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Selective or fussy eating is a widespread feature of early childhood but can pose plenty of problems for parents and practitioners alike. According to the eating disorders team at Great Ormond Street Children’s Hospital, eating a restricted range of foods is a common feature in young children, with up to 20 per cent of children under five displaying fussy behaviour and the problem persisting up to the age of eight in about a third of these. For some, the problem persists throughout childhood and even beyond.
Understandably, fussy eating habits in children create a feeling of anxiety in carers. Paediatric registrar Ilana Levene explains, ‘From an evolutionary perspective, we are deeply programmed to nurture our children, ensuring that they survive and thrive. What could be more important than providing food, the most basic survival need?
‘The short-term concern is the child isn’t getting enough energy, enough variety or enough vitamins and minerals. The long-term concern is the child will never have a varied diet and the carer should be doing something different now to impact that future development.’
GENETICS
Whether or not we like divisive foods such as beetroot, coriander or Marmite is generally attributed to genetic variation in our taste perception. But recent research has suggested that genes may also play a role in how fussy children are, with academics at University College London and the Norwegian University of Science and Technology finding that 46 per cent of cases of food pickiness may be down to genetic influences rather than simply a result of upbringing.
‘Fussy eating is to some extent genetic and is related to sensory responsiveness,’ explains Gillian Harris, consultant clinical psychologist at the University of Birmingham. ‘Some children are genetically determined to be sensory hypersensitive, and may undereat as a result.’
However, the researchers stressed that children’s behaviour can be changed. Natasha Chong Cole, postdoctoral research fellow at the Children’s Nutrition Research Center at Baylor College of Medicine in Texas, says this is a positive finding for parents and practitioners.
‘Parents and caregivers can gain some reassurance that children’s fussy eating isn’t just their fault; perhaps they are more sensitive to certain smells or tastes,’ she says. ‘With that being said, genetics isn’t destiny, and children can learn to like certain foods through repeated exposure and modelling.’ (See box.)
NEOPHOBIA
Similar approaches can also be used to help children experiencing neophobia, the reluctance to eat specifically new, unfamiliar foods, as opposed to foods they might already have tried and later decided they don’t like.
Children start to display neophobic responses at between 20 months and two years of age, and this can continue until age eight. The sensory properties of new foods are highly scrutinised.
Nutrition adviser Sofie Hope explains, ‘Food neophobia is based on a hard-wired evolutionary response. This is a throwback to when our ancestors would check that a food was safe.’
While children might take against any food, unfamiliar vegetables are often the first to be rejected. But rather than just an indication of fussiness, this can be attributed to natural neophobic responses, as generally green or bitter foods have represented potential toxicity to humans throughout history.
Dr Harris agrees there is a ‘clear evolutionary benefit’ to food neophobia. ‘Children like to see other people eat foods first and be sure they are fine. Once a child has been exposed to a variety of foods they can start to form their own categories. They realise a big orange probably tastes like a small orange, and a roll is likely to be another example of bread, and so on. This is part of a whole line of neophobic reactions, with children also not liking new faces or toys until they get used to them. Only when they are sure it is safe will they go forward.’
Dr Harris adds that a child’s genetic predisposition towards fussiness may also affect the level to which they experience neophobia. ‘Those who are sensory hypersensitive towards food will go through neophobia to a greater extent, when anything that doesn’t look right will be rejected, whether they are new foods or foods children have eaten before but somehow don’t seem quite right; if they have a mark on them or are a slightly different colour to usual, for example. Neophobia is easier for children who are not as genetically fussy.’
REDUCING FUSSY EATING
Dr Chong Cole has carried out research into whether fussy eating can be reduced by an early introduction to solid food, finding that early exposure to various tastes and textures may affect children’s willingness to eat later on. She warns, however, that introducing solid food too soon can be related to unhealthier diet patterns later in childhood, such as eating more foods that are higher in fat, sugar and salt.
‘Parents and nursery practitioners should be encouraged to delay solid food introduction until the child is six months of age,’ she says. ‘They should also offer a variety of different tastes and textures between the ages of six and 24 months.’
However, Dr Harris disagrees. ‘There is a big debate about whether and why children are becoming more fussy, and although it is controversial, I would say the earlier you introduce solids the better for sensory-sensitive children, even as early as between four and six months old. When they wait, it becomes impossible to get all the textures in quick enough, so then everything becomes delayed.
‘Of course people are busy and babies are often fed separately and rarely given food that has been cooked for them. But mothers often go back to work when babies are four months old, and the median age across Europe for introducing solid food is five months, so there is no reason we shouldn’t start earlier.’
FOOD PHOBIA
A fully fledged food phobia might occur in isolation or as part of a more general anxiety problem. Types of phobia vary, but can include a fear of vomiting, a fear that food is contaminated in some way, or a fear of choking or being unable to swallow. As a rule, however, food phobias are much more common in school-age children.
A new diagnosis, replacing what were previously known as ‘selective eating disorders’, is ‘avoidant/restrictive food intake disorder’ (ARFID). ARFID is an eating or feeding disturbance resulting in a persistent failure to meet appropriate nutritional or energy needs, but which is not caused by another disorder such as anorexia. Children with ARFID are likely to show significant weight loss or fail to achieve expected weight gains.
Dr Harris explains that children with ARFID ‘do not ever come out of the neophobic period, and are much more likely to be on the autistic spectrum’.
The prevalence of ARFID is still being studied, but American organisation the Eating Recovery Center estimates that it affects up to 5 per cent of children. However, Dr Levene warns against too much panic over fussy eating.
She says, ‘Very few children will have such selective eating that they are physically unwell, but parents or carers can get so worried that they set up unhealthy attitudes to food by forcing children to eat, or allowing the child to eat junk food out of desperation.
‘The long game is what is important – bringing up children who have a healthy attitude to food. This means that by the end of adolescence they can pay attention to their own appetite, enjoy healthy foods from all the main food groups, and have the knowledge and ability to limit their own consumption of unhealthy foods.’
TOP TIPS FOR DEALING WITH FUSSY EATERS
Repeated exposure
- Do not avoid giving foods.
- Research shows that it takes 15-20 exposures of a small amount of the same food before it will be accepted. Eating is a learning process, so give children the chance to learn to like a new taste.
- Be creative – if steamed carrots don’t appear to work, try them as raw sticks with a dip instead. Be artistic with how food is plated up – faces, shapes, etc. all help.
- Do not give up!
Educate
- Teach children about food groups and the importance of a balanced diet.
- Introduce children to food away from mealtimes and in the form of play such as making a pasta necklace or doing potato printing to help break down any fear surrounding certain foods.
- Grow vegetables with children, visit farmers markets or cook together.
- Educate yourself too by learning about the nutritional properties of ingredients. If children are avoiding meat, include more pulses to replace a lack of protein. If vegetables are the problem, many of the same vitamins and minerals can be found in fruit. Just don’t overdo it as fruit is high in sugar.
Role-modelling
- Make sure you are not seen or heard being fussy about food. Talk about food in a positive way and allow children to see you enjoying healthy food.
- Don’t have chocolates, crisps and fizzy drinks around. If these foods are not visible, children are less likely to ask for or crave them.
Avoid…
- overt food restriction, such as eating chocolates in front of children but not letting them have any
- unhelpful pressure at mealtimes. This is linked to reduced willingness to try new foods
- large portion sizes, as these encourage overeating which will numb a child’s natural ability to sense when they are full
- using food as a reward for good behaviour as this can cause emotional reliance on often unhealthy foods such as chocolate.
