NHD Issue 150: FUSSY EATING IN TODDLERS, IS IT JUST A PHASE?

PAEDIATRIC

FUSSY EATING IN TODDLERS: IS IT JUST A PHASE? Children go through lots of phases.

To parents some of these phases can feel like an eternity with much emotion and energy expended. Fussy eating is one such phase and dietitians and nutritionists can play a vital role in supporting parents and carers through this complex stage.

It is not enough to say your child will grow out of it. That fails to recognise the impact of the fussiness on the child, the parent and the wider family. It also fails to recognise the importance of good nutrition throughout childhood for the prevention of ill health in later life. Peak bone mass is reached by the early 20s,1 so, for the prevention of osteoporosis, optimal calcium and vitamin D intake is crucial in childhood. The evidence is strong that obesity in childhood increases the risk of obesity and its associated diseases in adulthood. And the impact is not just in the long term, in 2017-18 there were 12,783 tooth extractions in the 0-5s due to tooth decay.2 Most toddlers will go through a stage of fussy eating called neophobia (the fear of trying new foods); though the length and extent of this stage varies. Fussy eating is not limited to neophobia however. Many parents will report that their children will eat a food one day and then completely refuse it the next. It is helpful for parents to learn at the point of introducing solids that fussiness is a strong likelihood, so they can be prepared for it and reduce the likelihood if possible.

Taylor et al (2015)3 states, “Picky eating (also known as fussy, faddy, or choosy eating) is usually classified as part of a spectrum of feeding difficulties.

It is characterised by an unwillingness to eat familiar foods or to try new foods,

as well as strong food preferences. The consequences may include poor dietary variety during early childhood. This, in turn, can lead to concern about the nutrient composition of the diet and, thus, possible adverse health-related outcomes. There is no single widely accepted definition of picky eating and, therefore, there is little consensus on an appropriate assessment measure and a wide range of estimates of prevalence.”

Aliya Porter, RNutr (Public Health), Porter Nutrition (freelance) Aliya is a Registered Nutritionist with experience in the voluntary sector, NHS and private practice. She has a special interest in family nutrition.

Aliya runs Porter Nutrition, focusing on healthy eating as part of normal life: www. porternutrition. co.uk

CAUSES OF FUSSY EATING TO RULE OUT FIRST

Without a clear definition, how should we advise parents? Firstly, we need to rule out other causes of the fussiness and refer to the GP if there are any concerns.

These include but are not limited to: • infection – eg, if the child has a fever or a rash or a runny nose; • constipation – using the Bristol Stool chart, get the parents to tell you what their stool is like and the regularity; • reflux – sometimes the child will have had this problem before starting solids, so ensure a full history is taken, although most reflux in babies does not persist beyond one year; • symptoms in addition to the fussiness, including frequent vomiting, regurgitation of food and re-swallowing, persistent cough, pain in the throat; • other stomach pain – this covers a range of issues including coeliac disease;

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PAEDIATRIC • allergies and intolerance – if the parent has seen patterns in the food behavior, eg, rashes, coughing, sickness, it is helpful to rule out allergies; • autism – sometimes autistic children can have more sensitivities to food than other children. Autistic children need additional support with their fussy eating due, in part, to the heightened sensory awareness, including taste, touch and smell of foods.

Once such causes have been ruled out and dealt with, or are being dealt with, it is important to establish the severity of the fussiness. Some parents will report that their children are fussy, but when questioned further, it is apparent that the child is consuming adequate variety across the food groups, is gaining weight along their centile and is healthy, active and has good bowel movements. It is key not to dismiss parents in this position because it may be that the child’s food habits are causing strain on the family all the same.

Listen to them and encourage them to continue to be a role model for good nutrition, offer new foods and to allow their children to experiment.

If children are cutting out whole food groups and are not getting the range of nutrients needed and/or they are not gaining weight adequately, or have little energy, then giving support to parents is crucial.

WHAT CAN WE DO TO SUPPORT PARENTS?

Firstly listen. As with any nutritional counselling, build rapport with the family and gain a full understanding of the situation. It is helpful to ask the following questions: • Who does the child spend time with at mealtimes? Are there different caregivers at different times and do they have different strategies around food?

• Are any other family members, adults or children particularly fussy with their food?

• Which foods will the child eat and which won’t they eat? Do they eat different foods in different settings, eg, is grandma’s chicken acceptable but mum’s isn’t?

• Are there specific ways they like their food prepared/cooked/presented? (For example, shape of the veg, how soft it is, whether it’s touching something else on the plate) 16

• How long has the fussy behaviour been going on?

• What do mealtimes look like? Does the whole family sit at the table? Does the child sit at the table? What happens when they get down from the table?

• Which toys, TV characters, etc, does the child like? (This can help with motivation.)

It is unhelpful to play the blame game. There are all sorts of reasons why children choose not to eat the food they have in front of them. Sometimes the discussion can reveal family challenges which need to be handled sensitively; other times it is just the main care giver who needs support to feel empowered to make changes.

Strategies which can be used to help parents include the following: Make mealtimes fun Turn off the TV, phones and music and give the child attention, eg, asking what their day was like. Avoid a battle over eating. If they get down from the table, don’t get them back again, take the food away and wait until the next meal/ snack.

Give the child choice Even at a very young age we can give children some choice. Which shape pasta to have – penne or fusilli – or which vegetable to cook out of two options. This helps them feel involved and not passive.

Give them control Control over where they sit at the table, which plate, cup and cutlery to have, how the food goes on the plate, how the food is cut. It might seem counterintuitive to carers to do this because they may feel like the whole process has been the child dictating mealtimes, however this is about specific control: control over the things they can control and building independence in other ways, so it is not all about getting control over which food they actually eat.

Get them involved . . . . . . in growing food, shopping and food preparation. Even under one-year-olds can help with some things: bread dough is just like

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PAEDIATRIC Figure 1: Steps to trying food

playdough; they could use a spoon to spread the tomato sauce onto homemade pizza. With the growth in online food shopping, children have less involvement in food shopping. It can be helpful to write a list for the top-up shop with pictures and let the child help put things in the basket. They could even choose which fruit or veg to get in the supermarket. Older children could be challenged to make a rainbow with their veg choices.

Use different rewards Lots of rewards are food related. Help parents to find alternative rewards. Children can be rewarded for trying a food, but they shouldn’t be rewarded for eating all their food. In this stage, you can also help parents to use positive language for all foods, not just the yummy chocolate cake, but the yummy carrots too.

Other strategies to consider • Help parents to avoid getting their children to eat their main meal before they can have their pudding, otherwise the child will see the main course

as something to endure before the satisfaction of the pudding.

• Putting one piece of everything on their plate and letting them ask for more. For some children having food on different plates can be helpful. Parents need to know that the child doesn’t have to have eaten everything on their plate before they ask for more, but each food does need to be on the plate. There are different levels to this (see Figure 1). Depending on the severity of the fussiness, these stages may take a couple of meals each or weeks each. A child should never be bribed or forced to eat the food, as this leads to further problems down the line.

• Consider whether vitamin and mineral supplements are necessary.

CONCLUSION

Fussy eating is a complex stage in the life of many toddlers. Each child is different. Supporting families takes time and requires adapting to their needs. Empowerment is really important.

Involving the child in the process and giving them control can help.

A wealth of useful dietetic resources for all dietitians and nutritionists

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Click here to read the Dec/Jan issue Articles include: • Weaning preterm babies

• Nasogastric tube feeding • Fussy eating in toddlers • Constipation and treatment • Popular liquid diets

• Plant-based diets • Care caterers in social care • Follow-on formula new regulations