PERSONAL PRACTICE

Food refusal in the sensory-sensitive childGillian Harris

Case study

A 4-year-old boy, Thomas, attended a feeding clinic with his

parents, both middle-class professionals. Thomas had no medical

problems, but was refusing to eat and to chew solid foods. The

parents reported that Thomas’s food refusal meant that every

mealtime took over an hour, with much coaxing, rewarding and

bribery. The parents reported a history of force feeding, and

admitted that they still shouted at Thomas when he ate or drank

very slowly and that this frightened him. Thomas was currently fed

blended or pureed food, mostly by his mother. He still drank milk,

but very slowly. Some of the foods that he was fed he would eat

quite quickly, and would feed himself some food at nursery school.

Thomas’s parents were very worried about his growth; and

Thomas’s weight was on the 2nd centile, his height on the 9th

centile. Thomas’s height and weight had been following these

centiles since his first year, and so he seemed to be getting enough

calories to maintain growth along appropriate centile lines.

He was not suffering from constipation, and had had a blood

test to rule out anaemia, both of which commonly cause poor

appetite and intake.

Further history

Thomas had been formula-fed, and although he took his feeds

quite well from birth he refused the bottle from 3 months and

had to be fed by syringe. He was introduced to solid foods at

5 months and accepted pureed food without too much problem.

However, as soon as lumpy solids were introduced at 8 months,

Thomas began to gag and ‘choke’ on the lumps. He also did not

like to pick up finger foods.

Thomas dislikes getting his hands and face dirty; he will not

touch sand or put his feet down on grass. He startles easily at

loud noises and reacts negatively to food smells. Thomas attends

nursery school, but is rather shy in interactions with others.

Thomas will eat quite specific pureed or mashed foods such as

Weetabix, fromage frais and yoghurts without lumps; he shows

preferences for specific flavours, and it is more difficult to feed

him some foods than others. Thomas’s parents have tried putting

different foods in the empty yoghurt pots to trick him, and have

mixed new foods into the purees that Thomas would accept. This

led to refusal of these foods.

If Thomas is fed a blended food with any small lumps in it he

will vomit the food back immediately. He will put some more

Gillan Harris Phd MSc BA CPsychol is a Senior Lecturer in Applied

Developmental Psychology at the School of Psychology, University of

Birmingham, Birmingham, UK, and a Consultant Clinical Psychologist at

the Children’s Hospital, Birmingham, UK.

PAEDIATRICS AND CHILD HEALTH 19:9 43

solid foods such as chocolate in his mouth. He will suck and

swallow fruit flakes, he will suck Smarties and chocolate buttons,

and he will lick crisps. Thomas will suck and swallow small

pieces of biscuit; he also chews small jelly sweets but then spits

them out.

Thomas is hypersensitive to most sensory input.

Relevant family history

Thomas’s parents are both short: the mother 5 ft 1 in, the father

5 ft 4 in. We would therefore expect Thomas to be short and his

height to follow along the lower centiles. Thomas’s parents did

not, however, realize this and Thomas’s relatively short stature

contributed to their anxiety about his intake.

Thomas’s father showed the same feeding behaviour when he

was a baby; he had to have his food blended and was very

‘fussy’. Food refusal because of texture has a genetic component.

The paternal grandmother helps in the home with Thomas’s

mealtimes and continues to force feed him as she did his father.

Points from the history

� Sometimes, when a child is reported as choking on food, this

is really just a gag response. Food is caught on the back of the

tongue and the child coughs and retches to clear the food

from the tongue. This might then be followed by a vomit,

especially in a child who has a history of vomiting (e.g. past

reflux).

� A vomit that is in response to food, such as a disgust vomit,

happens immediately, as soon as food is put into the mouth

and an attempt made to swallow it.

Alternate diagnoses

All children go through a ‘faddy’ developmental stage from the

age of 18 months to 2 years (the neophobic stage), during which

they refuse to eat both new foods and some foods that they have

eaten before. Most children grow out of this stage, and the

neophobic response diminishes up to the age of 5 years.

However, a few children continue with this acceptance of only

a limited range of foods past the age of 2 years.

Some children might be able to accept lumpy solid foods from

an early age and yet from the age of 18 months continue to refuse

all but a narrow range of foods of different textures. These

children are still likely to be highly anxious and sensory-sens-

itive, but rather than being sensitive to tactile stimulation, as

Thomas is, they are visually hypersensitive to changes in the

food’s appearance.

Force feeding can cause food refusal in any child, but children

who are texturally sensory-sensitive will show a specific refusal

to take more solid-textured foods and a reliance on pureed foods,

yoghurts, and bite-and-dissolve foods (such as biscuits, crisps

and chocolate).

Many young children dislike food and drinks with ‘bits’ in

them, but the texturally sensory-sensitive child will have

a history of gagging and retching in response to foods from the

first introduction of lumpy solid foods.

Sensory hypersensitivity and specific food refusal is more

often seen in children who are on the autistic spectrum; children

who attend the feeding clinic will often be diagnosed as ASD, but

not all of them meet the diagnostic criteria.

5 � 2009 Elsevier Ltd. All rights reserved.

PERSONAL PRACTICE

Intervention for parents

I explained to the parents how fear at mealtimes reduces appe-

tite, and that children are able to regulate the amount of food that

they eat to allow themselves to grow along expected centile lines.

I calculated Thomas’s expected height based on parental heights,

and they could see that he was growing as expected.

We agreed that they should pay attention to Thomas’s food

preferences and signals of satiety, with no force feeding, coaxing,

bribing, giving rewards for eating, shouting or arguing at meal-

times about the child’s eating. Mealtimes should last no longer

than 20 minutes.

I suggested that they give Thomas the foods that he prefers at

this point, rather than worrying about dietary balance, while they

try to get him back to enjoying mealtimes. I also suggested

that they give small regular meals frequently during the day,

because this reduces parental anxiety and maximizes the child’s

intake.

We discussed how to pair good attention with Thomas’s

mealtime, by talking to him or listening to a story, ensuring,

however, that the activities are contingent on eating; when the

eating stops so does the activity.

Thomas’s parents were also going to work on exposure to

different textured foods, slowly, using bite-and-dissolve foods

such as chocolate buttons or soft biscuits.

Take-home points

� Parents force feed because they are anxious about the child’s

growth or weight gain.

PAEDIATRICS AND CHILD HEALTH 19:9 43

� Some children can be more difficult to feed than others, and

may show a very rigid eating pattern which has nothing to do

with the parental mealtime management strategy.

� Choking, when reported in a child at mealtimes, might be

a gag response, which tells you that the child has difficulties

with certain food textures e usually small lumps in otherwise

smooth food.

� Parents often think that because a child won’t chew food

(they dislike the texture in the mouth) they can’t chew (that

there is some neurological or motor impairment).

� Parents might worry that the child will choke on textured

foods. A community speech and language therapist can

always assess the child and reassure the parents that the

child’s swallow is safe.

� Sensory-sensitive children who adhere to a limited range of

foods, in terms of either texture or visual presentation, are

highly anxious about eating new foods. These children do

usually accept new foods either in later childhood or in their

teenage years, and, even on a restricted diet, grow along

expected centiles and seem to maintain good health.

However, they only grow as would be expected if they are

allowed to eat the foods that they like; where these foods are

withheld then weight loss will follow.

Outcome

After 6 weeks mealtimes are calm and Thomas is allowed to eat the

amount of food that he wants to eat and then finish. He is fed the

food that he likes. He feeds himself yoghurts at nursery school, and

has begun to eat soft cakes and biscuits at home. A

6 � 2009 Elsevier Ltd. All rights reserved.