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Nutrition Requirements for young people – is it simply fussy eating?

Let me preface this by saying that I am absolutely NOT a specialist or expert in this area – it is just something I have done a lot of research into, it is a great area of interest of mine and I have undertaken a few lectures with an advanced specialist dietitian in eating disorders like ARFID – Avoidant and Restrictive Food Intake Disorder.

In order to make full nutrition recommendations the person in question must be considered as an individual, taking into consideration things such as their weight and height, growth charts and BMI and by looking at their medical history and diet history.

So what is ARFID? ARFID is characterised by avoidant or restricted behaviours around food across varying age ranges. For diagnosis it doesn’t matter if a child is of ‘normal’ height and weight. You may know ARFID as food refusal, sensory food aversion or food avoidance. It can present in a number of ways including lack of interest in eating at all, avoiding food for sensory reasons or concern about the consequences of eating food.

It can and often will result in a failure to meet appropriate nutritional needs, this can manifest physically, psychologically and psychosocially so is very important to get to the bottom of and may need clinical attention. Failure to grow and develop sufficiently may result, especially if a child is denied access to the things that they will eat in a bid to encourage them to eat more ‘normally’. It can also cause young people to find social situations extremely difficult as they are unable to join in at meals, parties and activities.

It MAY look like a child never seeming hungry, finishing after only eating a very small amount or they may be content enough to go long periods of time without eating. They may avoid foods that look different and be particularly sensitive to taste, texture or smell of foods. They may express concern around things like tummy pain that comes from eating or choking.

ARFID can commonly occur alongside anxiety, autism and ADHD which often appears more troublesome as medication used to treat these disorders often results in a decreased appetite – excellent!!

I’m sure you have tried bribery, hiding foods, trying to reward or threaten perhaps, trying to change the environment in which food is consumed and changing the people around at meal times – to no avail, right? These things CAN even result in the child eating less due to the increased feelings of anxiety around food and making it less and less ‘normal’.

Foods commonly eaten by those with ARFID (not limited to, of course) include ‘beige’ food, carbohydrates, smooth things without bits like yoghurts and custard, chocolate, things that ‘dissolve’ in the mouth like crisps, processed foods as they are visually often very similar and branded foods that also often look, taste and feel the same every time. They may eat one brand of turkey dinosaurs but not another if they look totally different; chips if they are thin French fries but not thicker chips, a whole biscuit but not a broken one, pasta but not spaghetti – sound familiar? It can also manifest to other areas of their lives, for example, it has been known that children required to take medication will refuse it if it comes in different packaging.

The trick is often to GO SLOW, changes take a long time but keeping a record and looking at how far you have come may just help longer term.

Additional pressure on a child to eat, as discussed above can be extremely unhelpful. Over encouraging or too much praise and things such as clapping when they eat something tends to encourage the entire opposite to what you’re after. Using guilt around ‘some children not having access to such yummy food’ also is unlikely to work. Threatening with things like early beds, missing out on social occasions and making them sit there until all hours eating up and force feeding, again, unlikely to be effective. Children with ARFID are so hypersensitive around food that hiding it or trying to disguise it is also unlikely to work. Even putting new foods alongside ones that they already eat can be slightly damaging in that it MAY cause them to then reject the food that they would ordinarily eat. DO NOT worry if these are things that you have tried, most parents have, it’s normal.

While these things can work with most children if they are refusing to eat something in particular, in those with ARFID it can potentially be even more damaging by increasing anxiety further.

By the same token, as you probably know, leaving children with ARFID to go hungry which may even have been advised by some, saying ‘they’ll eat eventually when they get hungry enough’ is rarely successful – they often don’t even recognise their hunger, they are totally disinterested in food and this can risk weight loss and dehydration. The child doesn’t understand their needs!

Another thing that is often a misconception is that eating around others eating the foods you would like them to try may help – as in, if they eat around children at school consuming the things you would like them to, they may be tempted to do the same. Again, often NOT the case leading to heightened anxiety and refusal of even more due to the heightened sensory things going on around them at these times. In fact, minimising sensory disturbance may prove to be effective providing things like ear defenders at meal times, having cups with lids, split plates like in the school canteen so food isn’t touching other food and sitting away from others.

It may be tempting to try and try and try to get your child to eat healthily as they are missing so many of the nutrients that they need but know that first and foremost before you think about a healthy and balanced diet, they simply need enough energy, just allow them to meet their energy requirements in whichever way you can. If you need to increase the amount of food eaten before the range of foods eaten, know that is okay. Health for them may actually be allowing them to eat chips or chocolate everyday – not perfect, but better for them than nothing!

Talk to the child about what they find horrible – is there a theme here, things with strong smells? Lumpy things? Slimy things? Have a think then about what they may in fact find acceptable to try away from those themes.

Perhaps, if you haven’t already, try not overreacting when they show interest in something new and expose them to new things when you, as parents, aren’t around (sorry but children often find this more pressure!).

Professionals talk about a concept known as ‘graded exposure’ whereby exposure to foods happens in steps:

1. Looking at pictures of the food online

2. Having it on the table at meal times

3. Having it nearer their plate on the table at meal times

4. Having it on their plate at meal times (note that there has been NO mention of encouragement, eating the food or paying attention to it at all yet)

5. Playing with the food or handling it

6. Touching the food nearer to their face after they have touched it with their hands

7. Putting it in their mouth but allowing them to spit it out

8. Eventually they may feel ready to swallow tiny amounts

It is SUPER important that you look for good, professional help in this area, cognitive behaviour therapy or medication may often be recommended if necessary. It is increasingly important that you see someone if the child has less than around 20 foods that are acceptable to them, if they aren’t gaining weight at the normalised rate, if puberty is becoming delayed or they are experiencing such high distress that it is interfering with them socially.

We don’t just talk about young children in this area although that is where it is most common but it can manifest in teenage years too although often it is when children ‘outgrow’ their ARFID due to the pain of not being able to move on becoming too much, they find motivation to change.

It is important not to worry though – some fussy eating is a normal part of the development of children. In fact, it isn’t necessarily too much of a problem, as toddlers tend to regulate their appetite over a month rather than day-to-day as adults would, however, the best way in which to combat this is often thought to be offering a variety of tastes and textures during weaning. Eating with others over time often improves these children but it can take up to 30 offerings of a particular food before they accept it – don’t panic too soon! They will often eat less if they are under the weather, tired or distracted but will generally self-regulate what they need over time – don’t overestimate what they need and equally try not to be more attentive to them refusing food than you are when they are eating well. Be aware though if their appetite is poor that too much fluid can suppress that hungry tummy.

The ways in which to combat fussy eating are often the total opposite to those with ARFID although we should still not force past your child’s typical ‘no’ signals. Encouraging them to feed themselves is often effective but again, do not try to force feed, hide food or bribe or sit for hours upon end trying to encourage them to eat. Limiting distractions like TV will be helpful, smaller portions to begin then offering more with some praise if they finish is worth trying and toddlers eating with others as they love to copy is a good idea with fussy eaters in contrast to ARFID children.

Important supplements we would likely recommend for all children under the age of 5 at least are vitamin A & D, particularly those that aren’t great eaters, those living in the UK and particularly those of Asian, African and Middle Eastern origin.

I hope in some way this was helpful for you, please just let me emphasise that if you are in doubt you must see a medical professional. Anything I can help with though or any questions, fire away!

Peace and Love, A x

Recommended books if you would like to read further:

ARFID – a guide for parent and carers by Rachel Bryant-Waugh

From Timid to Tiger – a treatment manual for parenting the anxious child

Food refusal and avoidant eating in children by Gillian Harris and Elizabeth Shea

Food Chaining – The Kid Tested Solution For Stress-Free Mealtimes

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