Eating disorders in early childhood: “the child who doesn’t eat”


Wed, September 28, 2016
Author: Hero Instiute for Infant Nutrition

How is “the child who doesn’t eat”?
Paediatric and primary health care consultations due to appetite-related problems are very recurrent during the early childhood −an estimated 10-25% of children up to 10 years− since these kind of behaviours usually raise parents’ concerns.

But does the child really have a health problem? In principle, we can only state that if the aforementioned lack of appetite causes a weight loss or a growth rate significantly below the average. Therefore, most paediatric consultations end up being rather linked to an emotional and subjective factor or vision about what the child should or should not eat and, in many cases, the problem comes from not having consolidated appropriate eating habits during the first year of age.

The objective of this article is to analyse the main causes of this kind of appetite-related problems in the early childhood, as well as to offer their treatment guidelines.

Ruling out pathologies
The priority at the consultation room is to assess whether a medical history and a complete physical examination are necessary −including anthropometric measurements to determine if there is any problem with the weight and growth charts, as well as an evaluation of the child’s diet paying special attention to medical and behavioural symptoms which may require immediate care:

  • Organic symptoms: disphagia, aspiration, vomits, diarrhoea, developmental delays, apparent pain when feeding.
  • Behavioural symptoms: food obsession, forced feeding, anticipatory nausea.

Furthermore, it will be assessed the quality of the child’s (and family’s) eating habits through a conversation with the parents: regular mealtimes, suitable environment, use of technological distracting devices (phone, tablet), disruptive and stressing meals, lack of a suitable independent diet (consumption of sweet and sugary drinks), failure to accept different textures of food, etc.

If there is no clinical suspicion of a secondary cause −either organic or psychiatric−, there is no need of performing additional medical examinations or referrals to other specialists.

First years of age are essential to set the standards that will guide the future eating habits of children. Some problems such as the lack of appetite or the rejection to some foods are common to arise in this stage. Occasionally, those difficulties may be a sign of allergies or diseases that should be diagnosed and properly treated. However, most cases are merely due to behavioural or educational problems: “the child who doesn’t eat”.

Causes of poor appetite in children
In this article, the concept of “child who doesn’t eat” involves either those who do not eat well, those who are picky eaters −they only want to eat certain foods− and those who reject to try any new food (neophobia). Nevertheless, if we distinguish among pathological and behavioural responses, we can set the following categories:

  • Picky eaters: it is the most common case, an estimated 20% of children has gone through this phase. Children reject all those foods whose flavour or texture do not like (e.g. vegetables) and compensate it by consuming other foods more “comfortable” for them.
  • Acute illness of any kind (fever): it may cause them loss of appetite until their full recovery.
  • Organic pathologies: chronicle illnesses of different kind (gastrointestinal, respiratory, cardiovascular and autoimmune) may affect children’s appetite severely.
  • Psychiatric pathologies: such as infantile anorexia nervosa and bulimia nervosa, mood disorders, pervasive refusal syndrome, food avoidance emotional disorders, feeding phobia, etc.

How much should children eat?
Every child has different nutritional requirements depending on their metabolism, digestive capacity, growth rate, height, etc. In any case, the nutritional recommendations are a perfect guide applicable to the majority.

Difficult stage: the introduction of new foods
The introduction of new foods during the breastfeeding stage (between 4 and 6 months of age) is usually the most complicated phase and the one which causes most consultations: the never-ending question about the recommended order of food introduction. The Spanish Association of Paediatrics does not offer strict guidelines regarding this issue, but recommends offering the baby local foods according to the culture and the family’s habits.

Experience recommends a patient and progressive approach to those easily digestible and palatable foods such as fruit (banana, pear, apple), vegetables (carrots, courgette), cereals (rice, wheat) and/or white meats (chicken, turkey). It is advisable to leave large margins of time between new foods in order to identify possible allergies or intolerances.

At the beginning, children reject fibrous textures very commonly; therefore, foods are usually offered in the form of purées or baby foods to make them easier to accept. However, as the child is progressing in her/his adaptation to the new diet, they can try “real” food: pieces of fruit, for example. It is exciting and fun for them!

Moreover, parents should assume that the introduction of complementary feeding does not imply the end of a stage: breastfeeding on demand remains the basis of their diet.

“The child who doesn’t eat”, parents and the excess of zeal
Parents sometimes have a distorted vision about the real meaning of “not eating” and tend to impose food, even in disproportionate amounts compared to children’s age and size. In this way, they can induce children to reject food through this negative association: mealtime understood as a punishing moment repeated several times a day.

Therefore, it is necessary for the family to learn how to distinguish those behaviours that may be worrying −either the child only wants to eat with certain people, rejects solid foods or rejects, precisely, those foods more valued by parents (vegetables)−; from those irrelevant cases, such as the child’s varying appetite from one day to another.

A detailed survey on the child’s eating habits (and also the family’s, since the treatment must be related to the parents’ diet) will help us to set the reasonable standards to overcome this difficult stage.

Behavioural guidelines
The “child who doesn’t eat” is not being rude or manipulating, s/he is just a child who does not have appetite or who rejects food either because s/he likes more other foods or because has reached the point −that seems to be of no return− of feeling stressed at the very moment they sit at the table. It is important to encourage parents to associate the act of sitting at the table with a moment of peace and even, why not, of fun, by following the next recommendations:

  • Respect children’s satiety mechanism: if the child does not want to eat anymore, it means s/he is satisfied.
  • Have 4-5 meals a day, avoid snacks between meals and offer them water instead.
  • Offer them portions of food suitable for their size, using their own service, chosen by the child her/himself if possible.
  • Never force them to eat: food should be offered, never imposed.
  • Mealtime should be associated with a calm routine and preestablished timetables.
  • Do not let the child take ages at the table: if the child did not finish after half an hour approximately, the dish should be removed.
  • Regarding picky eaters: do not allow them eat only those foods they like, since it may cause them a nutritional deficiency.
  • If the child rejects outright a new food, it is better to wait for a couple of days before offering them the same food in a different format, either with a more attractive presentation or prepared differently in order to change the routine which does not work.
  • It is recommended to make the most of the child’s natural curiosity and let them eat on their own certain “safe” foods during the last months of the first year of age: it is a fun and stimulating way for them to learn to regulate their appetite.
  • Do not prepare anything special for them, whatever the family eats is also good for the little one.
  • Try to reduce all distractions at mealtime: avoid television, phone or any other kind of technological device.
  • Children imitate their relatives’ behaviour: they should have a nutritious and balanced diet high in fruit and vegetables to set a good example.
  • Children can go with their parents to do the grocery shopping and even help them −as far as possible− choose the foods. In this way, the child is more involved in the social act of food.
  • Foods are not rewards (sweets) nor punishments (vegetables). Eating should not be rewarded, even less so with sweets or desserts.
  • Medical prescription: drugs (appetite stimulants) or substitutes (multi-vitamin products) will not be needed in most cases.

All these guidelines involve a behavioural change in the family’s relationship with food and have the objective of setting healthy nutritional habits from the early childhood.