Fussy eaters: When should you worry?

It’s a common experience for parents to have children reject new or different foods at mealtimes. But when does natural wariness veer into problem picky eating? Nutritionist Jennifer Bowden investigates.

Many parents worry about their child’s eating habits, and with good reason — our eating habits in childhood have a big influence on what and how we eat as adults. The child who refuses to eat vegetables and fruit may well become the adult who lives on pasta, pizza and bread.

Two factors can contribute to the rejection or acceptance of different foods: food neophobia and fussy or picky eating. Food neophobia is the fear of eating new or unfamiliar foods, whereas fussy or picky eating is when people eat a limited variety of foods because of refusal to eat many foods, whether familiar or unfamiliar.

What is ‘normal’?

Food neophobia is a normal behaviour that may protect us from harmful foods. Young children become more neophobic around the time they begin to walk — this natural fear protects the child as they explore their environment.

Neophobia typically peaks at around two years of age and mostly disappears by around four to six years of age, though it can reappear in older age.

During the preschool years almost all children show neophobic behaviour towards vegetables and fruit. Some children, however, will be worse than others, with highly neophobic preschoolers typically eating 35 per cent fewer vegetables and fruit than low neophobic children. Around two-thirds of this variation is genetic.

Thankfully, most children outgrow their dislike for bitter flavours and learn to enjoy vegetables and other healthy foods. Parents can help this process by encouraging healthy eating behaviours within the household (see Parental behaviour – how it impacts, below).

Picky eaters

Some children, however, don’t outgrow the neophobic phase and instead become extremely fussy or picky eaters who seriously restrict their diet, explains Dr Cath Conlon, co-founder of Massey University’s ACTIVE (Advancing Children Therapeutically in Variety Eating) Programme which specialises in treating children who are picky eaters.

Picky eaters reject a wide range of familiar and unfamiliar foods. They typically eat a very limited number of foods, often limit their vegetable intake and sometimes other food groups, have strong food likes and dislikes, may require special preparation of their foods and are unwilling to try new foods.

Picky eating can worsen to the point where all foods with a particular texture are refused.

“We’ve had children in the clinic that literally eat five foods,” says Dr Conlon.

“What eventually happens with those foods is because they’re over-consumed, they’ll eventually drop off. And the child that originally ate five foods will go down to four foods.”

Unlike food neophobia, children don’t automatically outgrow picky eating, so picky eating children often become picky eating adults.

What causes picky eating?

Genes play a role in picky eating, but parenting style and behaviours, pressure to eat and social influences are also important. Picky eaters can also have underlying medical, developmental and/or behavioural issues that make eating more challenging. For example, picky eaters are more likely to be sensitive to bitter tastes. They’re also more likely to have a problem with sensory sensitivity and struggle with varying food textures.

When is picky eating a problem?

“Really, it’s a problem when you think it’s a problem,” says Dr Conlon.

Picky eating often causes arguments within families and parental concerns about the well-being of picky eating children. Concerns are well founded, because picky eaters don’t compensate for their lower vegetable and fruit intake, as do food neophobics, so they often weigh less in early childhood and eat fewer foods containing vitamin C, E, folate and fibre. This can lead to cell damage, lower immunity and digestive problems such as abdominal pains and constipation — which then increases picky eating even further.

“And it’s not just about nutrition, it’s also about the social effects,” says Dr Conlon.

Children and adults who are picky eaters often aren’t able to share in social events that revolve around food, such as birthday parties and dining out with friends.

Extreme picky eating

Avoidant/Restrictive Food Intake Disorder (ARFID) is a new diagnostic category used to describe individuals who have an eating problem that means they don’t consume enough kilojoules or nutrients, leading to things such as: significant weight-loss or failure to achieve expected weight gain or growth in children, significant nutritional deficiency, dependence on tube feeding or oral supplements, or marked interference with psychosocial functioning.

How do we overcome picky eating?

For parents, it’s important to focus on creating healthy eating habits in childhood (see Parental behaviour – how it impacts, below). This requires patience and commitment as picky eaters may need more exposure to a new food than a ‘normal’ food neophobic child, for example.

A positive food environment is also crucial, as negative pressure or arguments about food can worsen picky eating. Allow the picky eating child to choose how much food they will eat. Create enjoyable food experiences — involve picky eaters in food shopping, vegetable gardening and cooking to increase their eating enjoyment.

What to do if you’re worried

If you’re concerned about a picky eater, keep a food diary for three days to get a better overall picture of their diet — it may ease your concerns. However, if picky eating is compromising your child’s health or growth then consult your doctor.

Knowledge about picky eating among the medical community is in its infancy. However, some District Health Boards run publicly-funded programmes, says Dr Conlon. So it’s worthwhile contacting a local health professional to ask about multi-disciplinary assistance for picky eaters.

Dr Conlon’s ACTIVEating Programme involves a team of experts such as a clinical psychologist, speech and language therapist, occupational therapist and dietitian.

“So if it’s a sensory aversion to a food, if it’s a textural thing, you might need help from an occupational therapist and a clinical psychologist to change the behaviour,” says Dr Conlon.

If the problem is serious, an occupational therapist can assess whether the picky eater has a sensory sensitivity problem. Treatment for sensory sensitivity may help with picky eating issues.

But often, picky eating is due to a range of issues, explains Dr Conlon, so one approach won’t fix the problem. Instead, support from a multi-disciplinary team is needed to address a range of problems behind the picky eating.

The 12-week ACTIVEating programme is parent-led, with assistance from health professionals. Either group therapy or individualised sessions are used because while some children are encouraged to eat by watching their peers try new foods, other children find the group setting distracting and make better progress individually. Parents also complete an educational programme to create behavioural change in the home.

The programme involves sensory preparation exercises for the children. And a set routine is created before mealtimes, such as sand or water play, to calm the children. Parents watch their children eating their meals with a therapist through a two-way mirror, explains Dr Conlon. Week by week the children are encouraged to touch new foods, smell them, lick them and eventually taste them. Food graduation is also used, so a child’s favourite brand of chicken nugget might slowly be changed over several weeks, in a series of very small food steps, into a chicken pie, in the process, moving the child from a food they eat to a more composite meal, explains Dr Conlon.

“We don’t proclaim to solve every single problem,” says Dr Conlon. Rather, they think of themselves as the tip of the iceberg, providing the knowledge needed for families and picky eaters to slowly create a healthier diet.

Healthy eating habits in childhood create a foundation for life. But no matter the age, now is the best time to help picky eaters eat a healthier, more varied diet.

Parental behaviour – how it impacts

Parents can help children overcome neophobia and eat a greater variety of healthy foods.

Be a good role model. Eat plenty of veges and fruit, drink water and milk, and try new foods. A mother’s acceptance of new foods has a strong influence on their child’s food intake.

Create a comfortable, positive environment around mealtimes. Stressful mealtimes don’t encourage children to try new foods.

Avoid negative feeding habits. Pressuring children to eat and restricting foods leads children to eat less of the foods you want and to have a preference for forbidden foods.

Don’t let your food preferences limit the variety of food offered to your family. Provide a variety of healthy foods in the home rather than sugar, fat or salt-laden processed foods.

Parents choose what foods are served, when, and where. Children decide how much or little they eat. Provide age-appropriate portion sizes then respect your child’s appetite.

Prepare the same meals for the whole family — that includes toddlers. Just adjust the texture for younger eaters. Preschoolers who eat the same food at mealtimes as parents eat more veges and fruit. Preparing separate meals may promote picky eating.

Create enjoyable food experiences. Ask your child to select veges, fruits and other foods at the store. Create a veges garden together, ask them to rinse veges for dinner or set the table.

Make food fun. Serve veges with tasty dipping sauces, cut foods into fun shapes, serve brightly coloured foods.

Share regular mealtimes with your child to model healthy eating and encourage social interaction. Children eat more when they eat with parents.

Don’t offer dessert as a reward. It sends the wrong message — that dessert is the best food.

Mix it up. Add chopped or puréed veges to casseroles, soups and sauces. Note: don’t try this with highly picky eaters as they are more likely to taste the hidden veges, refuse the dish and become even more nervous about mixed dishes.

Stick to a routine. Serve meals and snacks at around the same time every day, with at least one-and-a-half to two hours between snacks and main meals so they have a good appetite for main meals.

Limit juice and sweetened drinks. Offer water between meals and snacks, and juice or milk with or just after meals so they don’t dilute their appetite.

Be patient with new foods. Let your child touch and smell new food, place it in their mouth and take it out again. In fact, praise them for doing this!

Persist with new foods. Most children need 10 to 15 taste exposures, or daily tasting for a fortnight, to happily eat a new food, yet many parents mistakenly give up well before then. Highly neophobic children may need more than 15 exposures.

Minimise distractions. Turn off the TV and focus on eating.

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