Managing eating issues in children with Asperger Syndrome: Parents’ and Professionals’ Suggestions Shu Hwa Ong, Bruce D’Arcy, Melinda White & Sylvia Rodger

Table of Contents Introduction .......................................................................................................................................... 1 Case study #1: Sam, aged 7 .............................................................................................................. 2 Case study #2: Tom, aged 12 ....................................................................................................... 5 Case study #3: Sue, aged 14 .................................................................................................... 8 Case study #4: Ben, aged 9 ....................................................................................... 11 Supplementary Materials Meal Portions ..................................................................................................................................... 15 Creative Lunch Box Ideas .................................................................................................................. 17 Food and the Senses ........................................................................................................................... 21 Food Selection by Colour .................................................................................................................. 23 Food Selection by Texture ................................................................................................................. 26 Suggestions for Texture/Taste/Nutrition Modification ...................................................................... 28 Food and Nutrition ............................................................................................................................. 30 Does Your Child Need Nutrient Supplementation? ........................................................................... 37 Healthy Snack for Children................................................................................................................ 38 Reading the Food Label ..................................................................................................................... 40 Ideal Mealtime Practices .................................................................................................................... 41 Food and Growth ............................................................................................................................... 42 Importance of Physical Activity ........................................................................................................ 43 Physical Activity Alternatives ........................................................................................................... 44 Activity Sheets Daily Food Group Intake Checklist for Children............................................................................... 46 Meal Planner ...................................................................................................................................... 47 Negotiation Chart ............................................................................................................................... 48 Helpline .............................................................................................................................................. 49 Additional Reading Resources .......................................................................................................... .51

Managing eating issues in children with Asperger Syndrome: Parents’ and professionals’ suggestions Introduction Parents/ caregivers have access to considerable nutritional advice about how to keep their child healthy. Selective eating patterns are more commonly exhibited by children with Asperger Syndrome (AS) compared with typically developing children. This booklet aims to share some strategies gathered from health professionals and parents/caregivers. These strategies can be used to manage selective eating in children with AS.

The booklet details four hypothetical case studies of children with Asperger Syndrome. It lists the possible dietary implications for managing the children’s eating issues. In addition, this booklet is supplemented with relevant handouts to provide additional information for parents.

It should be noted that the written case studies are hypothetical; however they were developed from the discussions with parents of children diagnosed with Asperger Syndrome.

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Case study # 1: Sam, aged 7 Physical status: Sam’s height and weight are within the healthy acceptable range. Sam is experiencing a healthy growth pattern. Clinical: Generally well, with no special health concerns. Common eating behaviours of Sam: -

Likes finger-foods, e.g. fish finger and chicken nuggets;

-

Refuses to eat steak, but accepts meat in the form of mince, sausage, stewed or braised;

-

The only vegetables eaten are cooked carrot, mashed potatoes and corn;

-

Prefers foods not touching other foods on the plate;

-

Fruit juice and banana are the main fruit sources;

-

Enjoys eating crackers, crisps, chocolate and yoghurt;

-

Likes adding sauces to his foods, mainly tomato sauce and barbeque sauce;

-

Mum comments he is always a picky eater, especially regarding food texture.

Possible nutritional risk(s): -

Risk of inadequate micronutrient (i.e. vitamins or minerals) intake

-

Excessive sodium intake from sauces and processed foods

How did the parent and professionals manage Sam’s eating pattern: Parent’s suggestion #1: Only allow Sam to leave the table after he has eaten all the food served to him

Professionals’ suggestions: Let your child judge how much s/he eats  The serving portions for children are often smaller than those for adults. The quantity of foods required by children depends on their age, gender and physical activity levels.  See “Meal portions” handout for guidance in judging how much your child requires for meeting his/her daily nutrient requirements.

Possible outcomes #1 : Over-eating and stress at mealtimes; remain at the table 

Sam could be over-eating in the long-term, particularly if meal portions are misjudged and over-estimated.



Stress introduced at mealtimes could provoke a negative association with foods and mealtimes.

2

Parent’s suggestion #2: Allow Sam to include his favourite sauce when a new food is being introduced Professionals’ suggestions: Limit seasonings/ sauces to no more than one (1) tablespoon per meals  Seasonings/sauces are commonly high in salt content. Try low salt varieties of seasonings/ sauces. Children should be encouraged to drink at least 6 – 8 glasses of water daily to help in excreting excess salt.  Keep a food record of the foods eaten and not eaten by your child could help to determine his/her food preferences. Such a food record can be used to decide which of the child’s preferred foods could be replaced without compromising nutrition; while at the same time, gradually decreasing any dependence on seasonings/ sauces at each meal.

Possible outcomes #2: Excessive salt intake 

Sam might regard the sauce as a reward food; whilst the new food could be perceived by Sam as a punishment at mealtimes, especially when the new food is not within the acceptable range of Sam’s food preferences.



Sam might excessively use the sauces/ seasonings in his meals so that the taste of the new food offered could be masked. Thus, a dependence on the use of sauces during the introduction of new food could lead to an excessive salt intake by Sam’s through his diet.

Parent’s suggestion #3: Only allow Sam to reject a food after he has tried it (at least with a bite) Professionals’ suggestions: Expect rejection, accept disappointment  Your child is still learning to eat different foods and is developing eating skills. Here, a learning plate could be offered next to his/ her usual eating plate. Ask your child to place their customary food on his/ her learning plate when s/he refuses to try a bit. If s/he refuses to do this, you can help to place the customary food on his/her learning plate. Although your child is not eating it, s/he can become familiar with the look and smell of the new food on the eating plate and to tolerate its presence.  You could invite your child along on food shopping trips. Next, allow them to hold, smell and touch new foods. In addition, you need to be aware of their food preferences. Touching and playing with the food is part of the learning stage of food acceptance.

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Possible outcomes #3: Battles at family mealtimes when the caregiver and the child refuse to listen to one another 

Disputes that happen around mealtime increase everyone’s frustration, with negative experiences being associated with the offering of new foods.



Children might feel their food preferences are not being understood and respected by their parents, if they were required to take at least a bite of the new food.

Additional suggestions:  If your child by the age of 5 only eats one food texture, especially for a food requiring less chewing (soft/ mince/ meltable), you should consider seeking professional advice.  Children with AS are commonly reported to have highly selective food preference that relate to texture. If your child makes unhealthy food choices (e.g. fried fish finger, deep-fried potato chips), you may wish to provide healthier choices (keeping in mind their texture preferences, e.g. grilled crumbed fish, oven-baked potato wedges) – See “Food Selectivity by Texture” and “Suggestion for texture/taste/ nutrition modification” handouts.  You may consider the use of a divider (e.g. silicon cups) in your child’s lunch box when foods need to be separated from another food – See “Creative lunchbox ideas” handout.

What have you learned ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

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Case study # 2: Tom, aged 12 Physical status: Tom’s weight and height are within the acceptable healthy range. Tom experienced an average growth of 3 cm and 2 kg over a period of three months (which is normal average). Clinical: Diagnosed with ADHD in addition to AS Common eating behaviours: -

Repetitive and rigid eating patterns in a cyclic pattern;

-

Same meals and snacks offered daily lasting for 3 – 6 months;

-

Consumed less than ten food items over the past few years;

-

Changed only one food in his limited food repertoire;

-

Lack of vegetable, fruit and meat intake in his diet;

-

The only vegetable eaten is hot chips;

-

Had strong preference for salty, vinegary and plain foods;

-

From his room, he can smell cooking in an open kitchen, particularly the odours of garlic, onion, and spices.

Possible nutritional risk(s): -

At risk of inadequate fibre, vitamins and minerals intake due to low vegetable and fruit intake;

-

At risk of low iron intake since his meat intake was lacking;

-

Might consume excessive salt intake from his strong preference for salty foods.

How did the parent and professional manage Tom’s eating pattern: Parent’s suggestion #1: Let Tom decide what he eats; let Tom have a separate meal from the rest of the family. Professionals’ suggestions: Respect Tom’s food preferences if nutrition is not compromised  To do this, draw up a weekly meal planner for Tom by ensuring he eats daily at least one type of food item from each food group.  Use the “Daily serving checklist for children” handout when planning Tom’s weekly meal. It assures his nutrition intake is adequate yet meeting his food preferences.  Encourage Tom to sit at the table with the rest of the family at mealtimes, so that he is exposed to the daily foods eaten by other family members, while learning to accept the foods through role modelling.

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Possible outcomes #1: A reduction in stress at family mealtimes; a risk of poor food choices when made by child; additional time in food preparation. 

Most children have limited nutritional knowledge about foods. They often choose the food based on their preferences, especially the taste and texture of food. As a consequence, their nutritional intake could be compromised when poor food choices (i.e. those high in calories/salt/fat and low in good nutritional values) are made.



Parents who offer foods that are acceptable to their children reduce the battles at family mealtimes, when compared to parents who try to persuade and negotiate with their children about trying those foods they dislike.

Parent’s suggestion #2: Accept the stereotyped behaviours of Tom. “After Tom was diagnosed with Asperger Syndrome, we knew he was different and we learnt to accept how he behaves and what he eats,” Mum.

Professionals’ suggestions: Do not treat your child with AS too differently from your other child  Listen to your children’s opinion/ interest.  Respect their food and sensory preferences.  Set up a positive mealtime environment that is acceptable to your child. This is essential to encourage their food acceptances. See “Ideal mealtime practices” handout for more information.

Possible outcomes #2: Allows parents to have an open, optimistic mind 

Children with AS have little ability to manage their stress. Thus, for avoiding possible unexpected events (e.g. choking from foods, disgust of the food taste), they may prefer to eat familiar meals. Thus, a repetitive, rigid eating pattern is displayed. However, that could also be explained by their stereotypical behaviours of disliking change.



Accepting and understanding a child with AS gives parents an optimistic mindset in guiding the child throughout his/her challenging daily environments.

Parent’s suggestion #3: Involve Tom in meal preparation; avoid cooking garlic/onion/spices at home when Tom is around

Professionals’ suggestions: Making mealtime fun by involving your child  Plain, bland foods are usually preferred by children with AS. 6

 Keep every meal easy and simple. Involving your child in simple meal preparation can be fun.  Wrap-up foods are often popular dishes as children get to choose their own fillings and wrap their own foods. For examples, sushi, tortilla, burritos, rice paper rolls, wraps and crepes.  Getting ideas from children’s cooking recipes allows your child to learn about foods by cooking them; consequently, this increases their food acceptances when they know more about the food they eat.  Growing and eating herbs/ vegetables in your garden can be fun!

Possible outcomes #3: Increase the food exposure to your child; encourage a positive mealtime environment 

The involvement of your child in the kitchen allows them to learn about food properties and it preparation. In addition, this gives your child more knowledge about the foods that he/she eats, such as knowing the type and quantity of ingredients used in a mixed dish.



Children with AS are commonly experience difficulties in sensory processing. Sensory sensitivities for smell and taste could influence his/her food acceptances. Children with a high sensitivity to smell are more readily able to accept food served at the dining table when they are not distracted by an intolerable smell from the kitchen.

Additional suggestions:  Introducing fruits as desserts. For example, frozen fruit cup (prepare using fresh mango, yoghurt and lemon juice - can add passionfruit pulp if your child likes more texture in food), stewed/ grilled/ caramelized fresh fruits or fruit kebabs.  Try expanding your child’s vegetable intake. Slowly replace some of your child’s mashed potato with mashed broccoli, and followed by sweet potato (white flesh), mashed sweet potato (orange flesh), pumpkin, and mashed carrot. Only introduce half a tablespoon of “new” food at a time.  Avoid your child adding salt from the dinner table. Use salt sparingly in your child’s diet. The higher salt intake in child’s diet, the higher risk of experiencing hypertension in adulthood.

What have you learned _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

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Case study #3: Sue, aged 14 Physical status: Height and weight are in the healthy range. Clinical: Generally well, with no special health concerns. Common eating behaviours: -

Likes beige-coloured food (Sue commented she felt safe to eat them);

-

Has a strong preference for sweet food;

-

Only likes tuna in sushi, but she never ate fish on its own;

-

Enjoys finger-foods (e.g. sushi, tortilla, enchilada), but not self-limited to;

-

Skips her meals when she was obsessive in her present activity;

-

Displays aggression and temper tantrum if being served meal that were outside her food preferences;

-

Dislikes fresh fruit due to its fibrous texture;

-

Fruit juice is the main fruit source in her diet;

-

Mum reports Sue’s food variety has expanded gradually.

Possible nutritional risk(s): -

At risk of inadequate fibre intake;

-

Irregular mealtimes could affect Sue’s satiation and appetite level towards her next meal.

How did the parent and professional manage Sue’s eating pattern: Parent’s suggestion #1: Never give up introducing food variety at each meal; includes at least one acceptable food in the meal Professionals’ suggestions: Introduce new foods by expanding one food item at a time  For example, if your child likes eating pasta, introduce cooked carrot or cooked pumpkin into the pasta to expand his/her vegetable intake.  Start introducing foods, that are generally eaten by your family throughout the year, and which share similar food properties with your child’s preferred foods.  Gradually increase the amount of “new” foods on your child’s plate by half a teaspoon at a time.  Only introduce another “new” food when some improvement was shown during the previous mealtime offer.  Be persistent! You are not the only parent who is struggling with feeding your child. If you need to talk to other parents, see the “Helpline” handout.

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Possible outcomes #1: Increase the chances of a new food being accepted by Sue in long term 

Studies have found that children learn to accept one new food after at least 10 – 15 times of exposure. When your child is learning about new foods, s/he could be sensitive towards certain food properties. In addition, remember your child is still learning to eat different foods and is developing eating skills.



Including familiar foods in each meal, together with the new foods, helps to ensure your child eats something from the plate. However, you may be placing your child’s food repertoire at risk by removing familiar foods with new foods. This is because your child may feel ‘threatened’ by the unexpected changes in his/her usual preferred diet. Remember most children with AS prefer routine, and such as similar meals.

Parent’s suggestion #2: Invite Sue to take part in a school camp, community event or family day where food is eaten. Professionals’ suggestions: When eating out, bring your own food while still offering the food at the table to your child  Offer the same foods to your child as what his/her peers (or other guests) have.  Contact the school before the camping/ travelling events to inform them of your child’s eating patterns, so that alternative meals can be pre-arranged for your child when required.

Possible outcomes #2: Increased or reduced chance of new food acceptance 

Social events with peers may help to promote variety in your child’s food intake through role modelling. As an example, encouraging participation at birthday parties when invited, may allow your child to learn from what others do or eat (i.e. outside of the family). However, new social events may increase social anxiety and lead to reduce your child’s food intake.

Parent’s suggestion #3: Communicate often; have a cooling period when child/ parent is distressed Professionals’ suggestions: Stay calm and be honest with your child  Avoid showing your anger and fear.  Communicate with your child when your mind is ready to listen and accept/negotiate in a calm manner.  Use a negotiation chart to jot down what you and your child think before making any further comments/ decisions about foods. 9

 Avoid empty promises that lead to mistrust.

Possible outcomes #3: Improved understanding between parent and child; avoid confrontation 

Communication is the best tool to understand your children better. Parents know their children best; however, a lot of effort is required to assist his/her.



Allow time for a person to calm down and think while speaking out their thoughts and perceptions towards a situation.

Additional suggestions:  Try offering Sue fruit with less fibrous texture. For example, canned fruit, stewed banana, and guava. The stringy fibrous material can be removed once fruits are cooked. Try stewed peaches, banana, and nectarines, which are sweet (i.e. meeting the child’s sweet preference).  If forgetting meal is an issue, set an alarm (e.g. using a digital watch or a desk alarm clock) to alert Sue of her mealtimes.  Try expanding Sue’s food variety based on her preference for beige-coloured food – See the “Food Selectivity by Colour” handout.

What have you learned _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

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Case study #4: Ben, aged 9 Physical status: Ben is overweight. He is experiencing an average weight gained of 2 kg per month, and grew taller by 0.5 cm per month. Clinical: Taking medication that hidden the possible adverse effect of weight gain to control his behaviour; Experiencing diarrhoea 3 times per day Common eating behaviours: -

Enjoys eating his food in large portions and in a repetitive manner;

-

Frequently complains of hunger;

-

Ben has access to food at all times when there is no supervision and raids the cupboard;

-

The main fluid source is milk;

-

Likes strong flavoured foods, e.g. curry chicken rice;

-

Prefers foods that require minimal chewing, e.g. white bread, biscuits, yoghurts;

-

Lacks vegetables and meat in his diet.

Possible nutritional risk(s): -

At risk of excessive calorie intake from his daily estimated needs;

-

At risk of inadequate fibre intake;

-

At risk of low iron intake since meat intake was low.

How did the parent and professional manage Ben’s eating pattern: Parent’s suggestion #1: Lock the food cabinet and fridge Professionals’ suggestions: Draw a weekly family activity schedule, including work, school, mealtimes, sport and household chores  Listing of the schedule provides a routine schedule for your child/family to ensure a healthy lifestyle is adopted.  Setting a regular routine at mealtimes and snack times allows your child to control their food intakes by reducing its frequency to 3 main meals and 2 snacks per day. In addition, it allows your child to learn the cues of hunger, so that she/he eats regularly at 3 – 4 hours intervals only.  When his/her time is being occupied with other activities (e.g. cleaning own room, homework, sports), excessive snacking at home can be avoided.  See the “Physical Activity” handout for ideas about the alternative activities in which your child might be able to get involved.

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 Providing a healthy snack food range in the food cabinet or fridge can prevent your child’s from eating high calorie, empty nutrient foods often (i.e. remove the temptations from the home). This can be difficult, since the whole family must cooperate.

Possible outcomes #1: Eliminates direct food access for children without supervision 

Ben’s meal and snack patterns can be controlled.



Supervising Ben’s food intakes avoid over-eating (of junk or large quantity foods), and thus prevents excessive weight gain.



Preventing food access by Ben at home reduces his exposure to foods to those of the families’ common food items.

Parent’s suggestion #2: Introduce fortified food into Ben’s diet since he is not eating enough diet variety Professionals’ suggestions: Offer food that is higher in nutrient value  Replacing your child’s food choice with another food, that shares similar textures/tastes but with a higher nutrient value, can be helpful to improve your child’s nutritional intake.  Ensure adequate fluid is consumed daily (i.e. at least 6 – 8 glasses of water per day)  See the “Foods & Nutrition” handout to gain ideas about the nutrient content in food sources.  See also the “Does Your Child Needs Nutrient Supplementation” handout to judge the need for nutrient supplementation in your child’s diet.  See the “Reading Food Label” handout to guide you in shopping for more nutritious foods for your child.

Possible outcomes #2: Nutrient overload; reduced willingness to be involved in food expansion 

When a child eats a large portion of fortified foods daily, she/he may experience nutrient overload at a higher risk than a child who does not consume fortified foods. This is because fortification in food promotes a higher nutrient absorption rate in the digestive system than a natural food. Some nutrients are stored and not excreted from the body when excessively consumed. For example, a high iron store in child’s body promotes constipation, particularly when his/ her fluid intake is inadequate.



Dependence on fortified food in the long term may encourage repetitive eating patterns in children with AS, if parents assumed the adequacy of their child’s nutritional intake was reached by using fortified diets. 12



Yet, the use of fortified foods can ensure that those children with a limited food repertoire are obtaining an optimum nutritional intake to meet their growth status.

Parent’s suggestion #3: Visit health professionals to managing Ben’s eating behaviours and gastrointestinal illness Professionals’ suggestions: Discuss your goals and priorities for your child with your health professional  List out your primary concerns with your child’s eating behaviours.  Prioritise goals for your child in the life context of the needs of your whole family.  Attempt one modification in your child’s life at a time. Ensure that you and your child are involved in the setting of goals related to eating behaviour.  Draw out a reasonable timeline in achieving the goals listed. For example, one goal could be to learn to accept yoghurt in the next six months.  Refer to the checklist below to guide you and your child in goal setting. Possible outcomes #3: Such a visit may help Ben’s parents understand his needs from his perspective (such as behavioural, clinical and psychological) 

Clarifications from health professionals means parents understand their children better, which can eliminate those unnecessary stresses in parents.



When a child experiences medical complications in eating, (i.e. diarrhoea in Ben’s case), appropriate intervention guided by health professionals will improve Ben’s eating behaviours, and therefore his/her overall nutritional status.

Goal Checklist:  Is the goal achievable?  Is the goal realistic?  What is the degree of difficulty to achieve the goal?  What are the barriers to achieving the goal?  How might you manage/ solve those barriers?  What help/ support can assist you?

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Additional suggestions:  Try to encourage your child’s fluid intake to be at least 6 – 8 glasses of water per day. If your child dislikes water, try to place lemon wedges, mint leaves, or strawberries for flavour infusion into his/her drinking water. Alternatively, on summer days, prepare ice-blocks using fruit juice/frozen berries and place them into their drinking water.  If your child likes spices, try to introduce new foods that sparingly use those types of spices preferred by your child. For example, when child loves curry, try to cook a vegetarian curry using tofu (i.e. white, soft, smooth) instead of chicken (i.e. white, soft, stringy). You may try slowly changing the food texture in your child’s diet one food item at a time.

What have you learned ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

Some ideas to start with: 1. Set good mealtime practices in your family 2. Know your child’s food preferences 3. Communicate with your child often with regards to food 4. Draw a daily schedule, e.g. meal planner and activities 5. List out goals to be achieved in improving your child’s food intake

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Meal Portions Children’s food intake is hard to judge when they keep growing each day. Each child requires different energy requirements based on his/her gender, age and activity level. The Australian Dietary Recommended Guidelines for Children and Adolescents (NHMRC 2003) are designed to meet their general requirements. They can be used as a basic guide for judging the meal portions for children. However, regular monitoring of your children’s meal portions and food choices is essential to ensure your child’s appetite and nutritional needs are met.

As a general rule: 

Use your child’s palm size to measure a serve of meat



For children under 5 years, one tablespoon of vegetables is approximately equal to one serve of vegetable



The more active the child is, the more energy is required to meet their demands



Let your children serve themselves and allow them to judge their fullness. It is not essential to require your children to empty their plates



Set regular meals and snack times in order to monitor the type and quantity of food intake of your children consistently

Approximate average proportion of food groups served in a healthy lunch box:

1 bottle

Dairy

Water

(1 serve)

Bread/rice/ Vegetables

pasta/

(2 serves)

couscous/

Meat/ meat

noodle

Fruit

alternative

(2 serves)

(1 serve)

(1 serve)

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Recommended daily intake for children Number of servings/day Food groups

1 serve equals

Cereals, bread,

1 slice bread,

rice, pasta,

½ bread roll/ bagel,

noodles

1 crumpet/ English muffin, 2 Weet-Bix,

Children aged 4 – 7 years

8 – 11 years

12 – 18 years

5–7

6–9

5 – 11

2

3

4

1

1

3

2

2

3

½

1

1

1

1

1

¾ cup hi-fibre breakfast cereal, ¼ cup untoasted muesli/oats, OR ½ cup cooked rice/ porridge/ pasta/ noodles/ couscous ½ cup cooked vegetable,

Vegetable

1 cup salad vegetable, ½ cup cooked legumes, OR 1 small potato 1 medium piece of fruit,

Fruit

2 small pieces of fruit, 1 cup canned fruit, 1.5 tablespoons dried fruit, OR ½ cup fruit juice 1 cup milk / calcium-enriched dairy alternatives,

Dairy

200 g yoghurt/ custard, OR 40 g cheese Meat,

fish, 65 g cooked meat,

poultry,

eggs 1/3 cup lean mince,

or alternatives

2 slices roast meat/ ham, 80 g cooked fish, ½ cup cooked legumes, 1 egg, OR 10 nuts

Extra

2 sweet/ savoury biscuits,

(Sometimes)

1 scoop ice-cream,

foods

1 small packet potato crisps, 1 ‘fun-size- chocolate bar, OR 200 ml fruit juice/ soft drink

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Creative Lunch Box Ideas Simple yet creative healthy lunch box ideas can be a struggle for fussy eaters. Two common questions are: “What can I provide in my child’s lunch box when their food choices are so limited?” “How can I encourage my child to eat more foods from the lunchbox?” Hence, our objective is to share some ideas in preparing lunches. We aim to: 

Encourage your child to eat the food prepared in the lunch box;



Encourage your child (and not the bin) to gain the good nutrients offered by the food you prepare;



Promote safe and healthy eating at school.

Three (3) points to keep in mind when preparing a lunch box for children are: 1. Food safety 2. Food preference and nutrition 3. Quick food presentation in a hurry

1. Food safety tips  Practice good hygiene during food preparation/ handling  Wash hands before handling food. Avoid touching food directly with bare hands, but use gloves or utensils if necessary.  Ensure clean utensils and food containers are used.  Use separate cutting boards for raw meat and fruit/ vegetables.  Do not prepare raw meat together with ready-to-eat salad/ fruits to prevent cross-contamination.  Clean the kitchen before and after food preparation.  Cover the cooked hot dishes with muslin clothes or net to prevent the bacteria contamination from insects, especially during hot weather, while cooling down the dishes before storing into lunchbox.

Food temperature check 

Store the cool food below 5oC and the warm food above 40oC. Temperature between 5oC and 40oC is the most desirable environment for the growth of bacteria. Use insulated flask or one with freezer pack to store those foods that required safety attention. 17



Try to eat perishable food items, such as dairy products, egg and meat, within about 4 hours of preparation.



Cool down cooked food completely before packing into a lunch box to reduce the condensation and thus the moisture content in the lunch box. Alternatively, fridge the food overnight before packing into the lunch box for next day.

Foods that should be avoided from lunch box are:  Raw fish/ seafood  Undercooked meat  Half-boiled or runny poached egg  Leftovers that appear to be a bit stale  Egg-based/ cream-based dressings, e.g. mayonnaise, ranch, Thousand Island dressings, unless keep it very cool  Tofu

2. Food preference and nutrition 

Lunch box planner (as designed by Makiko Itoh: http://www.justbento.com/)

Encourage your child to get involved in the preparation of the lunch box, such as choosing and packing the foods into the lunch box. You should set a role model by preparing yourself a healthy lunch box. 

Discuss with your child about his/her food preferences in the lunch box

Ensure your child chooses one food item from each food group based on his/ her preferences. For example, if s/he prefers eating white-coloured foods, pick one white-coloured food from each food groups, so that a balanced nutritious lunchbox is warranted. Refer to ‘Food and Senses’ handout for more ideas. 

Most importantly and definitely, the lunch box has to be tasty as well!

The secret of making a tasty lunch box is by keeping the ingredients as simple as possible. As long as the ingredients used are fresh and good in quality, the simple cooking method, such as grill, roast, or steam, can bring up the natural flavour of the cooked ingredients fantastically (maybe a light shake with salt/ pepper as an indulge). This is particularly applicable to a child who is a sensitive towards smell and taste of food. 

Nutritious

Have the checklist of food groups handy. Tick the number of servings and type of foods offered to and eaten by your child in the lunch box-of-the day. Offer the rest of the lacking 18

food group intake in the later meals of the day, or make up those inadequacy intake to the meal next day. Make every mouthful count!

3. Quick food presentation in a hurry Essential tools in decoration/ arrangement Silicon cups: Place loose/ small foods, e.g. Baking paper cups/ foils: non-reusable, more cherry tomato, grated carrot, minced meat

hygiene; suitable for dry foods

Picks: For finger foods or as decoration

Plastic grass divider: “Baran”- separate the food from touching

Cookies cutter: Shape vegetable

Bread shaper: Remove crust & shape bread

Rice shaper

Mould/ Divider: Place loose food items

Accessories: Mini sauce bottles , Plastic cutlery

Speedy lunch box preparation tips 

Prepare as much as possible the night before.



Cut up vegetables the day before and refrigerate overnight for use in assembling the lunch box.



Cut up fruit at night and store in fridge after squeezing some lemon juice over the fruits to reduce the browning reaction on the fruits.



If possible, cook the meat for lunch box at night and refrigerate overnight, unless the meat has to be crunchy. That not only ensure the meat is cooled when packing in the lunch box, but also save the time in cooking.



Set aside some left-over for the lunch box.



Get ready with carbohydrate foods, such as bread, cooked pasta, cooked rice, cooked cous cous, and biscuits, the night before.



Set up all utensils and accessories required for the assembly and preparation of the lunch box in advance



Don’t spend too much time on fancy decorations by shaping every foods offered. Offering tidy arrangement, safe and nutritious food is more important in assuring a healthy appetite of your children than a fancy lunch box. Keep the craft work in preparing lunch boxes for family picnics or camping when more time is allowed to do so.

References: 1.

Itoh, M. (2010), “The Just Bento Cookbook: Everyday lunches to go”, Kodansha International, Japan.

2.

CSIRO. (2009), “The CSIRO wellbeing plan for kids”, Penguin Group, Australia.

19

Food and the Senses Understanding senses Our senses are: hearing, smelling, seeing, touching, and feeling movement. These senses affect how we, as individuals, respond to the world around us. Different individuals have different sensitivities to various sensory inputs. For some children, only a small amount of sensory input is needed to obtain a response (hyper sensitive or over responsive); while for others a lot of input is needed (hypo sensitive or under responsive). For example, a child can be over sensitive to the fluorescent lighting in the dining room and complain of glare. For some children, the smell of donuts cooking at the shopping centre (a distance away) may be experienced as unpleasant and intolerable; however another child might only smell the donuts cooking when s/he is close by. How the brain makes sense of incoming sensory input is known as sensory processing. Children learn to associate certain types of sensory input with pleasant or unpleasant experiences based on learning from past experiences. This could be affected by past family, social and cultural experiences. For example, if a child is forced to eat lumpy food while being spoon fed by an adult as a toddler, s/he might remember this as unpleasant; hence avoid any type of spoon feeding in future or avoid similar lumpy food. In general, our senses help us to be aware of, attuned to and engaged with the world around us. Each individual’s sensory preferences shape his/her level of alertness or arousal, and the brain’s readiness for learning.

Mealtimes and Senses Not only do an individual’s food preferences influence what s/he eats, but also the environment at mealtimes influences a child’s eating behaviours. Parents and caregivers need to be alert to children’s food preferences in order to offer nutritious food choices and promote successful eating and mealtimes. In addition, understanding the sensitivities of individual children related to smell, taste and touch can also help to build a positive mealtime environment – See Ideal mealtime practices handout. Some suggestions for managing sensory issues at mealtimes are listed below: 

Set up a mealtime environment that is practical for your family and acceptable for your child. For examples, check the child’s seating position (i.e. chair at appropriate height 20

for table using booster seat); consider the lighting, noise level (reduced background noise from radio/TV) and smells. Some children dislike the smell of certain foods cooking and will not come into the room. You may need to cook these foods earlier in the day. 

Use crockery and cutlery that are appropriate cutlery for your child’s age/size and the development of their eating skills.



Consider where they are best seated (e.g. next to parent or an older sibling who can role model appropriate eating behaviours) at the dinner table.



Establish a regular routine around mealtimes (e.g. sitting at table for certain period of time) rather than eating on the run or watching TV.



Be aware of any preferred and non-preferred food properties (such as crispy food vs. lumpy food) experienced by your child and also the child’s sensory style (neutral, over or under sensitive to certain types of sensory input).



Help your child to understand and manage his/her senses. Discuss with an occupational therapist if you feel your child is having certain sensory difficulties when responding to his/her daily home or learning environment. Ensure mealtimes are calm and relaxed to promote a positive social and sensory experience for your child.



Avoid force feeding under any circumstances, as this may worsen children’s eating experiences.



Use visual supports or social stories when introducing new foods.

By respecting and accepting individual preferences, parents/carers can gradually shape children’s food preferences and food choices. As a simple and quick reference in finding food alternatives for your child based on individual’s food preferences, see Food Selection by Colours, Food Selection by Textures and Suggestions for Textures/ Colours/ Nutrition Modification handouts. Please contact your local dietitian or occupational therapist for further advice when mealtimes, food and sensory issues are concerns for your child. References: 1.

Myles, BS, Cook, KT, Miller, NE, Rinner, L & Robbins, LA (2000), Asperger Syndrome and sensory issues: Practical solutions for making sense of the world, Autism Asperger Publishing Co., USA.

2.

Bogdashina, O. (2003), Sensory perceptual issues in autism and Asperger Syndrome: different sensory experiences, different perceptual worlds, Jessica-Kingsley, London.

21

Food Selection by Colour This table is for reference purposes only. It aims to provide food ideas for children based on colour selection. As an example, if you notice that your child has strong preferences towards white foods, then to expand the diet variety of your child, you could try to slowly introduce alternative white foods. To start with, try other white foods that have similar smells and tastes to his/her current food liking, such as replacing plain popcorn with rice cake. Increased food exposure might help to expand the familiarity of ‘new’ foods for your child. However, never give up on introducing new foods!

Food Colour

White

Food Group Bread & Cereal Barley Quinoa Rice Rice paper Rice noodle Udon noodle Mung bean (glass) noodles Oats Amaranth Rice cakes Plain popcorn Sago Pearl cous cous White bread (crust left) Flat bread

Vegetable White asparagus Peeled aubergines (Eggplant) Bamboo shoots Bean sprouts Cauliflowers Stem of Bok Choy Stem of Chinese cabbage Tapioca Chicory White corn White button mushroom Oyster mushroom (Grey white)

White potato White radish White turnip Parsnip Lotus root Taro

Fruit Peeled banana Peeled lychee Peeled longan Peeled rambutan Peeled mangosteen Peeled pomelo Peeled guava White currants White mulberry Nashi pear White peach White nectarine Water chestnut

Meat/Fish/Poultry/Legumes Butter beans Cannellini Large white kidney beans Macadamia nut Raw/canned peanut Skinless brazil nuts Lotus seed Lily bulb Octopus/ squid Oyster Tofu Pork White fish Chicken Quail Turkey Egg white Chicken/ Pork sausages

Dairy Milk Soy milk Yoghurt Vanilla ice-cream Milk pudding Feta cheese Mozzarella cheese

Notes:

22

Food Colour

Beige/ Brown

Orange

Red

Food Group Bread & Cereal Buckwheat noodle Whole-wheat spaghetti Brown rice Pappadum Wholemeal bread Rye bread Whole-grain bread Pita bread Fruit loaf Carrot cake Melba toast Bran Orange cake

Beetroot Tagliatelle Thai red rice

Vegetable Chestnut cap mushroom Brown mushroom

Fruit Brown pear

Meat/Fish/Poultry/Legumes Dairy Chestnut Chocolate flavoured Brown lentils dairy products Roasted cashew nuts Roasted peanuts Walnuts Almonds Hazelnuts

Carrot Orange sweet potato Pumpkin Orange pepper Butternut squash Tomato Red capsicum Red pepper Red radishes

Papaya/ Papaw Orange Mandarin Rockmelon Persimmon Cherry Strawberry Cranberry Raspberry Ruby/red grapefruit Watermelon Red Williams pear Red plum Red apple

Cooked salmon

Cheshire cheese Swiss cheese

Adzuki bean Red kidney bean Beef Veal Mutton Lamb Offal Game meat Red meat sausages

Berry flavoured dairy products

Notes:

23

Food colour Green

Food Group Bread & Cereal Spinach pasta

Vegetable Choko Cucumber Asparagus Broccoli Celery Pea Snap beans Snake beans Leek Iceberg lettuce Oak leaf Cos lettuce Little gem Okra Green pepper Snow pea sprout Spinach Watercress Ripe green tomato Green cherry tomato Asian green vegetables Wakame Brussel Sprouts Green olives Alfalfa

Fruit Kiwi Honeydew Green pear Avocado Granny Smith apple

Meat/Fish/Poultry/Legumes Dairy Pistachio nuts Pistachio flavoured Green Mung beans dairy products Green tea flavoured dairy products

Notes:

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Food colour

Food Group Bread & Cereal

Black/Purple Squid ink taglioni Black glutinous rice Wild rice

Vegetable

Fruit

Meat/Fish/Poultry/Legumes Dairy

Nori Wood ear (Judas’s ear) Black truffle Shitake mushroom Black radish Black olives Beetroot Purple-tipped asparagus Purple cauliflower (Green after cooked) Red cabbage Red oak leaf Lollo rossa Purple sweet potato Purple/black pepper Yam

Blackberry Blackcurrant Black mulberry Dried prune Purple plum

Black pudding Black pea

Taro flavoured dairy products Violet/ Lavender flavoured

dairy

products

Notes:

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Food Selection by Texture This table is for reference purposes only. It aims to provide food ideas for children based on texture selection. As an example, if you notice that your child only eats foods that require less chewing, such as crispy and/or soft-textured food, then you could try to slowly introduce alternatives. To start with, try alternative foods that have similar smells and tastes to his/her current food liking, such as replacing potato crisps with rice chips. Increased food exposure might help to expand the familiarity of ‘new’ foods for your child. However, never give up on introducing new foods! Food Texture Crispy

Bread & Cereal Thin pizza base Wafer Water cracker Rice cracker/chip Rice bubbles Baked filo pastry

Crunchy Hard

Soft

Vegetable/ Legumes Pappadam Iceberg lettuce Celery

Breakfast bar with Carrot nuts Corn on cob Nacho Dried bread Waffle Fruit-filled breakfast bar Rice cakes Corn thins Puffed grains

Fruit

Food Group Meat/ Fish/Poultry

Dairy

Miscellaneous

Fruit crisps

Grilled bacon

Potato crisps

Apple Green pear Guava

Dried nuts

Hard boiled lollies Soy crisps Taro/ Jackfruit chips Plain sweet biscuits Pretzels (snacked) Popcorns

Blanched broccoli/ Nectarine asparagus Raw button mushroom Rosti Baked potato wedges

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Food Texture

Bread & Cereal

Vegetable/ Legumes

Fruit

Food Group Meat/ Fish/Poultry

Dairy

Miscellaneous

Chewy Bread Thick pizza base Pretzel Muesli bar Yoghurt-coated breakfast bar Pasta

Soft Smooth

Puree

Fibrous

Pancake/ crepe

Cooked mushroom

pikelet/ Mashed and meshed vegetables (i.e. boiled, mashed and filtered the fibrous using a sieve) Oat porridge Mashed pumpkin/ Rice bubbles sweet potato/ potato soaked with added Mashed cauliflower/ milk broccoli/ pea Cooked semolina Bean dipping sauce (e.g. Hummus) Boiled couscous/ Baked beans Barley/ rice/ Tomato amaranth Boiled okra Cooked yam/ taro

Fruit rolls Dried fruits (e.g. apple rings/ apricot)

Fruit Jelly

Fruit puree Avocado Mashed pawpaw/ banana All soft fruits (e.g. mango, nectarine, peach)

Beef steak Cheese sticks Pork/ lamp chop Grilled Haloumi Salami/ pepperoni cheese stick Prosciutto Beef jerky

Silken tofu

Plain yoghurt Dairy milk drinks Custard/ Puddings Cheese fondue Smooth ricotta Puree scrambled eggs Smoothies Meat blended with gravy/ Ice-cream sauce Sorbet/ Gelato

Stewed/ Minced meat Canned fish Fish fillet Sausages

Gummy candy Liquorice Glutinous rice balls Sago Mochi

Jelly Chocolate fondue Marshmallow

Yoghurt with real fruit pieces

27

Suggestions for Texture/ Taste/ Nutrition Modification This table is for reference purposes only. It provides a few examples of food items according to their food groups. It also constructs the possible experiences of child when consuming those foods. The last column of the table suggests some ideas aimed at increasing food acceptability amongst children. Such suggestions also aim to improve the nutritional intake of children. If you notice your child experiencing any of the issues noted in the table, you could try to slowly implement changes in your child’s diet. Always check your child’s tolerance level and acceptability. For example, if skim milk is not accepted by your child, you could try to introduce semi-skim milk into your child’s diet to replace full-cream milk. Again, examine what is the priority for your child before implementing changes in his/her diet – such as, the nutrition of your child, or for ease of convenience during outings. Food Group

Examples of Food

Possible issue(s) experienced by child

Suggestions/ Strategies

Bread/ Cereal: Bread

White bread Wholemeal/ wholegrain bread Tortilla Taco shell

Cereal

Breakfast cereals

Rice

Basmati/ rice

Pasta Noodle

Spaghetti Egg noodles

Jasmine

 Crust on bread  Foods sticks to teeth during chewing  Grain in bread causes discomfort during chewing if your child is orally sensitive to tactile sensations  Poor nutritional value if white bread (i.e. low in fibre) is only eaten

 Remove the crust from bread  Toast bread or use flat bread  Use taco shells or thin crispy-crust pizza bases if stickiness is an issue  Use high fibre white bread  Offer highly nutritious fillings

 Mushy texture  Chewy texture  Difficulty in chewing long foods (e.g. spaghetti, fettuccine) with a firm texture (? Oral motor skills)

 Add dried/fresh crispy fruit to reduce the mushiness in oat porridge  Add seeds/nuts to oat porridge, when no food allergies are involved  Eat the cereal shortly after milk is added  Replace milk with yoghurt on cereal to better maintain the crispiness of cereal/muesli  Cook pasta longer to provide a softer texture  Provide a smaller form of pasta, e.g. penne/macaroni  Offer couscous to replace rice/pasta

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Food Group

Examples of Food

Vegetable/ Legumes

Green

Celery

Coloured

Asian greens Capsicum Carrot

Possible issue(s) experienced by child  Tough fibrous texture, e.g. celery and vegetable stalks  Hard crunchy texture, e.g. carrots  Bitterness in some vegetables, e.g. brussel sprouts and dark green vegetables  Hot sensation during the chewing of some vegetables, e.g. capsicum and onion

Suggestions/ Strategies  Cut stalk vegetables into smaller pieces in order to break their fibrous texture leading to improved chewing  Grate the carrot finely if raw is offered in sandwiches or salads  Cook the vegetable until soft, if chewing is an issue  Remove vegetables with a bitter taste or hot sensation from your child’s diet, if s/he is not ready to accept them, but replace with other various vegetables

Fruit Orange

Grapefruit

Yellow

Peach

Red

Cherry

Green

Kiwi

Meat/ Fish/ Poultry Red

Beef steak

Pink

Pork chop

White

Fish

 Tangy or sour tastes of citrus fruits  Waxy/hairy skin of the fruits (produces a hard to chew/greasy-like/irritating texture)  Pulp in fruits (can’t handle surprise popping sensation/course texture)  Seeds in fruits may cause choking if the child does not know to remove them  Edible small seeds in fruit that gives a course texture, e.g. kiwi/dragon fruit

 Avoid sour lemons/grapefruits/oranges if the child finds them distasteful  Choose Valencia or Sunkist oranges that are commonly sweet  Offer peeled fruits  Avoid fruit that contains pulp, such as citrus fruit and pomegranate  Remove all inedible seeds from fruits before offering them to your child  Avoid fruits containing edible small seeds, if they are unacceptable to your child.

 Tough, chewy texture from red meat/skin of meat  Fishy smell from seafood  Bony fish may choke your child  Afraid of blood stain on meat

 o o o  o o o  

If the child has difficulty in chewing: Remove all skin/fat from meat Stew/casserole meat dishes Offer lean mince meat or home-made patties If the child dislikes fishy smells: Cook fish with strong herbs , e.g. basil, thymes, rosemary, garlic, if a fishy smell is an issue Offer fish as a mixed cooked dish, e.g. seafood pot/pie Offer canned fish with marinates Offer fish fillets to prevent choking on bones Offer well-cooked meat, especially if cooking meat with the bones attached; OR remove the bone prior to cooking

29

Food Group

Examples of Food

Dairy: Liquid

Plain/ flavoured milk Malted milk drink Milkshake

Puree

Yoghurt Thick shake Cheese spread

Semiviscous

Ice-cream

solid

Panna cotta

Solid

Cheddar cheese

Custard

Ricotta cheese Cheese slice

Possible issue(s) experienced by child  Too much sugar/fat in commercial beverages  Dislikes the creamy/‘cowy’ taste of milk  Dislikes the waxy coating left on their tongue after eating  Difficulty in swallowing food with a puree consistency    

Can’t handle ‘surprises’ in oral texture Orally sensitive to cold temperatures Dislikes a ‘mushy’ texture in the mouth Over-consumption may lead to high sugar/fat intake

 Can’t handle the strong taste of certain cheeses, e.g. veined or goat’s milk cheeses  Dislikes the chalky taste of some cheese  Over-consumption may lead to a high salt/fat intake

Suggestions/ Strategies  Offer home-made milk beverages  Include low-fat yoghurt when preparing cold milk drinks  Offer low-fat milk or calcium-fortified soy milk that gives a less milky taste (as long as your child is above 2 years)  Add malt or chocolate powder (liquid) to the milk drink  Offer a milkshake that is prepared using low-fat yoghurt and low-fat milk  Offer a cheese slice on sandwiches or crackers  Avoid those dairy foods that are not tolerated well by your child. Find alternative dairy sources!  Keep this food category as occasional food  Prepare home-made low-fat milk ice-blocks as an alternative to commercial ice-cream during hot weather. Additional fruit blended into the milk ice-blocks may increase its acceptance.  Avoid strong cheese  Try processed cheese, e.g. cheddar or Cheshire, which has a mild flavour  Try low-fat cheese options  Offer no more than two serves (40 g/serve) of cheese per day

Notes:

30

Food and Nutrition Background If your child selects foods based on colour and texture, trying to include certain foods that are higher in nutrient values can assure the optimum nutritional intake. Acceptance of a variety of food is a common problem among the children with AS. Thus, including one or more of the excellent food sources for certain nutrients in your child’s diet can help to replenish their nutrient stores. Finding alternatives is one aim to promote healthy eating for selective eaters. This is because we need to respect children’s food preferences, yet help them to make wiser choices from their limited food repertoire. Good communication between parents and children can build a stronger bond, and that may enhance the process of food acceptance in children. Respect and communicate about your child’s food preferences while offering higher nutrient value foods promote healthier eating patterns. Three main nutrients, calcium, iron and fibre, are highlighted in our diet sheets as these are the common nutrients found to be lacking in children. They are needed as they play a significant role in assuring your child’s growth and development. See tables below that depict the nutrient content in each 100 gram of edible portion for comparisons to be made between each food groups. The nutrient values listed in the chart are based on NUTTAB 2006.

How to use the charts: Foods that are closely related to the food listed (e.g. strawberry yoghurt instead of vanilla yoghurt) can be offered to your child. In addition, certain foods may appear to provide high nutrient content; however it may only be eaten in a minute quantity (e.g. sesame seed and blackberry). Select your child’s food by considering their sensory preferences. Use the food group checklist to keep track the daily food consumed by your child. Always try offering food sources from the highest nutrient content, whenever possible, in each food groups. Reminder for vegans or those who dislike eating meat: legumes and nuts are good food sources to replace meat.

Iron Iron is important for our blood in replenishment and tissue cells. There are two types of iron in our diet: haem-iron and non-haem iron. Haem-iron is found rich in animal foods; whilst non-haem iron from plant foods. A child requires eating more quantity of plant foods to meet an equivalent amount of iron intake from animal foods, as haem-iron offers a better absorption rate in human body than non-haem iron. 31

Besides, foods with a high phytate, oxalates and tannins (found in black tea, whole grain and legumes) could reduce iron absorption; whilst foods with a high vitamin C (such as citrus food) could enhance iron absorption. Inadequacy of iron intake leads to lethargy. Iron overload from dietary intake is unlikely, except for children with metabolism disorder who failed to ingest iron promptly, or those who have frequent blood infusion or long-term ingestion of large amounts of iron. Alert: Having frequent, large portion of iron-fortified foods can cause excessive iron intake, particularly for those children who include meat and vitamin supplement in their daily meal patterns. Ensuring adequate fluid and fibre intake daily is important to prevent hard passing stools. The general iron requirements for children are:

Children 4 – 8 years 9 – 13 years 14 – 18 years

Food groups

Recommended iron intake per day (mg/d) 10 8 Boys: 11 ; Girls: 15

Foods

Bread & Cereal White bread, iron increased, toasted Mixed grain bread roll, toasted Breakfast cereal, mixed grain, extruded shapes Breakfast cereal, wheat bran flakes Breakfast cereal, puffed/ popped rice Meat/ Fish/Poultry/ Seafood

Vegetable/ Legume

Smoked oyster, canned in oil, drained Green mussel, steamed/ boiled Fish paste/ spread Lean mutton, casserole Dry fried mince lamb Chicken egg yolk, hard-boiled Grilled kangaroo loin fillet Grilled lean, round beef steak Stir-fried, lean beef strips Baked, lean duck Stir-fried, lean veal Pan fried, trimmed pork fillet Tempeh, fried in sunflower oil Sundried tomato Smoked tofu English spinach, boiled

1 Sample serve

Iron content (mg) per serve

1 slice, 30 g 1 slice, 33 g ¾ c , 22.5 g

2.1 1.9 4.3

¾ c , 30 g ¾ c , 22.5 g

5.1 2.3

2 pieces, 24 g 2 pieces, 16 g 1 tsp, 5 g 65 g 65 g 65 g 65 g 65 g 65 g 65 g 65 g 65 g

4.0 1.7 0.45 3.4 3.3 2.4 2.7 2.2 1.8 1.7 1.4 0.9

½ c , 90 g 1 piece, approx. 5 g 1 piece (6.3 x 2.9 x 2.5 cm), 120 g ½ c , 95 g

8.3 0.3 4.8 3.7 32

Food groups Vegetable/ Legume

Nut

Snack

Foods

1 Sample serve

Iron content (mg) per serve

Canned baked bean in tomato sauce, salt reduced

½ c , 138 g

2.2

Canned red kidney bean, drained

½ c , 95 g

2.0

Silverbeet, boiled

½ c , 58 g

1.6

Bok Choy, stir-fry

½ c , 80 g

1.7

Canned mixed bean, drained

½ c , 100 g

2.0

Canned cannellini bean, drained

½ c , 90 g

1.5

Roasted cashew, salted

10 nuts, 15 g

1.0

White sesame seed Tahini, sesame seed pulp Sunflower seed Almond with skin Liquorice

½ tsp , 1.4 g ½ tsp , 2.5 g ¼ c , 38 g 10 nuts, 12 g 30 g

0.07 0.1 1.8 0.5 2.6

1 bar, 30 g 1 c, 8.5 g

1.7 0.3

1 small packet, 30 g

0.8

Cereal & nut breakfast bar Air-popped, popcorn, no added fat, unsalted Soy crisps or chip

Calcium Calcium is the building block for our bones. Calcium stores happen during childhood to adolescence and ceases when we reach adulthood. Adequate calcium not only assures healthy growth development, but also the reach of peak calcium storage. Building up a strong bone foundation can help prevent osteoporosis and bone fractures in later life. The general requirement for children aged 4 - 7 is 700 mg/d, which is equivalent to 3 cups of milk, children aged 8 - 12 is 1000 mg/d, which is equivalent to 4 cups of milk, and children aged 13 – 18 is 1300 mg/d. Substitution of dairy to other calcium food sources (e.g. bony fish and nuts) is wise when your child does not like dairy products. Refer to the chart below to give you some ideas about the calcium food sources.

33

Food Groups

1 Sample Serve

Calcium content (mg)per serve

1 slice, 30 g

70.8

½ roll, 25 g

40.0

2 small (7.5 cm), 26 g

38.7

1 muffin, 58 g

78.3

¾ c , 30 g

32.1

1 ½ Tb, 25 g

50.4

1 regular scone, 85 g

82.5

2 pikelets, 40 g

40.7

Wholemeal bread roll

½ roll, 40 g

34.4

Dried apricot

1 ½ Tb, 16 g

11.5

Dried currant

1 ½ Tb, 18 g

15.9

1 piece (6.3 x 2.9 x 2.5 cm), 120 g

384.0

1 c, 250 ml

340.0

½ c, 95 g

161.5

1 piece, aprrox.5 g

4.8

½ c , 80 g

98.4

Tahini, sesame seed pulp

½ tsp, 1.5 g

4.6

Almond with skin

10 nuts, 12 g

30.0

Brazil nut, raw/ blanched

10 nuts, 35 g

52.5

¼ c, 38 g

38.0

10 nuts, 7 g

6.3

80 g

432.0

1 tsp, 5 g

22.0

Sardine, canned in tomato sauce, undrained

80 g

344.0

Salmon, Australian, canned in water

80 g

267.2

Green mussel, steamed or boiled

2 pieces, 16 g

55.4

Anchovy, canned in oil, drained

40 g

66.8

¼ c, 25 g

312.5

200 g

470.0

Foods

White bread, calcium increased Bread Cereal

& Mixed grain bread roll Pancake, prepared from commercial dry mix Muffin, English Style, white, toasted Breakfast cereal, oat bran

Fruit

Dried fig Dried fruit scone, home-made Pikelet, home-made

Vegetable

Firm tofu Soy-beverage, fortified

flavoured,

calcium

Boiled frozen spinach, drained Sundried tomato Bok Choy, stir-fried Nut

Sunflower seed Pistachio nut, unsalted

Seafood

Sardine, canned in water, no added salt, drained Fish paste/ spread

Skim milk powder Dairy

Yoghurt, unflavoured (natural) low fat

34

Food Groups

Foods

Yoghurt, vanilla flavour, low fat (3g

Total fat

40

Ideal Mealtime Practices As caregivers, we decide what to offer children and they decide what to eat. Children with AS tend to make their food choices based on their sensory preferences and past experiences. Food properties, such as texture, colour, shape, taste and smell, related to your child’s preference need to be closely monitored in order to offer better choices in their food intake. Although every mouthful of food taken by your children is important, we should not neglect the importance of a healthy mealtime practices. Mealtimes play a relatively important role in encouraging your child’s food intake. We should promote a mealtime environment that is enjoyable and relaxed for your children together with the whole family if possible. A quick checklist for positive mealtime practices is listed as below:  Have meals together with family where possible  Sit on chair with good posture to eat at meal and snack times  Set a regular and predictable routine for meal and snack times  Draw a menu weekly or daily to inform/ negotiate with your child what foods are being offered in each meal  Offer food in a suitable serving size for your child  Provide an appropriate set of utensils for the use in accord with their eating skills, age and size  Involve your child in food preparation or mealtime setting as children tend to accept more food from their own preparation  Provide a sociable and calm mealtime environment  Check if the mealtime environment suits your child’s sensory preferences. Examples: the lighting, the smell presented and the noise level  Remove radio, T.V or games from the dining area  Expect some mess when children are learning to eat independently; the younger the children the more likely the mess  Always clarify with your child and provide alternatives in a calm tone. Shouting does not help you to understand your child better  Encourage your child to try all food presented by using positive statements. Example: “I know YOU CAN take a bite of this carrot.”  Never force feed or pressure your child to eat  Talk about food and nutrition at mealtime to share knowledge about healthy eating  Talk about likes and dislikes with your child so that you learn about your child’s food preference 41

Food and Growth Understanding growth in children Many caregivers are anxious about their children’s growth and weight gain. Children grow differently at different stages in terms of their statue and physiology. In addition, girls and boys experience different growth spurt at different ages. Girls tend to experience their growth spurts in the early adolescence stage; whilst the boys in the later stage. Hence, the food and nutrition demands for boys and girls are different under the same age group. Refer to the ‘Meal portions’ handout to give you some ideas about the daily recommended dietary requirements of your children.

During the toddler stage, children gain approximately 2.5 kg per year in weight and a further 12 cm per year in length. Their growth continues at an average rate of approximately 2 kg per year and 10 cm per year, and a steady decline to 6 cm per year until the growth spurt at puberty (Shaw & Lawson, 2007). Remember parental statue, not only the children’s nutritional intakes, influences children’s height and weight.

How to monitor growth in children 

To monitor the growth status in your children at home, ensure the measurements of height and weight of your children are taken using the same equipment/ method respectively so that the readings are consistent and reliable.



Record the measurements and plot them into the growth chart provided in their Health Record Card according to their age measurement taken.



Measure up your child’s height and weight monthly or regularly.



Calculate your child’s body mass index (BMI) a.



If the records of your child’s BMI-for-age are below 3th percentile or above 95th percentile over an on-going period, you should seek further assistance from a health professional in monitoring and improving the growth status of your child. a

Note: BMI is calculated by dividing height in meter squared (m2) with body weight (kg).

Reference: 1. Shaw, V. & Lawson, M. (2007): “Nutritional assessment, dietary requirements, feed supplementation,” In V, Shaw & M, Lawson (eds), Clinical paediatric dietetics, 3rd edn, Blackwell Publishing, UK.

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Importance of Physical Activity “Stay active” and “Be active” are the two common statements used in promoting the physical activity to the current sedentary lifestyle of our community. We are responsible for encouraging and keeping our children active. Activity such as: joining sport games, playing in playground/ courtyard, helping out with house chores/ gardening, using active transport (e.g. walking to the station or shop), playing with a family pet or building blocks, and volunteering in community works. Keeping your children active is important in promoting healthy lifestyle from childhood through adulthood. Active children tend to stay active as they grow. That is an essential way to keep your children’s body fit and prevent them from being overweight/ obesity in their later life, which come with many risk complications of health. Active body promotes an active brain - children learn through play. Leisure screening should be limited to no more than an hour per day. Choose the educational programs that help in learning and improving children’s knowledge, and meet your child’s sensory preferences (i.e. background noise for soothing and calming). Active games should be introduced to your child to keep them moving (e.g. Twister TM, Jumping Jack, Hopscotch). Developing a daily routine for your child can help in setting and organizing their lifestyle, to assure active learning is promoted at all time. This allows your children to enjoy activities they get involved in, while helping them to sustain their interests. Refer to “Physical activity alternatives” handout to give you some ideas about activities your children may be interested to get involved in order to keep them physically active.

Websites for further readings: 1. Department of Health and Aging. Physical activity guidelines. Available [Online]: http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-physact-guidelines. Last updated on 01 October 2010. Accessed on 9 February 2011. 2. Healthy kids: Eat well, get active. Available [Online]: http://www.healthykids.nsw.gov.au/ Accessed on 9 February 2001. 3. Raising children network. Encouraging kids to be active. Available [Online]: http://raisingchildren.net.au/articles/encouraging_kids_to_be_active.html/context/227. Accessed on 9 February 2011.

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Physical Activity Alternatives The alternatives here refer to physical activities that your children can get involved besides participation in sport games. Our aim is to keep your children moving! This helps them spend less time in sedentary behaviours, such as playing computer games and watching television. Go through the list below and make a note next to the ones you think your children will be capable of and interested to participate in. Discuss with your children about these alternatives and draw out a weekly routine to ensure sufficient physical activity.  Join dancing classes  Action games and songs  Gardening (e.g. build a herb garden or flower garden, weeding, watering)  Tidy up own room/ play space  Set up table at mealtime  Simple food preparation tasks (e.g. mixing salad, rolling burritos, mashing potato)  Vacuuming/ sweeping floors  Dust the house  Empty filled garbage bag into the bin outside the house  Help with laundry (e.g. hanging, folding, collecting clothes)  Look after family pet (e.g. playing, feeding, brushing, cleaning the cat/ dog)  Jump on a trampoline/ ride a swing/ run around the blocks  Walk or Cycle to school/ shops/ station  Visit nearby beaches for a run/ play with sand in building castles etc  Play with a gym ball (e.g. bouncing or rolling). Choose one that suits their size  Play Hopscotch/ Climb tunnels or tyres/ Chase a friend or sibling in an open field  Involve in community works (e.g. visit retirement village, church, foster care)  Create new movements for stretching or balancing  Throw & fetch a billabong/ ball/ flying saucer  Collect newspaper/postage from mailbox  Run up and down the stairs  Dish washing

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Activity Sheets

You may like to photocopy them for use each time.

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Daily Food Group Intake Checklist for Children:

Is your child eating enough or too much?

Highlight the number serving eaten by your child in the respective food groups. Fill up one column for each child. Make a note when certain food group is eaten in excessive or inadequate. Recommended Daily Intake (Serves) for Children Food Group Breads, cereals, pasta, noodles

Sample one serve

3 – 7 years

8 – 18 years

Notes

rice, 1 cup cereal ¼ cup muesli ½ cup pasta/ rice/ noodle 1 slice bread 2 rice cakes/ Weet-bix

Vegetables

1 cup salad ½ cup cooked vegetable ½ cup beans 1 small potato

Fruit

1 medium fruit 2 small fruits 1 cup canned fruit

Dairy

1 cup milk/ soy milk 200g yoghurt 40g cheese

Meat, fish, poultry, 60g cooked meat eggs, or alternatives ½ cup lentils 2 eggs Extras

1 scoop ice-cream 20g potato crisps 2 sweet/savoury biscuits Designed by Shu Ong (2011)

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Meal planner: Week starting: Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Breakfast

Morning snack

Lunch

Noon snack

Dinner

Note: Designed by Shu Ong (2011)

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Negotiation Chart: Completed by child/ parent Suggestion TO:

Reason

Completed by opposition

By both parties

Acceptance

Solution if no deal

 Deal  No Deal

 Replace with:

If no deal, reason(s):  On hold until:

FROM:

Date: _______________  Other(s):

DATE:

RECEIVED BY:

TO:

 Deal  No Deal

 Replace with:

If no deal, reason(s): FROM:

 On hold until: Date: _______________

DATE:

 Other(s):

RECEIVED BY: Designed by Shu Ong (2011)

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Helpline:

AS Support Group in Australia

State All VIC

Organization Autism Asperger Advocacy Australia Autism Victoria

Website [email protected] www.autismvictoria.org.au

Email a4.org.au/a4/abouta4 [email protected]

NSW

Autism Help Autism Plus Aspergers Support Group Network Vic Aspect (Autism Spectrum Australia)

www.autismhelp.info/main.htm www.autismplus.com.au www.assnvic.org.au www.autismspectrum.org.au

[email protected] [email protected] [email protected] [email protected]

Autism & Aspergers Support Group

www.autismsupport.org.au

n/a

QLD

Asperger Syndrome Support Network www.asperger.asn.au (ASSN) Autism Queensland www.autismqld.com.au

[email protected]

SA

Autism Association of South Australia

[email protected]

WA

Autism Association of Australia Autism Aspergers ACT Inc.

ACT

TAS NT

www.autismsa.org.au

Western www.autism.org.au

[email protected]

[email protected]

www.autismaspergeract.com.au

[email protected]

Autism ACT

www.autism.anu.edu.au

Autism Tasmania Autism NT

www.autismtas.org.au www.autismnt.com.au

[email protected] (Info for group meeting) [email protected] [email protected]

Phone n/a 1300 424 499/ (03) 9657 1600 (03) 5221 2984 (03) 9782 1843 (03) 9845 2766 1800 069 978 (02) 8977 8377 0425 380 575 0425 380 574 (07) 3865 2911 (07) 3273 0000 1800 428 847 1300 288 476 (08) 8379 6976 (08) 9489 8900 1800 636 427 (02) 6140 1061 (02) 6176 0514 (02) 6290 1984 1300 288 476 (08) 8984 4424 1300 288 476

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Parenting Helpline in Australia State

Organization

Website

Phone

VIC

Parentline

n/a

13 22 89

NSW

Tresillian Parent Help Line

www.tresilian.net

1800 637 357 9787 0855(Sydney metro)

Karitane Care Line

www.karitane.com.au/services/careline.php

1300 227 464

Parent Line

www.parentline.org.au

1300 1300 52

QLD

13 Health

www.health.qld.gov.au/13health/

1300 30 1300

SA

Children, Youth and Women’s Health Services

www.cyh.com

1300 364 100

WA

Parenting WA line

www.communities.wa.gov.au/childrenandfamilies/

1800 654 432 6279 1200 (metro)

ACT

Tresilian Help Line

www.tresilian.net

1800 637 357

TAS

Parenting Line

n/a

1300 808 178

NT

Parentline

www.parentline.org.au

1300 30 1300

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Additional Reading Resources Meal time/ eating behaviour management: Autism Association of Western Australia (2011) Meal time management and overcoming restricted diets in children with Autism. Legge, B. (2008) Can’t eat, won’t eat: Dietary difficulties and Autistic Spectrum Disorders, JessicaKingsley Publishers, London.

Ernsperger, L & Stegen-Hanson, T (2004) Just take a bite: easy, effective answers to food aversions and eating challenges, Future Horizons, Arlington.

Raising children network 2011. [Online]: http://raisingchildren.net.au/

The National Autistic Society 2011, Dietary management for children and adolescents with ASDs: restricted

diet

[Online]:

http://www.autism.org.uk/living-with-autism/understanding-

behaviour/dietary-management-for-children-and-adolescents/dietary-management-restricteddiet.aspx.

Meal ideas and food pictures book: Williams, T. (2010) this = that child’s size: a life-size photo guide to kids’ food serves, Australia.

CSIRO (2009) The CSIRO wellbeing plan for kids, Penguin group, Australia.

Diet and Autism Spectrum Disorder: Connor, Z. (2006) Diet and Autistic Spectrum Disorder [Online] http://www.bda.uk.com/foodfacts/Autism.pdf.

Srinivasan, P. (2009) A review of dietary interventions in autism, Annals of clinical psychiatry, 21(4): 237-247.

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