Most children go through a phase of picky eating. As children transition from a milk diet to solid food, they learn a great deal about eating. Children at this age typically have a natural preference for sweet and salty tastes, and a protective evolutionary dislike for things that taste sour and bitter (6). This “unlearned preference” for tastes is a likely factor contributing to the success of the human race.
The appetite of the typical toddler is erratic – they eat a lot, a little, or not at all, and often prefer foods that are more energy-dense than nutrient-rich, much to the panic and worry of parents. In the absence of illness or lethargy, typically, this is considered normal child development.
“Parents believe that their feeding practices can exert a major influence on children’s food preferences and on developing control of children’s food intake, although recent research indicates that the influence is not necessarily in the ways that parents intend. The pervasive messages directed at ways that nutrition can improve health and appearance have created an increasingly complex eating environment in which parents attempt to foster healthy eating behaviors in their children. For example, the messages of the dietary guidelines convey the importance of consuming certain types of foods and limiting the consumption of others. The means by which parents attempt to shape children’s eating toward nutritionally desirable dietary outcomes can have unintended consequences for children’s eating behavior.” ~Birch and Fisher, 1998
What If This Isn’t Typical ‘Picky Eating’?
Approximately 20% of all children are born with a high reactive temperament. These children are, by nature, more anxious that the average, at higher risk for developing anxiety related disorders (7), and are often extremely selective with food.
Some kids really do not know how to chew or manage with certain textures of food. Some kids have uncomfortable reactions to foods or to eating in general. Sometimes a professional is needed to treat medical conditions or to develop skills required for successful eating.
Some kids have small appetites, or would just rather play instead of eat. Other kids are exceptionally sensitive to the sensory characteristics of food. Young children lack the cognitive ability to refuse to eat for the sole purpose of irritating their parents. There is always a reason why children refuse food.
Avoidant Restrictive Food Intake Disorder (ARFID)(9) is food refusal due to highly selective intake, lack of interest in eating, or fear of the unpleasant effects of eating without concerns of body image or weight. The ‘disorder’ part of eating disorder means the behaviour around food impairs the ability to function adaptively in social situations (8). Currently, ARFID clinical criteria makes psychosocial impairment optional, which is very odd indeed, as the ability to manage more than a very limited dietary variety often has negative implications for social eating occasions.
In the published literature, there is no consensus on the definition or even an agreement on a name for what is considered ‘picky eating’. Although it is estimated that 25-50% of parents consider their child ‘a picky eater’, only 1-5% of children meet criteria for a feeding disorder. This difference between parental concern and clinical feeding definition contributes to the perception that parents are unreliable at recognizing problem eating behaviour. Recent literature suggests that parents are more reliable at identifying selective eating behaviour that may be consistent with a potential ARFID diagnosis.(10) This is likely due to the recent agreement in clinical criteria. As a parent, you may still find support difficult to find through your primary healthcare provider, as many are not yet familiar with the DSM-5 category of ARFID.(11) Additionally, the majority of children with ARFID are a normal weight, therefore doctors may not take the accompanying parental anxiety seriously.
Research on restrictive eating disorders in children estimate incidence at 2.6 – 3.01% per 100,000 person-years. In clinical settings, 19 – 25% of children under age 13 years meet criteria for ARFID (1-2). One study from Switzerland (3) determined ARFID was present in 3.2% of school age children (age 5-12 years) in the general population. The data, although limited, consistently shows ARFID to be 10 times more common than Type 2 diabetes mellitus (roi 0.27% in children under age 10y). The American Diabetes Association has described the latter as “an epidemic” (4-5).
What Can I Do?
After addressing any medical concerns (ie gastrointestinal, swallowing, oral motor, autoimmune disorders), focus on a feeding relationship built on trust. Anxiety is high on both sides of the table: children are often exceptionally suspicious of unfamiliar food, and parents are (understandably) frustrated and worried by the persistent food refusal, often without support from the healthcare community. The key is to create an eating environment where anxiety isn’t the center of attention.
A home feeding environment that heals the parent-child relationship and supports the child’s eating ability is essential. The older the child, the more healing there is to do around eating. Feeding struggles impact the entire family, not just the child, therefore it is both unrealistic and unfair to expect the child to shoulder the entire responsibility for successful eating. What you and your child need depends on many factors, and in some cases, it may be necessary to involve the expertise of a knowledgeable therapist.
This is our journey with ARFID. We are learning to love food, or at least, like it more than we used to.
Welcome to the table.
1. Leora Pinhas, MD, FRCPC; Anne Morris, MBBS, MPH, FRACP; Ross D. Crosby, PhD; Debra K. Katzman, MD, FRCPC Incidence and Age-Specific Presentation of Restrictive Eating Disorders in Children: Canadian Paediatric Surveillance Program Study Arch Pediatr Adolesc Med. 2011;165(10):895-899. doi:10.1001/archpediatrics.2011.145
2. Kurz S, van Dyck Z. Dremmel D. Munsch S. Hilbert A Early-onset restrictive eating disturbances in primary school boys and girls Eur Child Adolesc Psychiatry DOI 10.1007/s00787-014-0622-z
3. Nicholls, DE; Lynn, R; Viner, RM Childhood eating disorders: British national surveillance study Br J Psychiatry 2011;198(4):295–301 doi:10.1192/bjp.bp.110.081356
4. Kaufman, FR Type 2 diabetes mellitus in children and youth: a new epidemic J Pediatr Endocrinol Metab. 2002;15:(supp 2) 737-744
5. Vivian, EM Type 2 diabetes in children and adolescents: the next epidemic? Curr Med Res Opin. 2006;22(2):297-306
6. Birch LL, Fisher JO Development of eating behaviours among children and adolescents Pediatrics, 1998 Mar;101(3 pt 2):539-49
7. Medina, John J The Genetics of Temperament—An Update Cultural Psychiatry, Addiction, 2010, March 10, Psychiatric Times
8. Satter, E What is ARFID and What Does It Have To Do With Feeding Dynamics and Eating Competence? 2014 Feb; Family Meals Focus #89
9. Fisher, M; Rosen, D; Ornstein, R; Mammel, K; Katzman, D; Rome, E; Callahan, S; Walsh, B; Malizio, J; Kearney, S. Avoidant / Restrictive Food Intake Disorder: A Proposed Diagnosis in DSM-5 J Adolesc Health. 2014; 55: 49–52 doi:10.1016/j.jadohealth.2012.10.027
10. Zucker, N; Copeland, W; Franz, L; Carpenter, K; Keeling, L; Angold, A; Egger, H. Psychological and Psychosocial Impairment in Preschoolers With Selective Eating Pediatrics, 2015 (peds-2014) doi:10.1542/peds.2014-2386
11. Norris, M; Katzman, D Change Is Never Easy, but It Is Possible: Reflections on Avoidant/Restrictive Food Intake Disorder Two Years After Its Introduction in the DSM-5 J Adolesc Health. 2015; 57: 8-9 doi:10.1016/j.jadohealth.2015.04.021