Fussy eating is one of the most common things that parents present with to both primary and secondary care.  My colleague, Ann Duthie, has kindly allowed me to paraphrase a recent talk she gave to the department on this subject.  I hope you find the structure as sensible, helpful and reassuring as we did.

FEEDING DISORDERS IN CHILDREN encompass the behaviour of those who have difficulty consuming adequate nutrition by mouth (impaired feeding), those who eat too much and those who eat the wrong thing (pica).  We have not covered here eating disorders such as anorexia or bulimia.

Common presentations include:

• Dysphagia
• Food refusal
• Self feeding inadequacy
• Excessive meal duration
• Choking, gagging, vomiting
• Inappropriate mealtime behaviours
• Food selectivity by type and texture

 

Normal feeding development is as follows:

• Up to 6 mths – breast/bottle fed milk
• 6-12 mths – solids introduced and increased in variety & volume.  Milk intake begins to decrease.
• At 1 yr – teeth; family diet; ½ pt milk/day; change in attitude to food; active and wt gain slows
• 15 mths – hold spoon, messy feeding, use feeding cup

The child moves from a state of total dependency on parents for food to one in which he/she can exert control & independence to determine what is
eaten, when and how.  Some parents struggle to adapt to this:

• Messy
• Feeding cues can be missed
• Parental fear that insufficient food will be taken, child will lose weight
• Parents own food preferences
• Rejection of a food and assumption that child will never like it
• Time pressures

The health professional must look for an organic cause of food refusal:

Organ system	GI disorder	Mechanism
Mouth	Carious teeth Structural with oral dysphagia	Pain Reluctance to swallow
Pharynx	Tonsils Aspiration	Pain, obstruction Choke, gag
Oesophagus	Reflux oesophagitis Cows milk allergy	Pain, burning
Stomach	Motility disorder	Reduced appetite, discomfort
Colon	Constipation	Pain, discomfort, reduced appetite

Children with neurodevelopmental problems or autism may have additional factors affecting their feeding behaviours.

There are 5 key elements to the assessment:

• How is the problem manifested?
• Is the child suffering from any disease?
• Have child’s growth & development been affected?
• What is the emotional climate like during mealtimes?
• Are there any great stress factors in the family?

 

Red flags to look out for include:

• Swallowing difficulty with cough, choke or gag
• Vomiting/abdominal pain/arching/grimacing/eye watering
• Recurrent chest infections
• Stridor on feeding
• Snoring with sleep apnoeas
• Constipation

The history is, as always in medicine, of paramount importance and needs to be fairly detailed:

• Birth History
• Previous illness (inc. h/o vomiting, respiratory symptoms) & hospitalisations
• Developmental progress
• Chronology of feeding problem
  – Diet since birth
• – Changes of milk formulae
  – Introduction of solids
• Current diet (typical day)
• What happens at meal times?
• Family & Social history

Height and weight must be measured and plotted on an age appropriate growth chart and corrected for prematurity if less than 2 years of age.  Refer children with red flags or significant faltering growth to secondary services.

• Management of the well child in primary care:
• Reduce milk intake if necessary (maximum of 500mls total in 24 hours)
• Encourage family foods
• Meal time management (see NHS Lothian’s dietetic advice)
• Aim: Improve infants comfort at meal times, relieve parental fears and improve parent-infant relationship

 

The multidisciplinary approach:

• Health Visitor – can assess child within home situation
• Dietician
• – Nutritional assessment and feeding advice
• – Calorie enrichment
• – Calorie supplementation
• – Enteral feeds (very occasionally)
• Speech & Language therapist
• – Direct assessment of feeding & advice in home situation
• – Parent-child interaction
• – Is swallow safe?
• – Toddler feeding groups (eg. Waltham Forest’s “Ooey Gooey” group at Wood Street)

Summary points:

• Feeding disorders in children are common
• Occur in healthy children but assessment should be made for organic causes
• – GI tract problems
• – Developmental delay
• – Autistic spectrum disorder
• Watch out for obligate milk drinkers
• Meal time management is crucial
• Involve Health Visitor

 

Further resources:

Weaning your premature baby.  Free download from Leicestershire Dietetic Service 2011

Help! My child won’t eat and My child still won’t eat.  British Dietetic Association.  Available to buy in packs from http://www.ndr-uk.org/

My Child Won’t Eat by C Gonzalez                    – these are both books and the links are to www.amazon.co.uk

New Toddler Taming by C Green