There are many different reasons why infants, toddlers, children and teenagers do not have typical eating behaviours. Picky eaters commonly grow out of their fussiness, whereas children with conditions such as avoidant restrictive food intake disorder (ARFID) are likely to carry their disorder into adulthood. Here, Paediatric and Adult Community Dietitian, Maiya Barha, RD, explains.

The prevalence of official diagnoses of ARFID has increased in recent years, likley due to awareness of the condiiton. However, there are possibly other reasons for fussy eating behaviours such as picky eating, neophobia and restrictive eating.

ARFID was added to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) in 2013 and to the ICD-11 (Feeding Disorder of Infancy and Early Childhood code) in 2022.(1-3) ARFID can only be diagnosed by a clinical psychologist and, unfortunately, this can be a long and arduous process.(4) The diagnostic criteria of ARFID in both the DSM-5 and ICD-11 specifically include restrictive eating behaviours.(1,2) Restrictive eating is seen to be avoidance of foods, or psychosocial distress due to specific sensitivities to sensory aspects of food.(1) This could mean restricting foods because of their taste, texture or temperature. However, there could be many other preferences.

PICKY EATING

Picky eating is the consumption of an inadequate variety or quantity of foods through the rejection of both familiar and unfamiliar foods. Prevalence in 2015 was reported as 5.6%-59%, which is a wide range; however, it demonstrates how common picky eating is.(5)

One of the main differences between restrictive eating and picky eating is that little ones can continue to be restrictive into adulthood, whereas those with picky eating will typically grow out of it.(5)

It is also very important to consider the age of the patient at diagnosis. With the increase in the number of children with ARFID (currently at 5% in the UK 6), it can be easy to forget other reasons why children might refuse foods, such as neophobia, which is the phase where children are likely to reject, or be reluctant to try, new and unfamiliar foods. (7) Neophobia is a common phase and it is thought that around 40% of children aged 2-7 years will go through this phase.(7)

NUTRITIONAL CONSIDERATIONS

It is common for little ones with restrictive eating behaviours to eat a non-diverse diet. Therefore, we need to monitor where appropriate their nutritional biochemistry as these children can be at risk of deficiencies.(8)

Some multivitamins that come in a sprinkle on format are useful as they are designed to not change the taste or texture of the foods that they are added to. However, these are unable to dissolve in fluids.

How dietitians can help

If a little one presents to a dietitian with restrictive eating behaviours (with or without a diagnosis of ARFID), there are some techniques to help increase the variety of foods they are currently eating.

Top tips include the following:

1 Ensuring that parents/guardians understand the child’s sensory profile.

• What are their child’s food preferences (as specific as texture, colour, taste, temperature, packaged/non-packaged and more)?
• What foods cause anxiety, disgust, gagging?

2 Creating a calm environment for mealtimes. It is key to reduce the little ones’ and parents'/guardians' anxiety around food and mealtimes. To do this parents/guardians can use distractions such as using a tablet during the meal or creating a routine in which the little one knows they are getting their safe foods during the mealtimes.

3 Introduce new foods outside mealtimes. Use different ways to introduce the child to new foods that don’t include the food itself during messy play such as:

 

• drawing the foods and colouring in;
• playing with objects that look like the foods;
• seeing the food on a video or TV.

 

When introducing a new food, it is important to consider whether the child is ready

 

• Do they show motivation?
• Have they been exposed already to the new food in a different way?
• Are they in a particularly anxious time in their lives?

 

4 Remember that small progress is good progress

• For example, interacting with foods in different ways such as having it far away, having it close, looking, touching, smelling, licking, ect.
• Try not to comment on negative interactions with food.

5 Food chaining. This is a proven technique to increase a child’s variety of foods by making small changes, for example, swapping a branded green crisps tube for a supermarket's own brand crisps tube with the branded green crisps inside (9). Therefore, you are only changing the outside packaging rather than the food contained within. For further information read here.

 

Restrictive eating is the eating behaviour that is sometimes associated with children who have a diagnosis of ARFID but are also seen in little ones with heightened anxiety. There are other reasons why a child’s eating behaviours are not typical including picky eating and neophobia.

 

CONCLUSION

Restrictive eating is the eating behaviour that is sometimes associated with children who have a diagnosis of ARFID, but it is also seen in little ones with heightened anxiety. There are other reasons why a child’s eating behaviours are not typical including picky eating and neophobia. A dietitian's role includes considering the nutritional profiles and providing parents with the tools to help widen their little one’s diet (variety and portion sizes) in order to maintian the health and well-being of the child.

Maiya Bahra, RD

Paediatric and Adult Community Dietitian,
Betsi Cadwaladr University Health Board

At present, Maiya works mostly within acute and community general
paediatrics as well as adult community dietetics. She is interested in
specialist acute paediatric dietetics.

Instagram: @dietitian_in_paediatrics
Website: https://mbahra247.wixsite.com/dietitianinpaeds

References

1. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders: DSM-5. 5th edn. Washington, D.C.: American Psychiatric Publishing.
2. ARFID Awareness UK. (2024). DIAGNOSING. [online] Available at: https://www.arfidawarenessuk.org/the-link-with-autism#:~:text=Only%20a%20medical%20professional. [Accessed 31 Mar. 2024].
3. Beat. (n.d.). Prevalence in the UK. [online] Available at: https://www.beateatingdisorders.org.uk/about-beat/policy-work/policy-and-best-practice-reports/prevalence-in-the-uk/.
4. Białek-Dratwa, A., Szczepańska, E., Szymańska, D., Grajek, M., Krupa-Kotara, K. and Kowalski, O. (2022). Neophobia—A Natural Developmental Stage or Feeding Difficulties for Children? Nutrients, 14(7), p.1521. doi:https://doi.org/10.3390/nu14071521.
5. Fraker, C. (2007). Food chaining : the proven 6-step plan to stop picky eating, solve feeding problems, and expand your child’s diet. Cambridge, Ma: Da Capo/Life Long.
6. Internation Classification of Diseases, Eleventh Revision (ICD-11), World Health Organization (WHO) 2019/ 2021 https://icd.who.int/browse11
7. Sanchez-Cerezo, J., Nagularak, L., Gledhill, J. and Nicholls, D. (2022). What do we know about the epidemiology of avoidant/ restrictive food intake disorder in children and adolescents? A systematic review of the literature. European Eating Disorders Review. Doi: https://doi.org/10.1002/erv.2964
8. Thomas, J.J., Lawson, E.A., Micali, N., Misra, M., Deckersbach, T. and Eddy, K.T. (2017). Avoidant/Restrictive Food Intake Disorder: a Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment. Current Psychiatry Reports, 19(8). doi:https://doi.org/10.1007/s11920-017-0795-5.
9. Whitelaw, M., Gilbertson, H., Lee, K.J. and Sawyer, S.M. (2014). Restrictive Eating Disorders Among Adolescent Inpatients. PEDIATRICS, 134(3), pp.e758–e764. doi:https://doi.org/10.1542/peds.2014-0070.