Case vignette 1

The parents of a 5-year-old boy are anxious that their child has a very restricted diet. On a typical day, he eats half a Weetabix with milk for breakfast, one round of peanut butter sandwiches for lunch with a chocolate biscuit and chicken nuggets and chips for dinner, sometimes with some tinned sweetcorn. For snacks, he likes a particular brand of crisps but will sometimes eat bananas or grapes. He drinks water and orange juice. He will not allow different foods to touch on his plate, and if there is a disliked food on the plate, he will not eat anything. He shows a limited interest in food and often needs encouragement and prompting to eat, which means mealtimes are prolonged and stressful. The child is growing along the ninth centile. The restricted diet is not impacting on his activities, education or social development. Is this child’s eating problematic? What would you advise the parents?

Case vignette 2

A 7-year-old girl with coeliac disease has developed significant anxiety about trying new foods due to fear of eating anything ‘unsafe’. She does not want to go to birthday parties or play dates at friends’ houses. She will only eat a specific combination of four prepackaged foods in her packed lunch at school and becomes very distressed if her parents try to include anything new. What support is likely to be helpful for this child?

What is selective eating?

There are many definitions of selective eating, also known as fussy, picky, faddy or choosy eating. A recent systematic review proposes ‘the rejection of a large proportion of familiar (as well as novel) foods, resulting in a habitual diet characterised by the consumption of a particularly low variety of foods’.1 Selectivity can be caused by a number of factors, including food neophobia—rejection of novel foods due to anxiety. There is a broad spectrum of severity in terms of how restricted a child’s diet has become and whether it remains balanced. Parents vary significantly in their perception of what level of selective eating is typical and what concerns them. Many parents will report their child to be a selective eater, but very few of these children will meet criteria for a diagnosis of any form of disordered eating.

The new diagnostic classification ‘avoidant/restrictive food intake disorder’ (ARFID)2 is defined as an eating or feeding disturbance resulting in persistent failure to meet appropriate nutritional or energy needs (and not caused by another disorder such as anorexia nervosa). This would include significant weight loss, faltering growth, major nutritional deficiency or dependence on enteral feeding and nutritional supplements.

How common is selective eating?

Food neophobia increases in prevalence from the age of weaning onto solids to a peak between 2 and 6 years of age.1 There is a large range in estimates of prevalence of selective eating, due to different definitions and study methods. Most studies estimate the prevalence to be between 10% and 30% of preschool and primary age children.3 A relevant example is the Avon Longitudinal Study of Parents and Children (ALSPAC), a cohort of 14 000 births in the UK in 1991–1992. Between the ages of 2 and 5 years, the prevalence of being ‘very choosy as far as food was concerned’ was 10%–15%, with a peak at age 3 years.3 Notably, only 26% of children over the 3-year period were never reported to be choosy, emphasising that selective eating is a typical part of childhood behaviour, with a fluctuant course.

Why does selective eating develop?

There are many different causes of selective eating. There is an evolutionary theory that caution in ingesting novel substances, particularly those with bitter taste, is beneficial to avoid poisoning in a young, mobile child exploring their environment.1 For some children, selective eating is a learnt aversion due to undesirable experiences such as choking, vomiting, reflux or burning. Sensory sensitivity can account for selective eating, and children with autistic spectrum disorder frequently present with selective eating for this reason. Children with food allergies or dietary restrictions, such as coeliac disease, can have significant anxiety over contamination danger. The development of selective eating can also be related to parent factors, such as mental health difficulties or the child–parent relationship; mothers of children with feeding problems have higher levels of depression and anxiety.4

Is selective eating problematic?

Children in the Western world generally eat a poor diet in comparison to official recommendations. For example, children in the UK eat too few fruit and vegetables, with high sugar, saturated fat and salt intake.5 Between 2009 and 2012, a third of UK children were overweight or obese.6 In the ALSPAC cohort, ‘normal eaters’ ate less than half the recommended fruit and vegetables, and ‘picky eaters’ ate less than half again.3 Some studies show that selective eaters have lower reported intake of iron, zinc, vitamin E and vitamin C than the general population, but there is no evidence of lower blood levels or an impact on health.1 7

Constipation is more frequent in selective eaters, with correspondingly lower fibre intake,7 but there is little agreement as to whether selective eating has any other short- or long-term impact on health. Long-lasting selective eating (eg, for longer than 2 years) may affect growth.7

Early childhood is an important time for establishing healthy eating patterns,8 and the WHO has made increasing fruit and vegetable intake a global public health priority.9 It is therefore clear that helping parents to increase children’s fruit and vegetable intake is a public health responsibility of all health professionals involved with young children.

For some children, selective eating can become a chronic difficulty and impact on health, socialisation and family relationships. Selective eating can also make dietary management more difficult in chronic diseases, such as type 1 diabetes or cystic fibrosis.10 A presentation of selective eating may also mask an underlying or emerging eating disorder in a school age child.

Parental experiences of feeding

Parents often feel under pressure and fear judgement about feeding from the time their child is born. Parents can feel like they are viewed as good or bad parents based on how they feed their child (eg, breastmilk or formula) and feel guilt and failure over early feeding decisions, even when they have not felt in control of these decisions.11 Parents receive messages from birth that easy feeding is associated with having a ‘good’ baby, and that more intake and more growth are desirable.

At weaning age, it is common for babies to push food out of their mouths and to have an expression of distaste when eating novel foods—this is a normal immaturity of oromotor skills. Parents may misinterpret this as disliking a particular food and, on average, will stop offering after five ‘rejections’.4 However, research shows that up to 15 exposures to a new food may be necessary for familiarity and trust, before even tasting is achieved12 13 (see box 1). A cycle of tension may build up when parents are anxious about their child’s intake, which makes meal times more negative and reinforces the child’s behaviour.

Healthy eating messages for parents are fairly prevalent, for example, eating a variety of fruit and vegetables and keeping the diet low in sugar and salt. However, this can be very challenging for parents in practice, and frequently, parents will prioritise the short-term goal of consumption (ensuring their child eats) over the longer term goal of a healthy diet.14

History, examination and investigation

The main areas to cover during assessment are the parents’ concerns, their expectations, what the child is eating, the strategies parents have tried and any physical or psychological factors.

Find out what the child is eating on a day-to-day basis, with particular emphasis on the major food groups (is there at least one source of carbohydrate, protein, fat, fruit and vegetable?). Assess constipation and dietary fibre sources. Ask about medical history, looking for conditions that may impact on eating, such as food allergy, prematurity and severe reflux.

Explore how the parents approach meals and any behavioural strategies they use to encourage their child’s intake. Find out the impact of the selective eating on their lives—for example, the effect on the child and family’s social life and relationships and the duration and experience of mealtimes. Explore whether the child eats better in other contexts such as nursery. Ask about trigger events such as choking.

Explore briefly the parents’ mental health, emotional resources and attitude toward food (previous or current eating disorder will be relevant). Suggest further assessment from their general practitioner (GP) if needed.

Consider the possibility of childhood-onset anorexia nervosa in an older child and look at the child’s perception of food and body image. Explore whether they are purposely restricting certain food groups or amounts and whether there is any bingeing or purging. If you suspect childhood-onset anorexia nervosa, the Junior MARSIPAN framework20 gives guidance on risk stratification and referral urgency.

On examination, look for causes of physical discomfort during eating, particularly mouth and throat pathology (including teething). Perform a general examination for underlying systemic disease. Measure the child’s height and weight, plot them on appropriate growth charts and look at their growth trends. Calculate mid parental height if the child is short.

Consider testing for iron deficiency anaemia if the diet is low in iron sources, as this is relatively common in children (5% of children between 18 months and 3 years have iron deficiency anaemia).5

How should I manage selective eating?

After ensuring that the parents have been able to fully explain their concerns, reassurance on the normal pattern of selective eating will be helpful. Specific advice on evidence-based practical and behavioural strategies to increase dietary variety is outlined in box 1. This can be summarised as presenting a balanced diet in a positive way, with non-food rewards for tasting new foods up to 15 times. If children experience anxiety about trying new foods, they may need to increase their familiarity with the food first and gradually build up to tasting it, for example, starting with being rewarded for having food present on the table or touching it (see table 1). Boundaries should be clear—no alternative meals or calorie-dense drinks when children refuse the meal provided. The small portion sizes that children need should be emphasised—as a rule of thumb a portion is the size of a child’s palm (see figure 1).

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Figure 1

Sample portion sizes for 1- to 4-year-olds (with permission from The Infant and Toddler Forum).

Parents will need reassurance that short-term refusal of meals is not harmful in a child of healthy weight and that it may take some time to see improvement. The aim is for the child to eat to their own appetite level from the major food groups, with occasional small portions of foods that are higher in sugar and salt. This change in parental strategy requires a large investment of time, energy and self-discipline—it is important to discuss support mechanisms and follow-up for the parents, for example, from a health visitor or GP. You can also direct parents to online resources to reinforce the central messages (see box 2) and local parenting courses. Group interventions providing education and social support for parents have shown positive effects on children’s eating patterns.4

In addition to management of selective eating, give specific advice on constipation if necessary, with medication if appropriate. Make parents aware of the UK recommendation for universal vitamin D supplements in children under 5, as well as vitamins A and C if the diet is poor (box 3). Explain to parents how to access free Healthy Start vitamins and vouchers for fruit and vegetables if they qualify (box 4). Recommending an over the counter multivitamin can help to allay parental anxiety.

When should I refer?

Primary referral is to a paediatric dietitian or psychologist, depending on available referral pathways locally. Some areas may have community paediatric or gastroenterology-led multidisciplinary services, whereas others may provide feeding groups at local children’s centres. Criteria for referral would be the following:

• Failure to meet appropriate nutritional or energy needs (diagnostic criteria for ARFID2 as described above);

• Children with medically limited diets such as food allergy;

• Coexisting chronic disease such as diabetes mellitus or cystic fibrosis (support may be available directly through the child’s specialist multidisciplinary team);

• Learning difficulties and autistic spectrum disorder;

• Significantly high levels of anxiety despite initial advice and follow-up.

Children who cough and gag on more difficult textures may require referral to a speech and language therapist for assessment of oral-motor dysfunction.

Management of clinical scenarios

• Vignette 1—Parents were given reassurance that their child was healthy and that he was eating a balanced diet, despite the selectiveness. They were advised to first try to reduce the stress at mealtimes, by focussing on them being enjoyable, rather than the amount and variety the child was eating. The reduction in the parents’ anxiety that came from the thorough assessment and confirmation that their child was healthy allowed them to be more positive about food and eating with their son. They then started to introduce new foods with a stepped approach (starting with acceptance of the food being present on a different plate on the table, moving through smelling, touching and licking the food, before taking small tastes). They rewarded him with stickers at each stage, working toward a particular pencil case that he really wanted. Over time, the child began to enjoy eating more, gradually increased his range of accepted foods and had some positive experiences of trying new foods. No onward referral was required.

• Vignette 2—The child is at risk for major nutritional gaps due to selective eating on top of a medically restricted diet. She was referred to a paediatric psychologist who completed an assessment of her difficulties and offered a course of behavioural therapy to work on the underlying anxiety, which included graded exposure to new foods. The involvement of a dietitian may also be helpful.