Is your child a resistant eater?

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Is your child a resistant eater?

Mary’s parents had every reason to be worried. Not only they were concerned over the limited number of foods she was eating: pizza, white bread, cheese sticks, blueberries and apples, this 6 year old also seemed genuinely disgusted by all other foods. After she gagged a few times and even vomited when trying spaghetti, the parents decided to look for professional help and learned that Mary was a resistant eater. After the thorough assessment by a team of health professional, including a doctor, speech therapist, occupational therapist and a dietitian, a treatment plan was developed and Mary’s parents learnt the strategies they could use when feeding her at home in between the visits to a feeding clinic. 

There are many resistant eaters like Mary who need more help when learning to accept a wider variety of foods. In order to better understand how they can be helped, I interviewed an experienced pediatric occupational therapist Tania Hanson OTD, OTR/L, C/NDT, who is also the owner of Achievement Therapy Center  and the co-author of  Just Take a Bite: Easy, Effective Answers to Food Aversions and Eating Challenges! 

Picky eater vs Resistant eater

Although there is no formal definition of picky eating, it is generally accepted that it is a developmentally appropriate phase in a child’s life which starts at around 1,5-2 years and lasts till the child is 5-7 years old. Division of responsibilityin feeding helps successfully outgrow picky eating. Division of responsibility is the authoritative approach to feeding, when parents take the upper hand with meal structure and food choices while letting children decide what to eat,

But sometimes eating problems are more complicated. Just waiting for some children to be hungry enough to eat will not work because of the bigger emotional or physiological issues that make kids prefer to go hungry rather that eat something new. Eventually the list of their favorites gets shorter and shorter as parents become more and more anxious. Tania Hanson OTD, OTR/L, C/NDT  who has been working in the medical and occupational therapy field for more than 20 years, explains that although there is no formal definition of resistant eating, we can identify it by certain characteristics that include:

1. Limited food selection. Resistant eaters often accept only 10-15 foods or fewer.

2. Limited food groups. Refusing one or more food groups is fairly common among resistant eaters.

3. Anxiety and/or tantrums when presented with new foods. Resistant eaters often gag or become ill when presented with new foods.

4. Experiencing “food jags”. Resistant eaters require one or more foods be present at every meal prepared in the same manner.

5. Resistant eaters are sometimes diagnosed with a developmental delay such as Autism, Asperger’s Syndrome or Pervasive Developmental Disorders- Not Otherwise Specified. Some of them may also have a diagnosis of mental retardation.

Improving feeding strategy is not enough

Switching to authoritative parenting style and using the division of responsibility is often not enough to help a resistant eater feed himself better.  According to our expert, there may be contributing factors compromising the child’s ability to accept foods into his diet, such as:

  • Inadequate oral-motor skills, when the child may not have enough jaw/tongue control to chew foods.
  • Sensory processing skills, such as sensitivities to smell and taste that can influence food choices.
  • Gastrointestinal factors can be a problem, when children refuse to eat the food that they associate with stomach discomfort or pain.
  • Environmental controls. These may include parenting around food, such as allowing the child to graze throughout the day, so that he is not hungry for meals or tolerating inappropriate mealtime behavior.
  • Medical issues such as food allergies or swollen tonsils/adenoid.

Parents need more help 

Hanson says that multidisciplinary team approach should be able to help the parent look at all the factors that may be contributing to the child’s eating choices. Parents need to be supported, they need to understand that they are not alone. Having a team of professionals including school teachers and clinicians to refer to will help them develop a plan of action to meet the child’s needs.

What can be done at home?

Involving a child in food preparation has been helpful for children of all ages. Often kids are expected to eat a food which they know nothing about. Hanson often asks parents whether they would be willing to put in their mouths food that they know nothing about. Most parents say they wouldn’t. Hunson stresses that allowing their child to learn about the food outside mealtimes is very important. Incorporating fun, play-based interactions with food often reduces the child’s anxiety. Everyone learns better when they are not stressed. Just take a bite teaches parents  how to introduce foods through the sensory stages of looking, smelling, touching, tasting and eating.

Besides, many parents are likely to introduce a food a few times and then give up when the child continues to refuse eating it, adds Hanson. Research proves that it takes 12-15 exposures to the food, and sometimes 12-15 exposures on every sensory stage such as viewing, smelling, touching and tasting the food, before the child accepts it into their diet. She recommends parents help their children keep a food journal. Children who cannot read yet can draw pictures of the food they are learning about.

When it comes to expanding food choices, Hanson recommends gradual changes to familiar food. Changing the food slightly by varying temperature, texture, shape or taste and involving the child in the process will serve as a stepping stone to accepting a wider variety foods.

Tell me, what are your biggest obstacles to getting your kids to eat well?

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15 Comments

  1. I really need help and have been unable to find it. My son has autism and is completely non verbal. As a baby he would pretty much eat anything given to him. One by one he eliminated each food until now all he eats is french fries, mini chocolate chip or oreo cookies, and chocolate pudding. PERIOD. Today he would not even eat the fries. He can not tell me the reason and everyone I have tried to speak with are of no help. He will not go to therapy because this time last year he had surgery where 5 adult people help him down to sedate him (because he wouldnt put the meds in his mouth) and he now associates any building with a glass door as a doctors office and will either refuse to go in..or have severe panic attacks inside. He also has chronic lung disease so the crying from being so scared is hard on his breathing. Does anyone have ANY ideas what I can do? I am so afraid he will starve himself to death. Also I can not give him multi vitamins because he will not put them in his mouth. I need HELP

    • Melissa, I will try to get help for you. If your son would not go to therapy, a home visit or a phone consultation with someone in your area may work better. Please email me directly at info@tribecanutrition.com and I will do my best.

  2. Hi thank you for this article, I have felt more and more like fussy and picky are not the right words for my girls attitude to eating. My 3 year old in slowly refusing more of the limited items she will eat.she gets very upset and would rather go hungry than try/bite/taste new things. The foods must look the same each time or she will not touch it. mostly white foods, bread, cheese, milk, yoghurt, banana if im lucky, and the little fruit pouches (at least its something healthy) along with junk, choc, biccies, icecream etc…Do you have an New Zealand resources I could contact? I worry her issue goes further than “she will grow out of it” “will eat when she’s hungry” and I am tired of throwing away food!1 nor can i afford it!…any advice for me? much appreciated :)

    • Hi Kara and thanks so much for your comment.

      I understand your frustration. My first child was a very picky eater, eating only white foods for a while and I remember how frustrated and helpless I felt. She is the reason I became a pediatric dietitian!

      What you describe looks like an extreme case of picky eating that may result from different issues. You may need to dig a little deeper to find out what exactly is going on. Unfortunately, I personally do not know any New Zealand resource to contact but I would recommend the following:

      1. Minimize pressure at mealtimes to the extent possible. I know it seems counterintuitive but children who are pressured to eat beyond of what they want or ready for, will under eat on other occasions and further restrict their diet. The formula is to offer at least 3 food groups at each meal, include at least one food your daughter typically eats and keep a strict schedule of meals and snacks. A good idea would be to find a dietitian who is familiar with the Division of Responsibility principle in feeding and will help you improve the mealtime environment and reduce food waste. Here is the link where you can book a coach through Ellyn Satter’s associates program:http://ellynsatterinstitute.org/res/coachingandmentoring.php. I also provide this service, so feel free to contact me directly or book a Google helpout here:https://helpouts.google.com/108424831058264095453/ls/bba837cff5212546.
      2. After starting to work with a coach or dietitian, it will be clear whether you need to find a local feeding or OT center where you could get chewing/swallowing evaluation and rule out out sensory processing disorder. If your daughter rejects foods of a certain texture, like crunchy or smooth, chances are she needs help to learn to tolerate them. Here is a website where you can learn more about the latter (http://www.spdfoundation.net/newsletter/2011/10/starlights-parents.html)
      3. Your dietitian will also be able to recommend whether you need to explore the link with food allergies and digestive issues.
      4. Once you have all these parts covered, you should have a solid plan on how to help your little one.

      I hope it helps! Please let me know if you have any further questions and good luck!

  3. My soon to be 7 year old has been a “picky eater” since he started solids and it has only gotten worse. Foods he used to eat are no longer his favorite and he won’t touch them. He only eats maybe 5-8 different foods and when a new food is put on his plate, he has a major meltdown. And if he is eating one of his favorite foods he inspects it first to make sure there are no dark spots or its not too mushy. Mealtime is so stressful I just don’t know what to do anymore. I would love to know if there are any food therapists or someone in the Bucks County Pennsylvania area that could help him. I am so desperate.

    • Jenna, from what you shared looks like your child may be a resistant/selective eater who may be diagnosed with as Avoidant/RestrictiveFood Intake Disorder http://eatingdisordersreview.com/nl/nl_edr_24_3_1.html. If you have a feeding clinic in your area (you can check with local hospitals), I would recommend full evaluation, to make sure no GI issues, swallowing problems or food allergies are playing a role. Whether or not there is an underlying medical reason for such extreme eating behavior, the best way you can help him eat better and gradually learn to like new foods is by eliminating mealtime pressure, allowing him to serve himself the food that he likes and making sure that each meal contains at least one “safe” food for him. Making mealtimes pleasant regardless of what and how much he is eating is your number one priority. Kids, especially those who are anxious around eating, will not do a good job at mealtimes if they are stressed. I think a great place for you to start would be to read the blog by a mom raising a selective eater. She is doing a great job using the Division of responsibility in Feeding and getting good results. http://mealtimehostage.wordpress.com. If you feel like you need more help, I will be absolutely happy to talk to you on the phone or via Skype. Just send me an email and we will arrange a time. Good luck!

  4. My daughter is 20 months old and she would only eat 3 different kinds of food and has to be puree, the only thing she would eat solid are chicken nuggets, I just wonder if I should take her to a food specialist or should I wait a little more.

    • Hi Mary.Thanks so much for your comment. I have a couple of questions for you. Since when did she start limiting her food choices? Also, did she have trouble transitioning between textures when you introduced solids? Is her growth steady? If she anxious at mealtimes? Are you? It is hard to say whether you need any urgent intervention without answers to these questions. If she eats chicken nuggets and purees, her swallowing/chewing might be fine. She might be a selective eater which means that she is limiting her diet with or without underlying medical issues. In any case, creating a pleasant mealtime environment is the first thing to do. She is not likely to start eating better if she feels any kind of pressure. I will share more after your response. If you feel more comfortable emailing me directly, feel free to send a message to info@tribecanutrition.com

  5. Thank you so much for this article. I have been severely struggling with my 3 year old since he started eating and have been looking for help but with no luck.

    My son has a very limited number of foods that he will eat. He has always been this way, eating has never been easy with him. When he was 18 months I started to realise that this was a problem so asked for help from my health visitor. After e few trips and many suggestions, none of which worked she told me it was time to go ‘cold turkey’ with him and, I quote, “a child will never stave themselves.” She told me to not give in and to offer him the foods i want him to eat and eventually he will back down. 3 days later my son was hospitalized and spent 2 days having convulsions. Although no one would actually admit to was due to that advice, I am positive of it. James would rather starve himself than eat foods that he is very uncomfortable with.

    James has about 10 food items that he will eat. He has to have waffles with every evening meal. He doesn’t eat any fruit, vegetables, bread products, and hardly any meat.

    If new food is put in front of him he will vomit. If something happens to one of his favorite food, ie, break, snap, dark spot or anything that makes it imperfect, James wont eat it and gets cross.
    Eating out is horrendous, we just don’t do it and going away is even worse. I’m so concerned about him as he isn’t getting any better and I don’t know what else to do.
    does James sound like a resistant eater? He has speech delay but other than that is developing well in all other areas.
    Please please is there any help or support I can get? I am from London, England. Thank you

    • Hi Claire. Thanks for the comment. If you have been struggling with feeding since your baby was on solids it is likely that he is a resistant eater. I definitely agree with you – starving kids out does NOT work and I am sorry you had a horrible experience due to someone’s poor advice. Your son seems to be very sensitive to new foods and reacting very strongly to them. I assume mealtimes are not easy. So first of all: I congratulate you on being a wonderful parent, feeding your child despite all the challenges and keeping to look for answers. Here is what I would recommend off the top of my head, without knowing much about the medical or diet history. First of all, minimize mealtime pressure. This works for all kids across the board. If there was pressure to eat or even try or smell foods in the past it may be still backfiring. So your first goal may be making the mealtimes less about who eats what but more about connecting with your child. Definitely keep including at least one food your child is capable of eating in all meals but feel free to round up the meal with new or less liked foods. Eat together as often as possible but give your child space to eat what and how much he wants from what is offered (he will be eating only his preferred foods for some time). Read here about why your child does not need balanced meals: http://tribecanutrition.com/2014/03/child-need-balanced-meals/. Instead, strive for eating competency (in the same post). Would definitely recommend exploring Ellyn Satter’s website here: http://ellynsatterinstitute.org/htf/iwfr1.php. When he (and you) start feeling more relaxed at mealtimes, he will be coming to the table more willingly and will start ever so slowly expanding his eating repertoire by pushing himself to learn to like new foods. Then it may be a good time to try food chaining – here is the link to a book:http://www.amazon.com/Food-Chaining-Feeding-Problems-Child%C2%92s/dp/1600940161. If you have resources and access, I would also check your son to make sure no allergies or gastrointestinal issues are interfering with his ability to eat a variety of foods. And please feel free to email me directly with more questions: info@tribecanutrition.com

  6. Hi,
    I write this here out of utter desperation as my toddler is sitting on high chair refusing to eat her breakfast. She has been resistant ever since she was born. Every time there was a transition breastmilk to formula, formula to cows milk. Also, she only started taking in solids in terms of purees only around 15 months. She started saying ok to table food at 25 months. But she hates mealtimes. I have to distract her for her to eat. Its like she ignores food. She is good at drinking milk (not great), she used to like yogurt but refuses now. Cheese and certain fruits I can get her to eat but that too in very little quantity. Does she any any feeding disorder? Where should I start looking for help? I dont want her feeding issues to be escalated as she grows up. I live in Maryland currently and if you have some resource I can avail of. I appreciate your help immensely.

    • Hi,

      Thank you so much for the comment. Of course anyone who is looking into your daughter’s eating history will need much more information than what is possible to share in a blog’s comments in order to diagnose her with a feeding disorder. But here are some thoughts on what you could do right now. If you have not read books by Ellyn Satter, I would recommend getting “Child of Mine” and reading the chapter on introduction of solids and feeding toddlers. I saw in my practice lots of feeding problems originating in the time when solids were introduced. Reading this book will help you establish the feeding dynamics called “Division of Responsibility” that is most conducive to good eating regardless of how resistant a child is. If you can get her evaluated for chewing/swallowing skills, gastrointestinal issues and food allergies, that would help identify if there are any underlying issues that need to be taken care of. In any case, get some support in establishing the “Division of Responsibility” during meals. You can do it by joining a Facebook support group by the author of the book here: https://www.facebook.com/ellynsatterassociates?fref=ts or another private group by a mom of a very resistant eater. I will email you the invitation. The group has a few Occupational Therapists and Registered Dietitians in it, and a lot of parents who are going through the same struggles. I also do online video sessions with my patients, so this could be another possibility for you if you feel like dealing with it alone os too overwhelming. Best of luck and please keep me updated!

  7. Hello-
    I came across an article you had written and then read through many questions from readers. I’m going in circles with what to do about my 15 month old and was hoping to get your initial thoughts. Jack is 15 months old and still only eats rice cereal mixed with organic purees. Happy Baby is the brand I feed him, usually two packets per feeding.

    He has eaten spaghetti a few times and seems to enjoy it. He loves mango. Jack likes gold fish, crackers, and smoothies.

    What I find strange is he has NO INTEREST in even trying new foods. I put all things in front of him- eggs, turkey pieces, baby corn and peas, rice, etc. He immediately starts tossing it onto the floor. When I force a piece into his mouth, thinking maybe he will like the taste and want more, he battles me and then spits it out.

    He’s not a big talker. He has said Mama, Da da, Nite nite, Duck, Ba (for paci). He doesn’t ramble and repeat these words. My other two children would say Mama and Da da non-stop.

    He did have nursing issues, never had a strong latch, and would somewhat thrust his tongue when nursing…. causing him to make loud sucking noises.

    He’s very engaging, makes eye contact, completely understands me, my instructions like “go get Mama a truck, or wanna go upstairs and take a bath?” He will turn and crawl upstairs. Follows his siblings around, loves playing with his 3 yr old sister and 6 yr old brother.

    He had torticollis at birth. He hated tummy time and would scream if I left him on his belly at 4-5 months old. I had him in physical therapy to help him roll over. He eventually did but was never a rolling baby. He was back in PT at age 9 1/2 months because he would not crawl. After 2 months of PT, he crawled on his own at 11 1/2 months. He crawls everywhere now, and fast.

    He started semi- walking about a month ago (age 14 months). Jack will walk pushing a toy cart for a long time, he will take 10 steps on his own. He’s initiating more sporadic walking to and from things in the house. Part of me thought the physical delays were because he doesn’t get enough down time. I’ve always got him in the car, picking up his sibling, running errands, etc.

    I don’t know if I’m jumping the gun with worrying or if Ive not been proactive enough to insist doctors help me more. Ive spoken to two pediatricians in the practice I go to and they don’t seem worried, but I’m just not feeling right about that?

    Oh gosh, I have rambled and rambled. I hope you have a moment in your busy life to provide your insight to my situation. I truly look forward to hearing back from you.

  8. My 4 1/2 year old has autism, and like Melissa I really need help too. I’m hesitant to start him on OT because we just shelled out tens of thousands of dollars out of our pocket for his ABA training. The ABA was awesome and he is at an above age appropriate speech level, but we really struggle with food and social anxiety. Do you think there might be a therapy out there that is covered by insurance?
    Your advise is greatly appreciated!

    • So sorry to have missed this comment, for some reason it went to the spam folder. Have you read any books by Ellyn Satter? Her philosophy is incredibly helpful for kids with autism and I keep recommending them to parents. I am sure some OTs are covered by insurance but I would first make sure they are familiar with Ellyn Satter’s approach and promote the no-pressure strategies. Also, make sure to read this post and even discuss it with your provider to make sure you find the best match.http://tribecanutrition.com/2014/10/just-picky-eating-selective-eating-disorder-children/

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