A restricted diet is occurs when a child accepts only a limited variety of foods and frequently refuses to try new ones. This behaviour is often referred to as fussy eating, faddy eating, or selective eating.

Restricted eating is very common in childhood and can be a significant concern for caregivers. (1) Caregivers often worry about the potential impact on their child's growth and nutritional intake. Concerns typically revolve around the variety and amount of food the child is willing to consume. (2)

Taylor and Emmett (2019) identify several underlying causes of picky eating in the paediatric population. Early feeding difficulties, such as delays in transitioning to solid foods, are significant contributors. Additionally, the late introduction of lumpy textures and parental pressure to eat exacerbate the issue.

Early manifestations of choosiness, particularly when combined with maternal anxiety regarding the child's eating patterns, further amplify picky eating behaviours. Conversely, offering a variety of fresh foods and parents partaking in the same meals as their children are protective measures that can mitigate these behaviours.

Several additional factors also contribute to the development of restrictive eating habits in children. After the age of one, children's growth slows down, which can lead to a smaller appetite and less interest in food. (3) As children grow older, they seek more independence, which can manifest in various ways, including food choices. Refusing certain foods can be a way for them to exert control. (4)

The fear response to new foods typically begins around the age of one to two and coincides with increased mobility. Neophobia is thought to have evolved to protect children from consuming potentially dangerous or poisonous substances5. Children with ADHD or Autism Spectrum Disorder (ASD) may exhibit strong sensory preferences, a need for routine, and differences in appetite and interoception (the sense of the internal state of the body). (5, 6)

By understanding these factors, healthcare professionals can better support caregivers in managing their child's eating habits. While restrictive eating can be a normal part of development, for some children, these habits persist into later childhood. Understanding the underlying reasons can help caregivers and healthcare professionals address these behaviours effectively.

Restrictive eating, like with most things is on a spectrum. First line advice should start with the basics of mealtime management.

1. Establish a consistent routine around meal and snack times. Avoid constant snacking and drinking between meals. Limiting drinks and snacks for one hour before main meals can help children feel hungry.

2. Eat together as a family. Children learn best by watching others eat and enjoy food.

3. Try to eat in a calm and relaxed area. Avoid having the TV on if possible.

4. Stay calm at mealtimes and avoid nagging, arguing, or fighting over food. If they don’t eat, take the plate away without making a fuss.

5. Keep mealtimes to around 30 minutes. Prolonged mealtimes are not helpful.

6. Use positive language around food, such as saying, “You don’t like this yet,” to encourage a more open attitude towards trying new foods.

Make it fun

Create fun shapes or faces with the food on their plate. This can make the food more appealing and less intimidating.

Pair with “safe foods”

Serve new foods alongside foods you know your child already likes. This can make the new food seem less daunting.

Repeated exposure.

It can take multiple exposures to a new food before a child accepts it. Keep offering the food without pressure. Exposure also includes reading books about food, playing with food models and involving children in cooking and shopping.

Messy play.

Encourage messy play with food. This can include:

• Pushing toys around in dry foods such as rice, pasta, or cereal.

• Finger painting with different sauces, ice cream, sweet sauces, cheese spread, and mayonnaise on a wipeable mat or mirror.

• Playing in jelly, mousse, or angel delight and then coating hands in hundreds and thousands or chocolate sprinkles.

Positive Reinforcement

Praise your child for trying new foods, even if they don't like them at first. Positive reinforcement can encourage them to keep trying.

Food chaining

Food chaining encourages your child to try new foods that are similar to the foods they already eat. It involves making small changes to your child’s safe foods so that over time, new foods are accepted. It is important that your child is aware of the food chaining process and agrees with it. Food chaining needs to be done slowly because trying new foods can be scary. Start by thinking about the types of foods your child will eat – are they all beige-coloured? Are they all crunchy? Are they a similar shape? Do they prefer colder foods?

Caregivers' expectations of improving picky eating need to be managed realistically, as improvements will take time, a lot of repetition and patience. It is important to acknowledge that progress may be slow and incremental, and caregivers should be encouraged to celebrate small victories along the way. Consistency in mealtime routines and positive reinforcement are key strategies, but it's essential to recognise that each child's journey will be unique.

Considerations need to be made for socio-economic status, as families with limited resources may face additional challenges in providing a diverse range of foods. Access to fresh, healthy foods can be more difficult for those in lower socio-economic brackets, and this must be considered when offering advice and support.

Family preferences and cultural practices also play a significant role in children's eating habits. It's important to respect and incorporate these preferences when suggesting strategies to encourage diverse eating. Family meals should be enjoyable and inclusive, reflecting the family's cultural and dietary practices while gradually introducing new foods.

The level of cooking ability among caregivers is another crucial factor. Some families may have limited experience or confidence in preparing a variety of meals. Providing simple, easy-to-follow recipes and cooking tips can help caregivers feel more equipped to introduce new foods. Offering cooking classes or resources that focus on quick, healthy and affordable meals can also be valuable.