Your Child Eats Nothing. An Eating Disorder?

Your Child Won’t Eat Anything. Is It an Eating Disorder?

Halyna Kostiak

Feeding therapist in the SOS approach, weaning and child nutrition consultant

Kateryna Slyviak

Family doctor, breastfeeding and baby nutrition consultant, feeding therapist in the SOS approach

A child is a person under 18 years of age, so the problem of “my child doesn’t eat anything” covers a very wide age range, and therefore a different spectrum of problems too.

Children who don't eat: how common is it?
Why a child does not eat
Limited appetite
Neophobia and other natural stages of development
Picky eating
Disorders in which a child eats nothing
Eating disorders (ED)
Feeding disorders in children
What is pediatric feeding disorder (PFD)
Red flags
What ARFID is
An eating disorder as a red flag for autism spectrum disorder (ASD)
Conclusion

Children who don’t eat: how common is it?

Various studies suggest that, on average, between ¼ and ⅓ of children run into some kind of feeding or growth problem at some point during the first 10 years of life.

Only about ⅓ to ½ of children “grow out of” these problems within 2-3 years.

It is important to spot such problems early, because according to one study of children aged 7-12 years who had problems with selective eating, it progressed with age and worsened the child’s weight, height and body mass index.

Why a child does not eat

Possible causes:

limited appetite because parents/caregivers misjudge how much the child eats;
neophobia and other natural stages of development;
picky eating (“selective, fussy eater”);
feeding and eating disorders;
developmental disorders.

Let’s look at each of these causes in more detail below.

Attention! This article is not intended to provide a diagnosis and is only a recommendation for further consultations with qualified specialists.

Limited appetite

The most important feature of misperceived poor appetite is excessive parental worry despite normal growth. Parents usually see genetically small children with a correspondingly “small” appetite as children who eat poorly.

A study was carried out with more than 400 children taking part, 30% of whom were described by their parents as eating poorly.

These 30% of children were somewhat smaller than the children in the control group, but their intake relative to body size was equivalent to normal eating and met their nutrient needs.

Parents do not realize that the rate of growth slows down towards the end of the first year, with a drop in appetite at the same time.

This misperception can become a cause of feeding difficulties if worried parents use the wrong feeding methods.

Neophobia and other natural stages of development

One of a child’s eating behaviors that causes considerable concern for parents is food neophobia.

Food neophobia is characterized by a child refusing new or unfamiliar foods, both visually and in terms of taste.

For example, your child may love and happily eat pasta with bolognese sauce, but pasta with spinach sauce is already a visually new food, so a child with neophobia may refuse it.

Another example: watermelon season starts and falls during your child’s neophobia phase, so they may refuse even to try it.

Neophobic behavior can appear as early as the first year of life, but most often it becomes stronger at 18–24 months, which is linked to the child becoming more mobile. This is a stage that eventually passes on its own.

It is worth noting that the food neophobia period coincides with a slowdown in the child’s rate of growth and development. This can make parents anxious, as they often link the changes in eating to the slower growth.

In response, they may choose the wrong strategies for encouraging their child to eat.

As a result, a natural stage of development that needs no treatment can turn into more serious feeding problems that will need correcting.

The first important period of natural development when a child refuses to eat what their parents offer is around 12 months.

At this stage your child starts to realize that they are a separate person and that they can start doing what they want, not what adults want. Your child is developing and becoming aware of more and more things around them — this is called cognitive development.

Cognitive development happens constantly and comes in periods.

When a child moves from one period to another and, so to speak, “gets smarter”, this can come with a worse appetite, worse behavior at the table and more pronounced selective eating.

The next developmental changes usually happen between 2-3 years, 5-7 years and 9-11 years.

Picky eating

Picky and selective eating are common.

So it is important to understand that it is normal for children to prefer certain foods, to eat different amounts from day to day, or to suddenly stop liking foods they loved only yesterday.

It is important to remember that children are still learning: familiar foods are comforting, and new foods can be frightening. Although picky eating can limit the variety in your child’s diet, it does not usually lead to significant nutrient deficiencies.

Picky eaters usually eat a wide enough variety of foods to meet their nutritional needs.

Signs of selective eating:

Picky eaters usually eat at least 30 different foods;
They may eat the same food over and over, and then suddenly stop eating that food, but after a while, about 2 weeks, they start eating it again;
If you put a new food on their plate, they can calmly accept it on the plate or next to the plate, and may even touch it or taste it. As a rule, there is no crying or tantrums around new food;
They eat at least one food from most food categories (proteins, carbohydrates, vegetables, fruits, fats) and textures (purée, soft food, crunchy, hard and so on);
Picky eaters often eat different food from the rest of the family, but they usually eat together with the family. To eat, they do not need to eat separately and alone in a different room;
Picky eaters add new foods to their diet over 20-25 steps of interacting with the food;
Selective eating lasts less than 2 years.

And what if it is more than selective eating? Then we may be talking about disorders.

Disorders in which a child eats nothing

In children’s nutrition we can identify two types of disorders that are a serious problem and a reason why a child eats nothing:

eating disorders;
feeding disorders in children.

These are two different concepts, even though they sound similar. Let’s look at the definition of each of them.

Eating disorders (ED)

Eating disorders are characterized by severe and persistent disturbances in eating behavior and are linked to distressing thoughts and emotions.

Types of eating disorders that involve eating very little food or refusing it outright:

Anorexia nervosa, which is characterized by the following signs:

the person is preoccupied with the way their own body looks;
excessive control of their own weight and shape;
low calorie intake;
exhausting workouts;
diets and restrictions;
dietary supplements for weight loss;
fasting;
purging: inducing vomiting, diarrhea, excessive urination;
a weight that is critically low for the body to function, grow and develop normally. However, there are other types of anorexia in which weight is normal.

Bulimia nervosa:

the person is also preoccupied with the way their own body looks;
excessive control of their own weight and shape;
a distinguishing feature from anorexia nervosa is a normal weight for the body to function, excess weight or even obesity;
there are episodes of uncontrolled overeating of high-calorie food followed by purging: inducing vomiting, diarrhea, excessive urination, and/or exhausting workouts, low-calorie diets.

Avoidant/restrictive food intake disorder (ARFID):

perception of one’s own weight and body shape is not the reason for avoiding certain foods and limiting the amount of food;
a person with ARFID has negative feelings about the smell, taste or texture of certain foods and/or has a fear of the possible consequences of eating certain foods — fear of choking, fear of vomiting. They may not feel hungry and may have no interest in food;
the avoidance and restriction of food are so pronounced that there is significant weight loss or a failure to achieve the expected weight gain in children.

Eating disorders linked to food restriction, such as anorexia and bulimia, most often appear in teenagers aged 11-18, when they start to become aware of their body and appearance.

In younger children — infants, toddlers, preschoolers and younger schoolchildren — these disorders are much less common, because they do not yet have this kind of perception.

In this article we will not look at the eating disorders typical of teenagers and adults; instead we will focus on why children aged 0-12 may refuse food.

In children younger than teenagers, the most common type of eating disorder is ARFID.

So we will look at this disorder and other reasons why a child aged 0-12 does not eat in more detail later in the article.

Feeding disorders in children

With feeding disorders in children, the child does not eat or drink enough food or liquid, or a wide enough range of foods, to achieve and maintain appropriate growth and development.

In other words, the concept of a feeding disorder can be applied to a child if they cannot eat the food or the amount of food that other children of their age can eat, and as a result they have problems with health, nutrition, skills or behavior.

Parents run into difficulties while feeding their child, and this has a direct and dramatic impact on the whole family, which can often lead to significant family stress or a feeling of failure.

This can lead to all family members dreading mealtimes, to the interaction between the child and one or both parents becoming difficult, and to the daily schedule revolving around feeding the child.

What is pediatric feeding disorder (PFD)

Pediatric feeding disorder (PFD) is defined as impaired oral intake of food that is not age-appropriate, lasts at least 2 weeks and is associated with medical, nutritional, feeding skill and/or social-emotional problems.

Sometimes a child does not eat or drink in the amount or variety they need for growth and health.

This is not only because they are “picky about food.” There is usually an underlying cause.

These causes can often be understood by looking at specific areas called domains, or spheres.

The four important domains linked to PFD are the medical, nutritional, feeding skills and psychosocial domains.

A problem in one domain can lead to problems in any of the others.

Medical

To understand this, the process of eating is a complex task that involves the whole body working as one. It engages 26 muscles and 6 cranial nerves working in perfect harmony to move food and liquid through the body.

Possible signs and symptoms in this area:

difficult breathing during feeding and outside of it;
a change in the color of the lips or face while eating or drinking;
sweating while eating or drinking;
recurrent upper respiratory tract infections;
crying, arching, coughing, grimacing while eating or drinking;
suspected food allergy;
frequent changes of infant formula;
vomiting;
digestive problems;
your child never seems hungry;
physical discomfort while eating or drinking.

Nutrition domain

Balanced nutrition is the foundation of growth and development.

A child’s unique nutritional needs can be met in several ways. A child may eat all the food they need by mouth.

In some cases, a child may also need to drink a nutritional supplement or receive food through a tube. Whether a baby or a child eats by mouth or through a tube, good nutrition allows them to grow and develop.

Possible signs and symptoms in this area:

your child is unable to eat or drink enough to grow or stay hydrated;
too little or too rapid weight change;
a deficiency of a particular micronutrient or vitamin, for example iron or calcium;
a need for nutritional supplements;
dependence on one particular type of food for nutrition;
a need for enteral nutrition, a feeding tube;
constipation;
limited variety in the diet for their age;
too few fruits and/or vegetables;
a limited or complete absence of a protein source;
too few foods eaten regularly.

Feeding skills domain

Learning to eat skillfully and comfortably requires the development of sensory integration and motor coordination that allows your child to suck, swallow, bite, and chew.

Possible signs and symptoms in this area:

labored, noisy breathing or shortness of breath;
coughing, choking, gagging, or vomiting;
loud and/or effortful swallowing;
being unable to eat or drink enough for optimal growth;
meals that are too short (< 5 minutes);
meals that are excessively long (> 30 minutes);
a need for thickened liquids;
a need for special foods or modified food textures;
a need for special strategies, positioning, or equipment.

Psychosocial domain

When children show difficult behavior at mealtimes, they are showing that eating is unpleasant or hard for them at that moment.

A positive feeding experience builds internal motivation, which in turn leads to long-term feeding success.

Possible signs and symptoms in this area:

not being able to come to or stay with the family at mealtimes;
refusing to eat what is offered, or to eat at all;
challenging behavior at mealtimes;
not being able to eat with others present;
your child shows stress, anxiety, or fear during meals;
stress, worry, or fear in parents/caregivers while feeding the child;
bribing, threats, or shouting at mealtimes;
a need for distraction and/or a reward for eating;
unpleasant interactions between parents/caregivers and the child at mealtimes.

Red flags

Which red flags may signal that it is worth seeing a specialist?

Feeding that causes choking, gagging, vomiting, and/or coughing;
Limited food preferences;
Difficulty maintaining nutrition and/or hydration;
Dependence on tube feeding or oral supplements;
Difficulty chewing or swallowing;
Fatigue during feeding;
Your child refuses to eat or drink;
Difficulty eating in certain situations;
Parents and caregivers feel stressed or exhausted.

What ARFID is

ARFID (Avoidant/Restrictive Food Intake Disorder) is an eating disorder that shows up as limited food intake, refusing certain foods or food groups for specific reasons, such as the texture, color or taste of the food, or because of a fear of negative consequences of eating — for example vomiting or stomach pain.

Criteria for this disorder:

An eating or feeding disturbance, for example an apparent lack of interest in eating, avoidance based on the sensory characteristics of food, concern about negative consequences of eating, shown by a persistent failure to meet appropriate nutritional and/or energy needs, associated with one or more of the following:

Significant weight loss, or the expected weight gain not happening, or slowed growth in children.
Significant nutritional deficiency.
Dependence on enteral feeding or oral nutritional supplements.
Marked interference with psychosocial functioning.

The eating disturbance is not linked to a co-occurring illness and is not explained by another mental disorder. If the eating disturbance occurs in the context of another mental disorder, the severity of the eating disturbance goes beyond what is usually associated with that condition or disorder, and requires additional clinical attention.

Concern about eating that cannot be explained by a lack of available food or by an associated culturally sanctioned practice. This eating disturbance does not occur exclusively during anorexia or bulimia, and there are no signs of a disturbance in how one’s own body weight or shape is experienced.

Signs of ARFID

Because ARFID includes a range of different types of difficulty that contribute to avoiding or restricting food intake, there is a wide range of possible signs and symptoms, not all of which will necessarily occur in one person.

Possible signs of ARFID include:

Eating a certain number of foods, but overall much less food than is needed to stay healthy.
Finding it hard to recognize feelings of hunger.
Feeling full after only a few bites and forcing oneself to eat more.
Long mealtimes becoming an obligation.
Not eating at all, especially when busy with something else.
Sensitivity to certain features of some foods, such as texture, smell or temperature.
Seeming like a “picky eater”.
Always the same meals.
Always eating something different from everyone else.
Eating only foods of a similar color, for example beige.
Trying to avoid social events where food would be present.
Strong anxiety while eating, chewing food very thoroughly, small sips and bites, and so on.
Weight loss, or not gaining weight as expected.
Developing a nutritional deficiency, for example anemia because of not enough iron in the diet.
Needing to take supplements to make sure nutritional and energy needs are met.

An eating disorder as a red flag for autism spectrum disorder (ASD)

Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by deficits in social communication and by the presence of restricted interests and repetitive behavior.

Some studies show that between 4% and 23% of people with an eating disorder also have autism spectrum disorder. Some studies show that anorexia is the most common eating disorder among people with autism.

Why do people with autism also develop eating disorders?

In many people with autism, sensory processing is different, and they may find the smell, taste and texture of certain foods unpleasant or repulsive.

For some people this can lead to a very limited diet, and sometimes it can lead to developing an eating disorder.

Conclusion

Feeding problems in children are many-sided and can be linked both to natural stages of development and to serious medical or psychological conditions.

It is important to distinguish between ordinary picky eating and more serious disorders such as ARFID or eating disorders.

Parents should pay attention to changes in their children’s eating habits and seek help from specialists if feeding problems persist or get worse, or affect the child’s growth and development.

Sources:

Your Child Won’t Eat Anything. Is It an Eating Disorder?

Contents

Children who don’t eat: how common is it?

Why a child does not eat

Limited appetite

Neophobia and other natural stages of development

Picky eating

Disorders in which a child eats nothing

Eating disorders (ED)

Feeding disorders in children

What is pediatric feeding disorder (PFD)

Medical

Nutrition domain

Feeding skills domain

Psychosocial domain

Red flags

What ARFID is

Signs of ARFID

An eating disorder as a red flag for autism spectrum disorder (ASD)

Conclusion