Why Kidfood Is King in Pediatric Foodservice

Mike Buzalka

Kids are picky eaters. They often don't eat what they should, or when they should, or even how much they should. Of course, in most meal contexts, adults who know the importance of nutrition see to it that healthy choices are made. But the tables can turn quickly when a child is ill and his or her appetite disappears.

"If we have a child in the hospital that has undergone a procedure and is not eating, we are all over it immediately," says Mary Keysor, director of nutrition services at Maine Medical Center in Portland, which includes the Barbara Bush Children's Hospital. "Our clinical staff is involved in daily interdisciplinary rounds and our customer service staff check intake throughout the day."

Besides the traditional feeding role, children's hospitals are

The sustenance mission is complicated by the wide range of conditions a typical pediatric ward sees: diabetics whose food intake must be closely monitored; children with exotic but debilitating conditions who desperately need nourishment; children undergoing treatment regimens that destroy appetites; children with metabolic conditions that require specialized diets.

Even those patients whose appetites are not compromised are undoubtedly scared, homesick and lonely. So food, the great cross-cultural symbol of comfort and pleasure, has a huge role to play aside from its basic biologic function.

Kid Food Heaven
Pediatric healthcare foodservice has evolved substantially from the days when child patients simply received downsized versions of adult menu choices, with perhaps a coloring book and a couple crayons throw in. Like many adult-focused hospitals, children's hospitals are increasingly turning to room service models to provide patient meals. For children's hospitals, this approach seems especially valuable in accommodating the erratic-under-the-best-of-circumstances appetites of kids. Even in institutions that retain traditional mealtime tray approaches, greater flexibility has been introduced.

Meanwhile, menus increasingly reflect the reality that basic sustenance—in a word, calories—trumps sound nutrition when the mission is to feed sick kids. Experimentation and lectures about "eating right" are in most cases put on the back burner.

The result: menus that sometimes draw the wrath of child nutrition advocates with their cavalcade of pizzas, cheeseburgers, grilled cheese sandwiches, chicken fingers, Tater Tots, Spaghetti-O's, cookies and sugary cereals. But directors make few apologies.

"When we developed our children's menu we had a philosophical discussion," says Keysor. "Do we offer foods kids like or foods we consider nutritious—or both? After getting input from all corners, including patients, parents, nurses and physicians, we decided that the kids are so sick our primary challenge is to get them to eat and our children's menu reflects a wide variety of their favorites."

Of course, there are exceptions to the caloric emphasis.

"I really fight over soda pop consumption," offers Bill Barkley, food service director at Kansas City's Children's Mercy Hospital for dining services provider Sodexho Healthcare Services. "It's not on our menu, but we do have it available in floor stocks. If patients have café privileges, they can also get it from there. Kids who come through here sometimes drink massive amounts, and I don't know how we can get past that. It's a huge issue!"

While they admit that nutrition is not the number one priority when designing a menu, pediatric foodservice managers note that the choices are hardly junk food either. "If you look at the choices, even the choices that are most popular, they are reasonably nutritious," says Jill Hanscom, MPA, RD, assistant director for patient services at Robert Wood Johnson Hospital in New Brunswick, NJ, which includes the Bristol-Myers Squibb Children's Hospital. "Pizza, chicken noodle soup, hamburgers, mac-and-cheese—none of these are terrible. Also, everything on our room service Cool Cuisine menu is made from scratch, and usually to order"

Working the Appetite Windows
Along with coaxing appetites and emphasizing simple nourishment, pediatric food-service operations must deal with the highly erratic nature of a sick child's hunger pangs. Those pangs often come at odd hours, and flicker on and off like firefly flashes on a summer night, forcing meal providers to meet small windows of opportunity.

"We try to get food to them as quickly as possible when they indicate they're ready to eat," says Hanscom. Bristol-Myers started its room service program two years ago largely in order to better accommodate hunger windows. Hanscom says her department's time studies indicate an average turnaround of 29 minutes for the typical room service order.

"The room service model is much more efficient in getting food to the children when they're hungry," she offers. "With the old system we often missed opportunities, and there was also a lot of waste."

The responsiveness and flexibility of room service can make a huge difference in patient relations. At Children's Mercy the approach has helped Barkley's department achieve high patient satisfaction levels (currently, it's at 1.47 on a 1-5 scale).

Barbara Bush Hospital uses a hybrid approach. Children can either order from the room service menu or wait for Katie Gibbons, the nutrition care representative, who takes meal orders with a Palm Pilot. Keysor says most patients prefer to wait for Gibbons, who has a knack for establishing great rapport with the children.

That rapport is especially important given that patients often are "repeaters," seriously ill children who came back time and again for treatment and get to know the staff and the hospital routine. For these youngsters, food is one of the few pleasant aspects of the situation, and many have favorite menu choices that they look forward to eating whenever they are admitted.

The staff of course do their best to accommodate them, often establishing close bonds with the children in the process. The experience can be profoundly moving. William Notte, food & nutrition services director for Shands Hospital at the University of Florida in Gainesville, recalls one terminally ill child patient who specifically asked to meet with the foodservice staffers before she died to thank them for all they had done for her. "It makes you realize just how important what you do is," he says. How do staffers cope with the ever-present shadow of death that inevitably looms over their workplace?

"Well, you have to keep telling yourself that you are doing something that makes a huge difference in the lives of the patients," says Lee Marlowe, RD, head pediatric dietitian at Shands. "And sometimes, you just have to go in the bathroom for a couple minutes and cry."