Food refusal – the parent’s role

Child characteristics
Children might refuse foods because they have not been introduced to the foods early enough in childhood, because they are sensory sensitive or because they are not really hungry¹.
Most children will take enough food through the day to meet their energy and growth needs. Infants can carry out this kind of regulation from the first weeks of life². However, many parents worry that their child is not eating enough, perhaps because they compare them with other children who are taller and therefore need more food. Also a child might eat enough of the foods that they want, but won’t eat the foods that their parents want them to eat.

Toddlerhood is a time when many parents begin to worry about their child’s eating behaviour. Children at this age are starting to self-feed, and will often refuse new foods, or indeed foods that that they used to eat. This type of behaviour, that of refusing new foods, is termed neophobia. It usually starts to appear within the second year of life, and is usually at its worst at about eighteen months³. In the first year, infants are more likely to accept foods that are offered to them⁴. They learn to like and accept the tastes that they are given, and to cope with the textures with which they have had experience. By the end of the first year, infants are able to recognise the foods that they have become used to, and at a time at which they normally become more mobile, they will reject any foods that they don’t recognise as familiar³ even if they have eaten these foods before. This response worries parents, who often think that their children are refusing food to get attention. But of course, the neophobic response has a function.

In the first year of life, infants learn to like the foods that they are given by members of their family or social group. In this way the infant learns to like foods that are safe and culturally appropriate. When the infant becomes mobile and starts to crawl around, it is safer if new foods are rejected. This is because the food might not be safe for the child to eat. It is not a good survival strategy to try an unknown food-type substance, it may well be poisonous, and the food should therefore be rejected on sight without tasting. This of course is what young children do, they look at a food that they have never eaten and refuse to eat it, without having tried it.

This neophobic response is at its most extreme during the toddler years. The response gradually improves as the child reaches middle childhood and when children do eventually start to taste new foods it may take quite a few tastes before the child gets to like that food.
To some extent though, the neophobic response perseveres into adulthood, but not all adults are equally neophobic. The extent to which adults and older children will accept or reject new foods on sight, varies according to personality type⁵.
Parental characteristics –How might parents contribute to their child’s fussy eating behaviour?

Neophobia
There are a number of parental factors that are associated with children’s fussy or picky eating, and children’s food refusal behaviour. For example, some parents will be more neophobic than other parents. The more neophobic the parent, the narrower the range of foods in their own diet and therefore fewer foods are likely to be offered to the child⁵. The parental neophobic response therefore impacts upon a toddler’s range of foods accepted in two ways. Firstly, the toddler might share a genetic susceptibility with the parents, to reject new things. Secondly, because the range of foods accepted by the child as they develop into toddlerhood is dependent upon the number of foods that have been offered to them in the first year, if fewer foods are given to them, then the range of foods accepted will be more limited.

Toddlers will therefore reject new foods on sight because this is a sensible thing to do, but they are more likely to go on to eventually accept those new foods if they have the right temperament type, and if they have parents who are not neophobic themselves. In addition, new foods are most likely to be accepted by the child in the toddler period if an adult is seen to eat the food⁶, or if the child is frequently exposed to the food⁷. Parents who are very neophobic themselves, will not model eating a new food, nor are they likely to be comfortable giving a child a food that they themselves do not like or want to eat. Picky children may have mothers with less variety in their vegetable intake, and the mothers of picky children also perceive their family as having little time to eat healthy foods⁸.

Rewarding and withholding
In an attempt to get their children to eat a wider range of foods, parents often try to get their child to eat a first course, or to eat ‘healthy’ foods, by giving a sweet course or ‘unhealthy foods’ as a reward. (“Eat up your vegetables, then you can have your pudding”). This does not work. It makes the reward food seem more desirable and the food that has to be eaten as less desirable. In the long term, the child will always want to eat the reward food⁹.

Similarly, withholding food, so that sweets, cakes and biscuits are only allowed as treats, will make these foods more desirable to the child. These foods will become comfort foods and eaten in the absence of hunger as the child gets older^{10, 11}.

Parental style at mealtimes.
Parents also differ in the way in which they try to get their child to eat. Parents may be authoritative, authoritarian or permissive¹². These parental styles differ in the extent to which the parent is sensitive to the child’s cues and intake needs. An authoritarian parent insists that the child eats the food that is put in front of them, and eats the amount that the parent has given them. Such parents are more likely to force feed a fussy child, and because of the stress that this sets up at mealtimes, the child is likely to become more anxious and to eat less. Even repeated prompting to eat is not likely to get a child to eat more¹³.

A permissive parent will not try to move the child on. They just allow the child to eat what they prefer to eat, even though this might be a ‘junk food’ diet. A responsive parent will try to prompt the child to try new foods, or will have new foods available in the house and at mealtimes so that the child is exposed to them.

An authoritative parent is responsive and gets the balance just right; they neither force the child to eat, nor do they expect them to finish up all food that is given. Instead, they give gentle prompts to try new foods, without making the child too anxious.

NB: It is important to remember that even the most responsive of parents might not be able to get a young child with an Avoidant Eating Disorder to try new foods.

Maternal mental health
The least responsive parent at mealtimes is likely to be those mothers with mental health problems. Symptoms of eating disorders, depression, and anxiety have been linked to the development and/or maintenance of feeding difficulties in infants and young children^14-16. For example, one study found that mothers with eating disorders were more concerned about their children becoming fat, and restricted sugary or carbohydrate foods more often from their child, than mothers without eating disorders¹⁷.

A further study demonstrated that mothers whose infants had faltering growth restricted the types of foods that they offered, with 50% restricting sweet foods and a further 30% restricting perceived ‘unhealthy’ or ‘fattening’ foods¹⁸. These practices are partly due to inaccurate maternal health beliefs, and partly due to the mothers projecting their own dietary restraint onto their children. In addition some mothers with eating disorders have been shown to have concerns “that their babies were overweight and tried to slim them down” and others have been described as ”excessively worried about their children’s shape and size and had significant difficulties with feeding their children”¹⁹.

Women with symptoms of anxiety disorders, such as Obsessive Compulsive Disorder, are also more likely to experience difficulties in feeding their children¹⁶. Research suggests that high levels of anxiety actually predict the development of feeding problems and are not necessarily a response to feeding difficulties¹⁶, although dealing with a child with feeding problems is likely to make a mother even more anxious.

Problems such as maternal obsessions and compulsions may interfere with normal development of feeding interactions, particularly if cleanliness or contamination is an obsession. Mothers may be driven to control feeding, in order to prevent mess. They might do this by continuing to spoon feed beyond the appropriate age, discouraging independent feeding and exploring of food with hands, or by providing a limited range of only those foods that produce little mess. Mothers may also be driven to intervene with excessive wiping and cleaning of the child and surrounding area whilst food is being eaten. Such practices are likely to inhibit the child’s normal development of eating skills and to alert the child to potential danger from food. This creates a tense and anxious mealtime and sets up a difficult feeding interaction.

Furthermore, a mother with these types of concerns is unlikely to be able to respond sensitively to her infant’s signals in feeding because she is preoccupied with dealing with the threat that mealtimes pose for her in terms of her anxieties about cleanliness. Sensitivity to infant’s signals of hunger, preferences and fullness are crucial skills in developing a harmonious and productive feeding relationship.

It is also important to acknowledge that feeding difficulties can arise in families where there are no mental health problems, but where infants are particularly difficult, or particularly neophobic. The presence of feeding difficulties in a family should not be taken as evidence of parental mental health problems or failure to care adequately for the child. However, a combination of low maternal self- esteem, lack of social support, and difficult childhood temperament have been shown to be strong predictors of the development of maternal reports of difficult feeding interactions with their infants at 6 months of age²⁰. Similarly, depressed and anxious mothers, who have infants who experienced difficulties in accepting lumpy textured foods at the age of the introduction of solids, are likely to experience continued problems in feeding their infants²¹. Therefore, difficult infants who have mothers with few psychological and practical resources are a particularly high-risk combination.

Anxious parents should always be reassured that fussy eating does not necessarily lead to poor weight gain, or poor health²².

Tips for Healthcare Professionals working with mothers of toddlers
The neophobic response is overcome by exposure and imitation.

Exposure
• New foods need to be frequently offered, or at least shown, to the toddler.
• BUT, it is important that the child is never forced to eat a new food.
• Parents who are themselves quite neophobic are less likely to make a wide range of foods available to their child.
• The more often a toddler sees a new food the more likely it is that the food will be tried.
• Even if a child tries a new food, they will not necessarily like it the first time they taste it.
• It may take anything up to fourteen tastes of the new food, depending on the age of the child, before they develop a preference for the food.
• The older the child, the more exposures they are likely to need.
• Sweet foods are more likely to be accepted than any other taste.
• Foods that taste or have a similar texture to foods that the child already prefers are more likely to be accepted.

Imitation
• A new food is most likely to be tried if the child sees a parent or another adult or child eating the new food.
• Parents should themselves eat the foods that they want their children to eat.
• If a parent has a problem with a food, the parent should set up the opportunity for the child to be exposed to that food in other places and with other people.
• Toddlers often benefit from meals and snacks at nurseries or playgroups because they will often imitate other children’s eating behaviour.
• Children need to see food being enjoyed by others before they are likely to want to try it.

Mental health problems
Mothers who have mental health problems are more likely to have children who refuse food.
This may be because they:
• Don’t give children a wide range of different textured or ‘messy’ foods.
• Limit the range of foods given to their child, to easy and safe foods.
• Do not model eating new foods.
• Continue with spoon-feeding for too long.
• Don’t allow the child to get messy and enjoy their food.
• Are not sensitive to the child’s cues about their food preferences.
• Are too anxious around mealtimes, and make the mealtimes tense for their child.


Observing a meal: Things to look out for:

• Child is alone
Children are more likely to find mealtimes enjoyable and try new foods if they are eating with other people.
• Mealtime Context.
Children should preferably be fed at a table, or in a highchair. Parents should set up a consistent mealtime context.
• Too large portions are served.
Toddlers need to be served portion sizes that they can easily manage. If they finish their food they can be offered more.
• Spoon fed into the second year.
Parents should not be exclusively spoon-feeding children after the age of approximately 10 months.
• Child not allowed to self-feed.
Toddlers should be attempting all forms of self-feeding within the second year, including finger foods, and beginning to use a spoon and fork.
• Texture of food inappropriate for age.
Infants should not be eating puréed foods exclusively after the age of 7 months, and should be consuming family foods and finger foods from 9-10 months.
• Child not allowed to get messy.
Children need to explore and enjoy food, and need to be allowed to get their hands and face messy.
• Child coaxed or coerced to eat.
Children can be prompted to eat, but the conversation at mealtimes should not be focused on whether or not the child has eaten something. Parents should not coax or plead with or threaten their child at any point during the meal, as this creates tension at the mealtime and reduces the child’s appetite.
• Playing games.
Similarly, playing ‘aeroplanes’ does not increase the child’s intake of food, but distracts everybody from the purpose of the mealtime and unnecessarily increases the length of the meal.
• Child is force-fed.
Any level of force-feeding will reduce appetite and make mealtimes aversive to the child.
• Child sits with meal for lengthy period.
In general, most children have eaten all they are going to eat within the mealtime in the first 20 minutes. Mealtimes should not usually go on longer than 30 minutes.
• Child is made to finish plate.
Children can regulate their own food intake to suit their needs. They should not be coaxed into eating more than they want.
• Parent ignoring extreme signs of disgust e.g. gagging.
Whilst it is appropriate to continue offering previously rejected foods, children should never be made to eat a food that makes them gag.
• Parents showing excessive anxiety around mealtimes.
Healthcare Professionals should look out for parents who show signs of excessive anxiety at mealtimes such as excessive cleaning, over-controlling and over-intrusive behaviour. Children react to parental tension by becoming more anxious around mealtimes.
• The use of rewards for eating foods.
Preferred foods (such as puddings) should never be used as a reward for eating non-preferred foods (such as vegetables).
• Child only given attention when foods refused.
This increases food refusal behaviour. The child needs to receive attention when they are eating.
• Long periods left between mealtimes.
Children will not eat more if you leave long periods between mealtimes. Children will maximize their intake if offered frequent meals and snacks.

Advice to give to parents
• Eat the foods you want your child to eat.
• Make new foods frequently available.
• Eat in different places and with different people so that your child is exposed to other people eating new foods.
• Move onto finger food by the end of the first year.
• Allow your child to get messy when eating - don’t always try to keep the child clean.
• Give the child three meals and three snacks a day, this means that if your child doesn’t eat well at one meal, then you need not get too anxious, they will eat again within a few hours.


References
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