Types of food refusal in children
Many children can be faddy about food, but in some cases there is a clinical reason behind their refusal to eat certain foods, or sufficient food.
A child who is hypersensitive to sensory experiences may refuse to touch food; will gag, retch or vomit when eating; will hold food in the mouth without swallowing; chews at the front of mouth, keeping food away from the sides of the mouth; and will eat only a limited range of foods.
A child who limits the foods they will eat based on the food’s appearance, smell, texture and taste may be diagnosed with avoidant/restrictive food intake disorder (Arfid). These children never seem hungry, go long periods without eating and do not seek out food. The child will be highly anxious around food and unable to join in mealtimes. They will typically only eat five to 10 foods, will eat only one flavour of accepted food, and only one brand of the same food. Their eating will be specific to context, so that they may be reported to eat something at school which they will not eat at home.
Arfid is often associated with autism, and some older children previously diagnosed with anorexia have been moved to this newer diagnosis.
Children with Arfid can fail to gain weight and grow if they are not allowed to eat just foods they prefer.
Why is my child a fussy eater?
1. The disgust response
Children go through a developmental stage at around 20 months, known as the neophobic (meaning disgust) response, when they will reject foods that they have previously happily eaten. They will refuse new foods on sight without tasting it, or foods that have a mark on it, or the same food in a different presentation. This is thought to be for evolutionary reasons, as a means to prevent poisoning from unfamiliar food.
In the neophobic stage, toddlers can’t make generalisations about food category – they attend to local detail rather than global detail, therefore a broken biscuit is no longer a biscuit.
It gradually declines with age, so that by the age of three only 29% of children will refuse a novel food, and by five only 1% of children will still have this response.
Children with Arfid do not move out of the neophobic stage.
Children with autism also struggle to move beyond this stage because they are not good at categorisation, for example understanding that many things are vegetables although each one is a different shape, colour and texture; and that the same fruit can have different patterns of markings or colour.
If the food changes in appearance, the child’s response will be that this food is no longer safe. ‘Where you get a further narrowing down from foods previously eaten this is usually because there’s been a change – they’ve opened a packet of crisps and found one with brown bit on, or the manufacturer has changed the wrapper,’ says Dr Gillian Harris of the Birmingham Food Refusal Service.
2. Late introduction of solids
Chewing skills develop most markedly between 6 and 10 months, but only if the child experiences food in the mouth at this stage which needs chewing. They need to learn the side to side tongue movement, and to desensitise the sides of the mouth. After this age they are more orally defensive to texture. ‘Among children where lumpy solid foods were not introduced until after 10 months, half still had feeding difficulties at seven,’ says Harris.
3. Sensory hypersensitivity
Food fussiness is an inherited trait, says Harris, because it is closely linked to sensory hypersensitivity. This means that a child may be unwilling to try new foods owing to its taste, smell or touch. These children might typically reject meat, fish, fruit and vegetables because they all have a stringy or slimy texture.
How to manage fussy eating
1. Setting goals
Start by being clear about what you most need to achieve – is it to increase the amount of food eaten (because the child is underweight), or is it to increase the range of foods accepted by the child?
‘You can’t do the two things together,’ says Harris. ‘If the target is to increase their food intake, build the amount they eat from their range of preferred foods. Parents resist this because think it’s not healthy, but any increase is good. Growth is more important than dietary range, and a child will grow well on a limited diet.’
Stage two is to increase the range of foods. You can do this by category generalisation, ie getting them to eat one which is similar. For example, if they eat mashed potato, make a baked potato look like mashed potato, or give them a biscuit which closely resembles the one they eat, or a different flavour of crisps. ‘Foods closer to the ones they eat will have less disgust factor,’ says Harris.
2. Understanding reactions
‘Think about a food that you don’t like, and ask yourself, would sitting down in front of a plate of that food until I ate it work for me?’ says Harris. ‘Always think about what you can’t eat when working with a neophobic child.’
The same applies when children can, seemingly irrationally, eat two foods but not together. ‘We retain disgust and contamination fears – would you eat custard and fish fingers together?’ Harris says. ‘If they will eat cheese and bread, but not a cheese sandwich, just let them eat them separately.’
It is also important to remember that appetite is affected by stress, and there are known key times, such as going into a new class in September, and any change at school or home, which can lead to appetite reducing or children restricting themselves to the same foods.
3. No hiding places
Parents are often advised by the well-meaning to hide healthy foods in those children will eat, but this will make the problem worse, says Harris.
‘Hiding and disguising food doesn’t work – if you put it in a sandwich, then they won’t accept a sandwich again. They will find the hidden food and reject the whole meal.
‘Some children will reject a liked food that has been touched by a disliked food – that is the disgust and contamination response in a sensory hypersensitive child.’
4. Reduce the pressure to eat
As a parent’s anxiety goes up, it increases food refusal.
The more you fuss, bribe, coerce, it increases the problem,’ Harris advises.
‘Never give them more than they want – don’t say “Finish what is on your plate”, instead say “Eat as much as you like then I will take it away”.
Letting children watch videos or look at an iPad can be helpful for children with autism and Arfid - by reducing the anxiety they have around eating, then they will eat more. But Harris says these types of distractions don’t make much difference for those with sensory hypersensitivity.
Strategies which work to get children to eat more
- Exposure and modelling are good tactics – so that the child sees the food, smells it, and sees someone else eating it.
- Try new foods away from mealtimes, and in a novel setting. Children are more likely to try foods in a new context (eg at school) and away from home. (This works particularly with autistic children because they are context-specific, but not so with high functioning autism because they can generalise across context). You can set up a new context at home by saying ‘Come into [another room], we’re going to try …’
- Reduce the threat by telling the child they are allowed to spit out the food if they don’t like it.
- Let the child choose the foods that they will taste.
- New food should be given on a separate plate away from accepted food, away from mealtimes, and in a very small portion (one square centimetre). According to Harris it may take up to 10 tastes before the food is accepted.
- Do it away from siblings, so that no-one is commenting.
- Taste trials are not usually effective until after age of eight, Harris says. School trips in years 5/6 can be a great motivator, as they want to be able to eat the things everybody else is.
- Combine food exploration with relaxation. Children who refuse food will be anxious, so train them to relax.
- Give them attention for eating – in some cases. ‘For a young child, attention is the most rewarding thing. But if they are an Arfid child, they don’t like people paying attention when they eat and it won’t work. And face to face attention might not work with autistic children, says Harris.
Strategies to avoid when children refuse food
- Force feeding, sitting them in front of new foods until they eat them, or leaving them to go hungry only increases anxiety and does not work.
- Do not reward eating ‘good’ food – that way you down-value vegetables and uprate pudding, says Harris.
- Preventing a child with Arfid from eating favoured foods. You will need school to get on board with this as Harris says otherwise the child will not eat at school, but will come home and eat their full load of calories for the day. ‘It looks like binge eating, but it isn’t. It is better they are allowed to eat the foods they want throughout the day rather than getting to the binge scenario.’
Dr Gillian Harris was speaking at a seminar on eating challenges run by The National Autistic Society (NAS). Contact the NAS for details of upcoming seminars.