Feeding toddlers can be stressful at the best of times: refusal to come to the table, throwing food on the floor, refusing today what they loved last week!
And at some point, they may go through a frustrating picky or fussy phase, and up to 50% of children may be described as picky eaters during childhood (1).
A feeding aversion, however, is a bit more serious. These are children who have developed an extreme version of picky eating.
This blog aims to take you through how to identify if your child has a feeding aversion and how best to support them, including when more expert advice may be needed.
What is an aversion to food?
Food aversion is when a child refuses to eat certain foods offered to them. It spans both picky eating and problem feeding.
There is usually an underlying reason for the aversion, and some children may not grow out of it; those children need specialist feeding therapy.
What’s the difference between problem feeding and picky eating?
Some people use the terms picky eating and food aversion interchangeably. You can have a food aversion that goes away, and children grow and develop, or not, in the case of problem feeding.
Picky eating is relatively common and is frequently seen in children between the ages of 1-4. It’s a combination of our mistaken expectations for our children’s food needs, a developmental stage called preoperational thinking coupled and part of this involves food neophobia.
Toddlers have reduced nutritional requirements
As parents, we have watched our babies eat anything and everything. They will have eaten portions of food much bigger than what you may have expected them to eat, then suddenly they hit the toddler phase and want a whole lot less.
This is normal.
Their nutritional requirements now are lower because their big growth spurt has slowed right down, and as a result, their appetites fall.
Toddlers enter a neophobic developmental phase
At the same time, toddlers enter a developmental stage called pre-operational thinking and part of this may involve ‘food neophobia’. This is rejection of food on sight, before they’ve even tasted it, because they distrust it.
And it invokes an actual fear response!
If you try to get a child to eat something they are desperately trying to avoid, you will witness a full-on meltdown.
Is this just expected toddler behaviour?
So, because of their reduced nutritional needs and their developmental stage, it’s not uncommon for toddlers to refuse certain foods, skip entire meals or go for days on end without eating much at all.
You’ll be left wondering how they survive!
There are also many other reasons your child refuses to eat, and they are all within the realms of normal picky eating. If you’re worried, do check out my blog to learn all about them.
Is it picky eating or a more serious problem?
If you are not sure whether your child has picky or actually whether it’s something more serious like food aversion, you can take my quick quiz here to find out.
What causes an aversion to food?
If typical picky eating has been ruled out, food aversion can come about for 3 different reasons:
They can’t eat
They won’t eat
They’re being prevented from eating
They can’t eat
For some children, there is a skills gap. They just haven’t learned how to eat certain foods…yet.
These include chewing, tongue movement, lip closure or other mouth skills required for eating.
For example, if weaning was interrupted and they were kept on purees for longer than advised, they may not have learned the skills required to eat other foods.
Some children’s feeding aversion can result from conditions that made feeding painful such as gastro-oesophageal reflux disease or a food allergy.
This is what we experienced with my daughter Maisie, she had an egg allergy and was exposed to it via my breast milk, and it went undiagnosed for 8 months.
Essentially her early experiences of feeding were that milk and food hurt.
An aversion can also come from previous traumatic experiences around food, such as a choking incident, or having had tube feeding as a baby.
And if children have medical problems, they might not well either.
They won’t eat
Sensory hypersensitivity (heightened) or hyposensitivity (low) is another cause of food aversion, in which children have unusually high or low responses to the sensory experiences that eating involves.
We all have sensory preferences and eating is an experience that involves all 8 (not 5) senses.
It could be the smell, taste, how food looks, its texture, temperature or even the sound food makes in their mouths.
For example if you are sensory hypersensitive to sound, you might struggle to eat in a noisy school dining hall.
Likewise if you have visual sensory hypersensitivity, you may struggle when faced with a big plate with lots of different food.
Children who don’t like seams on their socks, labels in their clothes or describe food as being too crunchy, too spicy, too cold, may have sensory integration issues that affect their eating.
Being prevented from eating
Finally, in some cases, children can develop food aversions due to negative food parenting practices.
Force-feeding, re-presenting a rejected meal back to a child, using bribes or dessert as an incentive to get them to eat, hiding less preferred foods in others and offering food rewards for eating foods they don’t like.
These are all negative food parenting practices but they nearly always come from a good place.
I get it.
As a parent, all we really want is for our children to eat something. Otherwise they might not be healthy, we think they’ll catch every bug going, it will affect their sleep and they might not grow.
These are all valid worries that we as parents have, but those negative food parenting techniques might give us short term gain, but they will backfire on us in the long run.
Find out how to be a positive food parent in the Happy Healthy Eaters Club.
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What are the signs that my child has an aversion to food?
Signs and symptoms of aversion to food can include:
Small list of accepted ‘safe’ foods – less than 20
Rejection of certain textures
Extremely long meal times
Coughing whilst feeding
Difficulty coordinating breathing with eating or drinking
Frequent gagging or vomiting
Frequent chest infections
Slow weight gain
This is not an exhaustive list.
What foods are common food aversions?
Fruit and vegetables as well as meat and fish are common foods that tend to be less well tolerated (2) by young children.
Is it an eating disorder?
An aversion to food can be a type of eating disorder known as avoidant/restrictive food intake disorder (ARFID).
Unlike other eating disorders, ARFID is not caused by a desire to be thin.
ARFID is diagnosed when a child doesn’t want to eat, either because of the sensory characteristics of the food (it’s taste, smell, texture, sound or appearance) or because they are scared of what the food will do to them.
A child who has ARFID may have a short list of preferred (or ‘safe’) foods they will eat and may exhibit gagging or retching, which is the ‘disgust’ response at the sight or smell of certain foods.
This results in children not getting the nutrition they need and can lead to failure to gain weight, nutritional deficiency or reliance on nutritional supplements (3).
Children with ARFID also find it difficult to be in the same room as food, they try to avoid social events where there is food, such as birthday parties and eating with others at nursery or school is distressing (4).
Does this mean my child has autism?
No, although children on the autistic spectrum are more likely to have extreme picky eating or food aversions (5).
Do seek professional help via the GP if you have concerns.
What do you do when your little one doesn’t want to eat?
This depends on the underlying reason that’s causing their food aversion. If they can’t eat or won’t eat they will likely need help from a paediatric feeding team.
For example, if it’s a sensory issue, they will need sensory integration therapy with an occupational therapist.
If it’s an oral motor skills gap, they will need therapy with a speech and language therapist.
If they have anxiety around eating, they will need psychological support.
Whatever the cause, all children with a feeding aversion will need to work with a paediatric dietitian on two things:
optimising nutrition for health and growth
positive food parenting & mealtime strategies
What NOT to do
You may have heard about Ellyn Satter’s Division of Responsibility of Feeding (6), where the:
Parent’s responsibility is to decide what to eat (e.g. the menu), where to eat (e.g. the kitchen table), and when to eat (e.g. the schedule).
Child’s responsibility is to decide how much they eat (if any) and when to stop.
This is not appropriate for children with a feeding aversion caused by a medical, sensory or psychological cause or ARFID, as they simply will not eat.
The Division of Responsibility is the goal or end point that we are working towards with successful feeding therapy.
Similarly, I have seen parents resort to bribery, praise and rewards, restriction and punishment out of sheer desperation and worry, just to get their children to eat something.
These are not the solution and often can lead to further problems down the line.
Should your toddler take a nutritional supplement or multivitamin?
All children from 6 months to 5 years old should have vitamin supplements containing vitamins A, C and D daily (7). But, if your child has a limited diet or ARFID, the Registered Dietitian will assess and advise on the correct supplement.
This is important as not all supplements are equal and excessive intake of some vitamins and minerals can be just as harmful as a deficiency.
How can your toddler overcome an aversion to food?
Again, this depends upon the cause.
Some children need years of therapy; others respond after a few months of changing the environment around mealtimes and using positive food parenting techniques.
I’ve worked with families who have reported results within just 5 days.
What is ‘Positive Food Parenting’?
Positive food parenting is a child-centred, responsive approach to feeding (8). It involves parents taking a diplomatic approach to what happens at meal and snack times and includes:
Planning meals and snacks appropriately to aim for nutritional balance.
Providing structure with an appetite schedule with regular and appropriate timings.
Ensuring the atmosphere and mood at mealtimes is pleasant.
Teaching manners through role modelling and asking for good behaviour.
Avoiding encouraging your child to eat, pressuring them, rewarding them or bribing them with a reward for eating something.
Having family rules or boundaries or limits such as asking before taking food.
Not supplying ‘rescue meals’ when something hasn’t been eaten or snacks on demand.
Abiding by the ‘You don’t have to eat it, but you do have to join us’ rule for all meals.
Avoiding distraction at mealtimes, TV, iPad or toys at the table.
Giving your child guided choices – you choose the food group and give them two options, e.g. would you like chicken or ham in your sandwich.
Noticing what your child has and hasn’t eaten and adapting your weekly meal plan to bridge nutritional gaps.
Role modelling by eating together, showing enthusiasm for the meal, saying thank you to the cook and displaying your enjoyment for the meal.
This is the cornerstone of what we teach in the Happy Healthy Eaters Club.
Can messy play help?
Possibly. Messy play using foods is designed to help the child learn about the sensory characteristics of food in a low pressure, fun environment where there is no expectation for them to eat anything.
Play tends to start with low sensory input, e.g. dry foods that don’t stay on the skin, such as pasta, and moves up the scale to wetter and stickier textures (9). We have an excellent masterclass on this in the Happy Healthy Eaters Club.
Children with a sensory integration disorder need to have a special messy play program designed for them so that they don’t become overwhelmed with the experience.
If you think your child has a sensory issue with food or ARFID please seek professional help first before embarking on messy play.
Does food chaining work?
Food chaining is an individualised feeding programme you can try at home with your child to increase the range of foods they eat.
It is designed usually by a dietitian, who will have your child’s nutritional needs in mind. It aims to expand their food intake gradually by introducing foods with similar sensory characteristics to those already accepted by them (10).
For instance, if your child will eat takeaway chicken nuggets, you can chain to a similar food, the another and another till you get all the way to grilled chicken breasts.
When to seek help
When your child is refusing lots of food, you may need to seek help. Take my quiz here to identify if this is picky eating or a feeding problem that needs an individual assessment and professional expertise.
The results page of the quiz will advise you on what to do next.
Red flags that we Registered Dietitians look out for that indicate additional help may be needed include your child having:
multiple food allergies or intolerances
omits an entire food group
eats less than 20 foods (not during weaning)
has ongoing weight loss or inadequate weight gain
has ongoing choking, coughing, gagging or spluttering during meals
has ongoing problems with vomiting
has severe reflux or cries or arches their back during all meals
has a history of eating and breathing difficulties
has not been able to transition from baby food purees to solid foods
avoids certain textures of food
has a parent with a current or previous eating disorder in addition to the child not gaining weight (this is because you as a parent may need additional support around food parenting rather than being the cause of your child’s feeding issues)
when their aversion to food affects family life or social interactions
When does a food aversion become a feeding problem?
Food aversion becomes a problem when your child’s diet becomes so limited that they can’t get all the nutrition they need without the use of supplements.
Seek your GP’s advice if you are concerned about your child’s eating and ask for a referral to an NHS dietitian with paediatric expertise or book to see one of the dietitians on my team here.
What should you do if your child is underweight?
Sometimes it can be difficult to tell if your child is underweight. If you’re not sure but think they’re underweight or not growing in height as quickly as you would expect, see your GP.
There is no replacement to an individual dietetic assessment, but here are a few tips to get you started (11):
Aim for 3 meals per day with 3 smaller snacks in between times.
Continue to give as much of a balanced, varied diet as you can.
Avoid low-fat dairy products or diet or light versions of food.
Try to separate food and drinks, so your child doesn’t fill themselves up on fluids.
With thanks to Carolina Pereira for the research that went into the production of this blog.