food. You’ve got weeks and weeks and weeks of abhorrent behaviour, of schools going haywire, you know of classes being evacuated when they go off the rocker, of issues with, you know, kids hitting their mom and dad who they love. It’s just that neurosensory issue. So there’s, everybody’s gotta have the patience of a saint here. I, therefore, have to ask, what do you see practitioners doing wrong where you have to pick up the pieces and start again? Where should we change our therapies?

Lisa: Well, it has to be a holistic approach. I know that’s a really bandied about term, holistic approach, but that’s truly what it has to be. So you have to tackle it from all the angles. So, you know, the sound bite that you always hear about fussy eating with practitioners is it’s a zinc deficiency, which absolutely it is a zinc deficiency. And for every child that does therapy with me, we do a hair tissue mineral analysis, and we assess the level of their zinc deficiency and we supplement accordingly. But that’s a 10th of the problem. So, you know, if someone goes to a practitioner and they prescribe a zinc and two weeks later, it’s like, “Oh, my child’s not eating.” You know, that’s why because it’s only looked at this small piece of the puzzle. So I think from a practitioner’s point of view, you need to refer the extreme fussy eaters to somebody who has the broader range of knowledge.

In SOS feeding therapy, about 90% to 95% of the SOS feeding therapists in Australia will be speech or occupational therapists. And that’s great because they can work on a lot of those oral motor skills, that posture stability. But then they’re not gonna look at the constipation, which is another big issue or the reflux. And they won’t also have the food skills to know, you know, how to actually desensitize children to a good sort of food. So I think it’s just… it’s calling in that team of experts and not just go, “It’s a zinc deficiency and we will treat the zinc deficiency.” You have to look at the whole child, the whole body, and even the whole family and what’s going on and treat it from every angle. And that’s how you get results. And whenever people start on my 12-week program, one of the first things I do is I give all the children a flower essence to take, to open their mind to new experiences at dinner time. And by about week two, the parents will go, “Ah, it’s really strange like my child just ate a vol-au-vent.” Or, “My child just had a pork chop and they’ve never had that before. Why? Like what has happened?” I was going, “It’s not one thing. It’s not just that we’ve been giving them a flower essence. It’s not just that we’ve been giving them the zinc. It’s not just because they’ve been having family mealtimes. It’s all those things working synergistically together to get the results.”

Andrew: Gotcha. I need to ask you, with regards to zinc, I remember the first instance where zinc was used in children for sore throats was because I think it was a girl with Down syndrome and she wouldn’t take her zinc supplement, but she’d chew it. I think that was the issue. She wouldn’t swallow it, she’d chew it. And that’s where they started to develop lozenges for kids. But you could be dealing with kids that are quite young. Do you tend to change the administration, the presentation of the zinc that you use, like liquid zinc or, you know, chewables, things like that?

Lisa: Yeah. So I use all of those. I use liquid, I use chewables and I use transdermal as well. The very young kids don’t tend to come to see me. So it’s sort of 2-year-olds up, even two and a half-year-olds up that actually start to see me because up until that point, parents are just told this is normal. Children are fussy, don’t worry about it. And it’s only when they get older that the parents realize that something isn’t right. But yeah, every child is different basically. And you might think that you’ve got the crackpot with the perfect zinc that every child will take and then a child will come along and they won’t take it. So you need to have a repertoire of zinc supplements even to make sure you get one.

Andrew: Gotcha. And you were mentioning constipation. How open are these kids? They’ve already got a restrictive eating problem. How open are they to taking other supplements, like for instance, fibres or probiotics that might help their gut when they’ve got the eating disorder that restricts the choice of foods that they’ll allow into their mouths?

Lisa: Again, it depends. Some kids and they will take a smoothie. Even the extreme, extreme, picky eaters. They will still drink a smoothie. And I get parents to throw in cauliflower, mushrooms like everything goes into that smoothie with the supplement and some will take it and then some just flat out refuse to take it. And we just have to…You know, with constipation, it’s so hugely driven by dairy consumption. And even if we can cut them down from having, you know, a litre of milk a day to having minimal milk a day, that’s going to fix 80% of the kids who come to me with constipation. Which is in itself a major challenge because if your child will only drink milk and you take away the milk it can be really scary. It will be absolutely foundational to getting them to eat more foods. But it will be really scary for parents that are worried like that their child has already been diagnosed with failure to thrive or things like that. And they know that at least the milk is keeping them alive, but you have to find a way to reduce it, to reduce the constipation, to develop their appetite for other foods.

Andrew: Right. And then, you know, you were mentioning results earlier. What percentage of kids do you get these positive results in? Are there some kids that are just recalcitrant, they’re really, really impossible to treat? Or is it just like if we do these steps, it’s a pretty sure bet that they’ll, I won’t say grow out of it, but learn to cope with it?

Lisa: Yeah. I would say the younger the child is the better. The older children are definitely more difficult to desensitize them. And that’s partly because cognitively, they’ve moved past the play with food stage. So you can’t, you know, juggle with your tomatoes or balance things on your head. They’re like, “We’re done with that.” And you need to use a different approach which is called the food science approach, but they’ve developed such rigidity and anxiety when they get to 8 or 9, that it’s harder. So that’s the population that doesn’t get such good results. With the 4… 3, 4, 5-year-olds, you know, they’ll go from eating zero fruits and vegetables at the start of the program to the end of the program, you know, having three different vegetables, five different fruits in the repertoires. So not eating everything under the sun, but eating enough fruits and vegetables to eat a different food every 48 hours.

Andrew: That’s quite incredible. Last question and I need to ask this because this is really..like it’s blowing my mind how complicated this must be. Like you’ve got a huge responsibility on your shoulders to start. But you’ve gotta be competent in what you’re doing to find so many different ways of attacking a problem. So where can we learn more about this? Where did you learn SOS feeding for instance?

Lisa: So I was very lucky in that I managed to do my SOS training pre-pandemic. So I did that as a face-to-face four-day conference a few years ago. But now there is a SOS feeding therapy website, which you can jump on, you can learn more there. My Instagram and my website obviously, are full of information about fussy eaters and underlying causes of fussy eating and all those sorts of things. So that would also be a great place to kind of learn a bit more about this.

Andrew: But you’ve got this mind that goes into the sort of, well, let’s call it the play of food. You know, the ingenuity to figure out that it’s different ways of presenting the food and to figure out those ways. So is this something that you’ve grown up with that you’ve always had this love of playing with food, or, you know, did you have to battle this sort of issue with your kids or anything like that, or?

Lisa: I’ve just always been a very, very food-focused person. And like I grew up within a very food, like whole food-oriented family with, you know, there was always a chicken boiling on the stove, but I actually did my master’s in food science like 25 years ago. And I’ve worked with food my entire career. So not from this perspective of a therapy perspective, but food has always been like a major, major factor in my life and everything I’ve done in my life. So I just.. I think food is absolutely foundational to everything. And if you don’t have a solid diet, then it’s really difficult to make any changes with your child’s health.

Andrew: I really take my hat off to you. Thank you so much for opening my eyes, opening our eyes to, you know, it’s not the issues, we knew there were issues, but just how complicated they are and what you can do to claw your way back because this is so frustrating for parents and, you know, everybody, the social network around these kids. And to see these kids embrace food must be an absolute joy. I’m getting teary here because my wife deals with this sort of child and to see a change in that sort of child and to see their behaviour develop and mature must be just joy for you.

Lisa: It is absolutely awesome. My family probably gets a bit sick of me. I’ll come up from my office and I’ll go, “He ate an egg, he ate an egg.” You know, and some of the kids I work with are just amazing. You know, they, they won’t talk a lot of the time and then they’ll come out with something, “We have now completed the rockmelon challenge.” Just out of the blue. And they’ll take a bite of the rockmelon. And yeah, it is absolutely awesome.

Andrew: Kids are awesome. You’re awesome. Lisa Moane, thank you so much for taking us through SOS feeding and extremely fussy eating today on “Wellness by Designs.” And remember…

Lisa: Thank you.

Andrew: Thank you for joining us as well, and you can catch up on all the other podcasts and we’ll put up some really important show notes for this topic today on the “Wellness by Designs.” Forgive me. On the Designs for Health website. Thanks so much for joining us on “Wellness by Designs.” I’m Andrew Whitfield-Cook.