Have you ever worried whether your child’s picky eating behaviour is something more serious?
Why do they refuse to eat certain foods without even so much as trying them and why nothing you do seems to help?
Some children become ‘problem feeders’ and what started as picky eating can develop into a picky eating disorder like Avoidant/Restrictive Food Intake Disorder (ARFID).
In this blog we’ll take a look at what is normal food refusal and picky eating behaviour, compared to what might be considered something a bit more problematic.
What is picky eating or fussy eating?
Let’s start by outlining that for the majority of children, picky eating is a normal developmental phase of early childhood.
During weaning, babies can refuse foods that they are unfamiliar with, which is why you often hear the phrase that it can take 10 times (or more) before babies accept a food. This is why repeated exposure is so important.
In the toddler years, cognitive, emotional and social development mean that toddlers enter a ‘neophobic’ phase where they become suspicious of both new food and some familiar foods.
It causes a true fear response so encouraging a toddler to eat something they are truly afraid of can cause drama at mealtimes. Again, what you need to know is that this is totally normal and an expected part of early childhood.
However, for some children, it is more than just a normal fussy phase. Picky eating disorders are much more complex, and can cause a lot of distress to both you and your child.
What is a picky eating disorder?
This is more than typical fussy or picky eating.
In 2013 the term Avoidant/Restrictive Food Intake Disorder (ARFID) (8) was given to the condition and it’s considered an eating disorder.
ARFID is diagnosed when a child doesn’t want to eat because of worry about what that food may do to them or because of an inability to tolerate the sensory properties of the food such as it’s smell, appearance or taste. It may also be caused by a medical condition.
Children with ARFID may have low weight or may not grow according to their centile charts and many would have nutritional deficiencies without heavy reliance on nutritional supplements.
Their lack of eating hugely interferes with the normal social functioning of life, so for example a child with ARFID may struggle to come to the dinner table to eat with the rest of the family or refuse to go to a birthday party because there will be party food.
Unlike other eating disorders, the lack of eating has nothing to do with the child’s perception of their body weight, shape or size. (1)
Children with ARFID often have a short list of preferred (or ‘safe’) foods and often certain textures are avoided entirely. It’s not uncommon for gagging/retching to occur at the sight or smell of certain foods. (3)
How do you know if your child has ARFID?
Remember that food neophobia (the normal refusal of foods) is a developmental phase that happens during toddlerhood and should pass.
If your child has persistent restrictive food behaviours, a list of less than 20 ‘safe foods’ or it is affecting their weight, growth, physical health, family life or social interactions, then please do seek help. You can see your GP initially.
You will be referred to a clinical psychologist or paediatrician who specialises in eating disorders who will assess your child and confirm the diagnosis. Other healthcare professionals cannot make an ARFID diagnosis.
There are certain reg flags that we look out for when we think a child’s fussy eating may be ARFID.
1. Significant weight loss or poor growth
Typical fussy eating that occurs in the early years generally will not result in weight loss or poor growth. Your child’s weight and height can be recorded in their ‘Red Book’ and they should follow their centile line. Falling away from the centile line is an indication that there may be an issue, however it’s important to note that not all children with extreme fussy eating have weight loss. (9)
2. Reliance on supplements
Weight and height growth may be normal but only because of a reliance on supplements such as nutritional drinks, multivitamin and mineral supplements and/or high energy and protein drinks.
3. Forgetting to eat or avoiding food
Children with normal fussy or picky eating will still want to eat sometimes and show an interest in some food. However, children with a picky eating disorder (ARFID) will have a lack of interest in food and eating. They may actively avoid situations that involve eating, or forget to eat, because food is not perceived as a priority.
4. Avoiding social occasions.
Children with a picky eating disorder (ARFID) commonly avoid social events that involve food because of anxiety around what they may be offered. For example, picnics, barbecues, birthday parties and even family mealtimes. The sight or smell of the food can cause an emotional feeling of fear or even have a physical effect like retching or gagging. (1),(2),(3)
Could your child have autism if they are a picky eater?
Children on the autistic spectrum or with ADHD often display the same problematic feeding behaviours, such as food refusal, sensory food aversions, restrictive eating, and anxiety associated with food and eating, etc.
Therefore, it is important that if you are concerned that your child is displaying any of the red flags mentioned above, that you seek professional help so that an accurate diagnosis can be made.
It is important to note that a child could potentially have both Autism and ARFID. (5)
What causes picky eating?
Normal toddler fussy eating or neophobia, is actually an evolutionary mechanism from hunter-gatherer times which helped to protect young children from picking up and eating things that could be potentially harmful.
It triggers a true emotional fear response and this is why persistent encouragement to eat can be upsetting for your child.
Here are some other common reasons why toddlers don’t eat what you want them to eat:
Preferences for sweet foods
This is common, as your child’s sweet taste buds are mature and yet the taste buds for bitter, sour, umami and salty foods still need to develop. This is why foods like vegetables or meat are commonly rejected.
Preference for ‘beige food’
Beige foods such as chicken nuggets, fish fingers, chips, breadsticks, toast, pasta are always the same, no matter which day you eat them. They are predictable for children. They are often also more processed and therefore easier to chew. Children will nearly always gravitate towards food that is easier to eat.
Where you eat
It’s not uncommon for a child to eat peas at nursery but not at home for example, and it’s got nothing to do with your cooking! The cues that lead up to the mealtime are just as important as the mealtime itself.
Enough of an appetite
Consider the last time your child had a snack or milk? It takes around 4 hours for the digestive system to process food. You don’t want your child to be starving but they do need to have an appetite as this is the desire that drives them to eat. For toddlers, around 3 hours in between a meal and a snack (and this includes milk) is about right.
Teething, a scraped knee, coming down with a bug, being poorly. These are all appetite suppressants.
Tiredness is a big one, if you’ve noticed that your little one always eats terribly at dinner time, it’s probably because they’ve been awake too long. Make breakfast and lunch more substantial nutritious meals and dinner something smaller and easy to eat. There’s nothing wrong with ‘breakfast for dinner’.
How you manage this toddler picky eating phase is key and your own personal eating habits will rub off on them.
Using positive food parenting strategies around how you interact with your child at mealtimes will determine how long this fussy phase goes on for and what eating habits your child grows up to have.
I teach parents the skills they need to become good ‘food parents’ inside the Happy Healthy Eaters Club if you want to dive deeper on this.
What causes ARFID?
ARFID is a relatively new diagnosis, so we don’t yet know why some children go on to develop this after the normal fussy eating behaviour seen in toddlerhood. What we do know is that children who have certain medical conditions, autism, ADHD or anxiety disorders are more likely to develop ARFID.
Because some children with ARFID have a sensory component, where the look, texture, taste or smell of the food is what stops them eating, it’s thought that a cause may be linked to sensory processing. (11)
Research has shown that some children with ARFID have experienced a traumatic event associated with eating such as a choking episode, an allergic reaction, vomiting after eating, reflux as a baby or even having been tube fed in infancy.
In some cases this trauma did not happen to the child themselves but they witnessed someone else having it. (2) Nevertheless they respond in the same way, by thinking that eating food could have disastrous consequences, like feeling they could die.
An anxiety disorder or stress can also be a cause.
Will my child grow out of picky eating?
Picky or fussy eating that is not ARFID is part of normal brain development in young children and in most cases, this phase will pass as your toddler’s brain develops and matures.
However, responding incorrectly as a parent during this frustrating phase can result in prolonged fussy eating, drama at mealtimes and unfortunately having a child who grows up to have an unhealthy relationship with food.
This might include your child eating to deal with emotions, eating out of boredom, eating to control their weight or shape and eating in the absence of hunger.
Knowing how to support your child to try new foods, how to ‘food parent’ and how to gently encourage them to learn to like foods is essential, and this is what you can learn inside the Happy Healthy Eaters Club.
Will my child grow out of ARFID?
No, unfortunately not without the correct therapy and treatment. In fact children with ARFID who may eat 20 foods now, can end up eating fewer and fewer foods over the years.
You can’t encourage a child with ARFID to eat more.
You can’t expose them to more and more foods to widen their diet.
Often a multidisciplinary team of different healthcare professionals is needed. There should be
a registered dietitian with expertise in feeding as well as nutrition,
an occupational therapist (if there are sensory issues)
a speech and language therapist if there are eating skills that need to be learned and
a child psychologist.
Can picky eating turn into an eating disorder?
Yes it can. If there is an underlying cause such as the premature baby who experienced repeated tube feeds in infancy, it’s best to get help to address that problem straight away.
If the cause isn’t obvious but your toddler has become a preschooler and is almost ready to start primary school, it’s also now worth seeking help.
Remember that anxiety is common in children with ARFID so working on making sure the family home (and particularly around mealtimes) is a relaxing stress free environment can be really helpful. Parents also need to practice calm at mealtimes too.
What are the health risks of a picky eating disorder?
Children with a picky eating disorder are most likely to have nutritional deficiencies and these will need addressing before any treatment starts. Nutritional deficiencies puts your child at greater risk of developing a whole host of health conditions.
Some children also suffer faltering growth and weight loss, this can lead to reduced immune function and malnutrition which can impact every system in the body. In extreme cases it can result in death. (10)
Extreme picky eating can also have a huge impact on the psycho-social development of the child, which is how they learn about interacting and communicating with others. (2)
Should your picky eater take a multivitamin?
As a general rule, all children from the age of 6 months to 5 years should be taking a multivitamin containing vitamins A, C and D, as a safeguard to ensure they are meeting their daily needs. These are the recommendations from the UK Department of Health (6).
Children with ARFID will need additional supplementation but will need to have their diet assessed by a Registered Dietitian experienced in paediatrics first so that the correct supplement is prescribed.
Excess vitamin intake can be dangerous too.
What will the professionals do to help my child with ARFID?
That depends on the underlying reason.
The dietitian will assess the feeding environment as well as your child’s nutrition. Often there are strategies around eating habits or parenting around food that have been put in place to try and help the child, but these need to be addressed.
The occupational therapist will assess your child’s motor abilities (muscle and co-ordination) and sensory response and if there are issues, will come up with a step-by step plan for helping your child tolerate foods from a sensory perspective.
The speech and language therapist will assess to see if there are any eating and drinking skills that the child hasn’t yet mastered and if so will suggest adjustments to their food textures and suggest exercises to practice so that they learn missing skills.
The psychologist may use behavioural interventions such as Cognitive Behavioural Therapy (CBT), similar to those used for treating other eating disorders.
Some children may benefit from regular ‘feeding therapy’ with a feeding therapist who will be one of the professionals listed above who has done additional training in therapy.
Together they may come up with a plan, for example your child may be happier eating smaller food portions but may have an altered taste perception because of nutrient deficiencies. (12) The occupational therapist may be able to help here because taste is a sensory response.
The more your child only eats the same foods, the more they will notice a difference between new foods and their preferred foods.
For younger children, and those with autism too, a playtime approach can be adopted. (4) ABA or applied behavioral analysis can be effective too.
I go into a lot more detail on helping children with picky eating disorders inside the Happy Healthy Eaters Club. I invite you to take a look.
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If you’ve enjoyed what you’ve learned here then I’d like to introduce you to the Happy Healthy Eaters Club. This is a members-only club where you’ll learn how to raise a child who skips to the table (without you having to ask 50 times first), sits down, and happily munches away.
The club will teach you all about food and parenting techniques so that you can nip fussy eating in the bud (or prevent it before it begins) and make you’ll feel safe in the knowledge your child has eaten their nutrients, that they’ll sleep well, grow healthy bones and brains, and not pick up all those bugs.
Your parenting around food means that your little one will learn to be excited to try new foods, family mealtimes are a breeze and there’s not a reward, bribe, or IPad insight and you haven’t spent hours in the kitchen cooking up different meals for everyone either. And I promise you… you’ll no longer be scraping rejected food from the floor! Here’s the link to learn more: https://www.thechildrensnutritionist.com/hhec-open
With thanks to Claire Pearson, Lauren Telford and Catriona Lawson for their help in putting this blog together.