When a child has a tiny appetite or a very selective and narrow repertoire of foods, it can be one of the most stressful and worrying parenting challenges. The standard approach to kids who are extremely picky or selective with their food choices is to stay cool and calm, and gently encourage their eating patterns, with the hope that one day they will become less resistant and more open to trying and enjoying new foods.
We see many kids in our clinic where their parents are incredibly dedicated to their cause and have tried all the tricks in the book, yet are still failing to help their child broaden their diet. Building better eating patterns can be so demoralising if it seems like these feeding problems are driven by an innate fear or poor relationship with food.
At NatureDoc clinic we believe that many cases of extreme fussy eating, where there’s no obvious medical cause, can still be driven by an underlying physical health issue. This may be gut related, metabolic, a sign of inflammation or reflects an out of sync immune system. We examine your child and run laboratory tests to establish the underlying cause of their feeding issues and these can range from stool test to urine test to blood tests depending on the presentation. Often, we also refer onto specialist paediatric gastroenterologists if we feel the child needs medical support and occupational therapists if there is a developmental or co-ordination issue.
This article highlights the key problems we are looking out for in a consultation and may provide food for thought if your child is not naturally accepting a nutritious and varied diet.
1. Trouble in the mouth
Always have a look in your child’s mouth if they are having difficulty chewing or swallowing. This may give you a clue as to what is going on and then you can then take positive action. Many of the kids that come to our clinics have several cavities in their teeth, overcrowding, high-arched palates, or are tongue or lip-tied.
We also frequently find the kids have chronically swollen tonsils which make swallowing uncomfortable, or chronic painful mouth ulcers which can put a child off their food. Dental braces can also be painful for teenagers, so this might be the cause of sudden fussy eating at this stage.
Sensory issues can also make some foods feel rather strange in the mouth, and there is a strong relationship between sensory issues and picky eating. This usually sends kids into two camps: either the crunchy one, or smooth where if your child only eats food they can chomp and munch such as crisps, crackers, bread sticks and toast; then they may be in the crunchy camp. Similarly, where kids who only choose ‘slurpy’ and blended foods such as porridge, yoghurt and fruit pouches they are probably in the smooth camp.
2. Gut Reaction
Regurgitation of food can be a big issue for children and reflux is not limited to the first year of life. It is just as common in older kids and teenagers, and it may cause a sudden narrowing of food choices. Stomach pain, acid bubbling back up the throat or, an overactive gag reflex can cause real problems with eating. If swallowing seems a problem or belching, hiccups and excess acid are issues it is important to get your child checked out medically for things like dysphagia (swallowing problems), Helicobacter pylori (a stomach bacterial infection), reflux or gastroparesis (delayed stomach emptying).
Constipation or loose, stinky stools with undigested food can be signs there is trouble further down in the gut. If your child complains of a sore tummy most days, then do listen to them as it could be the underlying cause of fussy eating. If your child is not speaking yet or they are unable to communicate their needs, you may be able to spot that they have a painful belly by the state of their nappies (a stool should be hazelnut brown, formed and easy to roll off the nappy; anything else, then something is out-of-sync in the gut). If your child has a habit of sleeping curled in a ball or if they tend to lie with their tummy pressed against furniture or on the floor during the day, then there may be pain and trouble in the tummy which needs sorting out.
I strongly believe that children prefer not to eat than to be in pain. If your child only eats one or two mouthfuls and then stop eating, it may be because on some level, they have made the connection between gut pain they are experiencing and the food they are eating. This may have got so bad that they fear eating food so much they can refuse food all together for several days on end. If the pain is ongoing then it will be a this will be the underlying major reason why your child is going to be a fuss-pot about food and this needs to be addressed as soon as possible to prevent malnourishment and its consequences.
3. Food Sensitivities?
At NatureDoc clinic we find that one of the most common causes of picky eating is undetected low-grade food allergies and intolerances. Instead of the more obvious IgE mediated allergies causing hive-like rashes and swelling of the throat, these non-IgE allergens and food sensitivities are usually subtler and can lead to gastrointestinal distress and consequent picky eating and eczema. So, talk to your paediatrician about non-IgE mediated allergic response to certain foods which may present as Eosinophilic Oesophagitis (EoE), Mast Cell Allergies or Food Protein-Induced Enterocolitis Syndrome (FPIES).
I generally find that kids with an out of sync gut tend to restrict their diets to the food that sit most comfortably in their tummy. Think about the foods you would crave immediately following a gastric upset – these are most probably plain biscuits, toast and yoghurts. If these are the foods your child is fixated on, them this a sign there might be something untoward going on in the tummy.
Milk and dairy products seem to be a common trigger, especially if the problem has been going on since before weaning. It may also become more obvious if the change in appetite was around the time when breastfeeding ceased or when milk formula or cow’s milk was introduced. Since there are still difficulties diagnosing a non-IgE mediated cow’s milk allergy, often a short trial of a dairy-free diet is recommended to see if symptoms go away.
Other common allergens that seem to be on the rise are egg, nuts, soya, wheat, and fish/shellfish. Problems related to eating gluten may be due to coeliac disease in 1- in- 100 children, and non-coeliac gluten sensitivity is now also being recognised.
Since laboratory testing for non-IgE allergy testing, including tests for food intolerance and are still in their infancy, it is worth thinking back to when the fussy eating began and if this coincided with the introduction of a new food. Try eliminating that food for at least two weeks and see if your child improves. If so then this food is the likely culprit, and they may need to keep off that food in the longer term. Often, I find that when you remove the suspected food allergen from the child’s appetite, their repertoire of other foods also increases beyond the parent’s expectations, and I am assuming this is because they now have a much comfier tummy.
If food fussiness started after a major illness or accompanied a longer series of milder infections, then a poor immune system may be part of the picture. If antibiotics were prescribed, then this can knock the fine balance of gut flora out of sync and I sometimes find that a shortfall in beneficial gut bacteria can be the root cause of fussy eating slowly getting worse. Antibiotics may trigger a low-grade yeast infection that can cause oral thrush and candida albicans in the gut and I find these yeast infections can trigger carbohydrate fixation and sweet cravings; and this could be why good feeding habits can disappear rapidly in children in favour of the sweet stuff. Probiotics and fermented foods may be the answer here, as they replace the lost beneficial bacteria that the gut needs to build immunity. A healthy gut microbiome that is well supported with beneficial bacteria can also support mood, development and learning which you can read more about here.
Sometimes infections can be the root cause of fussy eating. Scarlet fever or other streptococcus infections such as ‘strep throat’ can make it far too painful to eat and only certain foods feel comfortable enough to swallow. In most cases normal eating returns quickly once the infection has gone. However, if the food restriction continues beyond the time of the infection and is accompanied by a sudden change in personality, anxiety, tics, obsessional thoughts, urinary frequency or a decline in school work then it is important to seek out support from a paediatric neurologist or a paediatrician specialising in PANDAS (Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections). PANDAS is an autoimmune or misdirected inflammatory response to a common bacterial infection that can have a debilitating effect on a child’s health and wellbeing and often affects dietary choices. This and its ‘cousin’ PANS (Paediatric Acute-onset Neuropsychiatric Syndrome) may affect as many as 1 in 200 children according to the PANDAS network and is now increasingly recognised.
6. Nutrient Deficiencies
Did you know that a zinc deficiency can be a cause of poor appetite and low zinc stores can alter sense of taste and smell? Zinc is also an essential nutrient for immunity, proper growth and brain development, so this is an important nutrient to get right throughout childhood. When kids have a growth-spurt, they may need extra zinc. More zinc is also needed during puberty as it is a key nutrient for forming healthy hormones. It is also important for skin health and so teenage acne accompanied by a narrowing of food choices may be that there is a shortfall in zinc levels. Zinc rich foods include eggs, salmon, milk, chickpeas, peas, dates and dark chocolate.
Low iron levels are common in little children, especially if they do not eat much red meat or green veg. Iron is also an essential nutrient for children’s growth and for them to think properly. Iron helps to transport oxygen in the blood around the body and brain. There are many signs and symptoms of iron deficiency and these often can include poor appetite, pale skin, tiredness, general weakness, headaches, shortness of breath, dizziness, tongue swelling, tingling in the legs, and slow growth rate. Less common signs of low iron stores can include hair loss, feeling itchy, a change in taste, difficulty swallowing and spoon-shaped nails. Iron-rich foods include red meat, eggs, spinach, lentils, sesame seeds, apricots and molasses. Vitamin C is important for the uptake of iron, so also include lots of vitamin C rich foods such as oranges, strawberries, kiwi fruit, red peppers and parsley when trying to boost up iron levels.
If your child constantly chews on their clothes or is drawn to eating non-food items such as stones, dirt, ice, tissues, or paper, then they this might be a sign they have a feeding issue called Pica. Babies naturally mouth toys and non-food items, but if this occurs in children over two years old, then it may be Pica, which is a sign that the body is trying to correct a significant nutrient deficiency. These nutrient deficiencies are usually associated with iron and/or zinc deficiencies and this is probably where you will need to look at supplementation as well as diet changes to regain their lost nutrients until the fussy feeding has improved.
I hope that the information above has given you a greater understanding of some of the underlying reasons why your child could be extremely picky with their food and struggles to eat a nourishing diet. If you would like to know more or investigate any of these issues, then speak to one of our NatureDoc Nutritional Therapists who specialise in childhood feeding and development.