PAEDIATRIC
HOW TO MANAGE FUSSY EATING IN TODDLERS Dr Gill Harris Child and Clinical psychologist and member of the ITF Gill is Honorary Senior Lecturer in Applied Developmental Psychology at the School of Psychology, University of Birmingham. She is also Consultant Paediatric Clinical Psychologist at Birmingham Food Refusal Service.
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Coping with a fussy eater is something most parents find really difficult. The parents themselves have different histories and experiences with food and will also have taken advice from many different sources all conflicting and most not evidence based. Added to this, one family’s experience with their child will not be the same as the next family. For every parent who has succeeded with ‘sitting their child in front of the food until it is eaten’, there will be another parent whose child is hiding the food behind the radiators or feeding it to the dog. Food fussiness is on a continuum; we are all different. Some children will only eat an extremely restricted range of foods, whereas other children will be described as fussy because they are not too keen on green vegetables, but will eat most other things. Most of the really food fussy behaviour that is seen in children is genetically determined.1 It doesn’t matter much what the parents did in the early stages of introducing complementary foods,2 these children will always be fussy. Indeed, some parents will have three children who eat well and one who picks their way through every meal. There are also innate differences in taste responsiveness.3 An example of this is bitter taste sensitivity. Some children (and adults) will always find bitter foods rather disgusting and are never going to like them however hard their parents try with those bitter tasting foods, such as green leafy vegetables. However, having said this, most toddlers do go through a stage when they are fussier than they were in early infancy: the neophobic stage.4 This starts at around the age of two years
and gradually improves by the age of five years or so. This is the stage at which toddlers will refuse new foods just because of the way they look. They will also refuse foods that they have eaten before, especially if these are foods that are ‘mixed’5 and so can change the way they look from serving to serving. But there are differences here too, some toddlers are much more neophobic and reluctant to try new foods than others. This difference is linked to sensory hypersensitivity, a reaction to the taste, smell and, most importantly, the texture of foods.6,7 So, some fussiness is due to the taste of the food, but most fussiness is due to the texture of the food, i.e. the feel of the food in the mouth.8,9 And toddlers can tell whether or not they are going to like a food by the way the food looks,10 so rejection is on sight. The thinking is that, “If it isn’t a safe food - a food that I know that I like - then I’m not going to put it into my mouth.” And the more worried the toddler gets about whether or not they are being given a ‘safe’ food, then the more anxious they get. The more anxious they get, then the more hypervigilant they get; they focus on small differences between new foods and foods they know to be ‘safe’. They will refuse a biscuit that is broken, toast that is the wrong colour, yoghurt that is the wrong flavour, etc.11 www.NHDmag.com July 2018 - Issue 136
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PAEDIATRIC DO
DON’T
Toddlers have to become familiar with a food before they might be willing to try it, so they need to:
Don’t do anything which increases the child’s anxiety and contamination fears around food. Don’t:
• See the food around the house and see other people eating it at shared mealtimes.16-18
• Prompt aggressively - this will make the child anxious and less likely to taste the food.29,30
• Smell: be around the kitchen when food is being prepared.19
• Coax and force - again, this will make the child worried about the food they are being made to eat.31
• Touch: just handle food away from mealtimes; grow it in the garden; pick it up in the shops; help to prepare food without pressure to eat; messy play and some food play; make pictures from food pieces.20,21
• Bribe - reward only works with fussy children when it is given for tasting small pieces of food away from mealtimes; never reward eating one food by giving another.32
• Talk about the food that they are looking at; know the name; look for it in the supermarket.22 • And then perhaps Taste small pieces of food, away from mealtimes, as part of a game, with small rewards for trying,23,24,25 but remembering that it takes more than one taste to get to like a new food.26,27 These strategies work best of course when they are combined.
All of this might have had an evolutionary benefit: a newly mobile toddler is not going to pick up and eat a food that is not an exact match to the food they know to be ‘safe’. Unfortunately, added to this normal response comes a further problem. Any food that is not a ‘safe’ food can evoke a disgust reaction: “It is so horrible I can’t have it on my plate.” This response can be seen in toddlers as young as 20 months.12 Of course, this means that any food which is disgusting will act as a contaminant.13 If you put it next to a ‘safe’ food; if you hide it in a sandwich; if you chop it up small and try to hide it; then - disaster!
• Hide and disguise foods - you run the risk with a fussy child of triggering the disgust and contamination response; you might lose the safe foods.12 • Put disliked foods in the plate next to liked foods again this might trigger the contamination response and nothing will be eaten at all13 • Withhold liked foods for long periods - this will not make the fussy child eat a new food, it might make them lose weight though!
Both the new, disgusting food and the liked food might well all be rejected. Much of this resolves with time, but when coping with this behaviour, parents need to know which strategies are helpful and which are not. HINTS AND TIPS
For all fussy children at all stages, the advice is the same, but the first piece of advice is always: “Relax and stay calm.” An anxious child is less likely to try anything new, or to feel any hunger.14,15
To find out more about supporting families with practical advice, visit and the range of ITF Fact sheets at www.infantandtoddlerforum.org/health-childcare-professionals/factsheets More information on the ITF For further details on fussy eating: www.infantandtoddlerforum.org/toddlers-to-preschool/fussy-eating/ how-to-manage-fussy-toddlers For information on face-to-face training, email: info@infantandtoddlerforum.org Follow the ITF at @InfTodForum or www.facebook.com/InfantandToddlerForum
IN ASSOCIATION WITH THE INFANT AND TODDLER FORUM The Infant & Toddler Forum (ITF) promotes best practice in healthy habits from pregnancy to preschool through reliable, clear, evidence-based advice and simple, practical resources aimed at practitioners, healthcare professionals, 30
www.NHDmag.com July 2018 - Issue 136