Restrictive eating in children can present due to a wide range of underlying conditions, including autism spectrum disorder (ASD), avoidant/restrictive food intake disorder (ARFID), sensory processing difficulties, anxiety around food, and early signs of eating disorders such as anorexia nervosa, often linked to undiagnosed neurodevelopmental or psychological conditions. (1) 

The consequences of restrictive eating can be significant. These include growth faltering, micronutrient deficiencies, and considerable stress at mealtimes — both for the child and their family — due to the pressure to ensure adequate intake. (2) This stress can further exacerbate the restrictive behaviours and lead to long-term difficulties in feeding and nutrition. 

Dietitians play a key role in the management of restrictive eating by ensuring the nutritional adequacy of the child’s diet, monitoring growth and weight trends, and advising on appropriate food fortification and supplementation. (3) However, care is best delivered through a multidisciplinary team (MDT) approach that can address the complex and interacting factors contributing to restrictive eating. The MDT may include a paediatrician, clinical psychologist, dietitian, and, where sensory difficulties are pronounced, an occupational therapist. (4)

Despite this recognised best practice, MDTs dedicated to restrictive eating are few, and many children are managed by dietitians alone. This presents a number of challenges. While dietitians can support dietary adequacy, without psychological and sensory interventions, they are often unable to achieve meaningful progress in expanding food variety or improving mealtime behaviours. (1)

To explore these issues further, it is helpful to look at case studies that demonstrate the complex challenges faced by children, their families, and healthcare professionals when managing restrictive eating, particularly in settings where multidisciplinary support is limited.

Background:

9-year-old female referred by GP to community dietetic service with concerns around highly selective eating and poor weight gain.  The child is known to community paediatric services and has a diagnosis of autism.  The child was weaned normally and took a variety of foods and textures until around 3years of age. Since then, the variety has decreased, and the child now has five safe foods, which she consumes daily.  There is heightened anxiety around what will happen if these safe foods decrease further. 

The child dislikes playing with sand and dislikes her hands getting dirty or wet.  She can’t tolerate slime and prefers dry, crispy foods.  The child is in mainstream education but finds the dinner hall overwhelming with sounds and smells.

Growth:

There has been minimal weight gain for the last year, and weight has fallen from the 25th centile to just below the 9th centile; height continues along the 25th centile.  Mum feels the child looks slim.

Health:

Mum reports concerns around recent bruising and significant mouth ulcers; the child also has low energy levels.

Blood test results show low vitamin C, low vitamin D, and low haemoglobin suggestive of iron deficiency anaemia.  All other nutritional bloods are within normal range

Dietary intake:

White bread x two slices daily (toasted, no crusts), crisps (brand/flavour specific), chicken nuggets, rice cakes, digestive biscuit.  Will take tomato sauce with chicken nuggets.  Drinks flavoured water (brand specific), drinks apple squash, and 200ml milk daily

Sensory issues:

Struggles with texture, prefers crispy texture.  Struggles with temperature – prefers lukewarm/cold food.  Unable to be around others eating moist food such as spaghetti bolognese or dishes with a sauce, and unable to tolerate strong smells. 

1. Need to consider a multivitamin in view of deficient levels and gaps identified from diet history – tried over-the-counter chewy gummies, which were poorly tolerated.  Options include vitamin spray, vitamin sprinkles that can be added to ketchup, and prescribed supplements may be an option; however, palatability is often problematic.  Discussed with parents' agreement to trial sprinkles mixed with ketchup.

2. Concern re faltering growth, unable to increase calories or portion sizes due to restrictive eating – discussed options with parents.  Agreed to trial of gold top milk to increase calories, advised could trial oral nutritional supplements if needed, but acceptance may be problematic.

3. Discussion around strategies to help improve dietary intake – food chaining strategies discussed – to initially aim to introduce other brands of chicken nuggets, then to trial breaded instead of battered, then to trial chicken goujons, then to trial fish goujons

4. Discussion around school lunchtimes – did meals have to be in the dinner hall, or was there a quieter place they could be eaten? The head teacher agreed to a trial of meals in her office with a teaching assistant to see if it could improve intake at lunchtime.

5. Messy play encouraged to be offered both at school and at home to try and improve tolerance around different textures and acceptance of the same.

Biochemistry levels had all improved and were within normal reference ranges, the child continues to tolerate the sprinkles mixed with ketchup and appeared unaware that they were mixed in with food.  Weight had increased slightly moving upwards towards 9th centile as opposed to falling further away.  There had been minimal change to oral intake although school lunchtime in head teacher office was causing less distress.  Parents felt at times there was better engagement in messy play and hoped this would help improve variety.

While restrictive eating impacts on nutritional status, including growth and biochemistry, it also increases family anxiety around meal times and the challenges faced to try and widen the intake.  As paediatric dietitians, it is our role to explain to the families that the young person is not eating a wider variety of foods due to their neurodiversity and that this is more than ‘fussy eating’. 

Parents should be supported to understand the challenges faced by the children and young people when exposed to new foods and helped to understand their behaviour and reaction to this.  As discussed by Kate Roberts in January 2025, this is an extremely challenging group of young people to work with and results and improvement in oral intake can take a prolonged period of time, often months and years.

It is important that families have realistic expectations around the care plan for the child and that as dietitians we ensure key concerns such as growth and micronutrient status are tackled alongside providing strategies to help widen the diet.

An area that remains challenging for this patient group can be finding a broad-spectrum micronutrient supplement that is tolerated by the young person.  There is a growing expansion of over-the-counter micronutrient supplement options, and it is important as paediatric dietitians that we guide families to ensure they choose supplements that are safe and appropriate for the child/young person.  Supplements are now available in a variety of formats, including tablets, chewy gummies, powder, sprays, and patches, with evidence emerging around the uptake of micronutrients from some of the newer delivery methods, such as sprays and patches. 

The management of restrictive eaters is best managed as part of a multi-disciplinary team; however, this is not often the case, and dietitians are frequently left to manage these young people without an MDT.  As dietitians, we are able to support these families by ensuring the young person is growing adequately and has an adequate intake of micronutrients, recommending supplements where appropriate. 

We can also discuss strategies such as messy play, food chaining, and general good mealtime behaviours to help, as well as to reduce stress and anxiety around meal times.  The management of restrictive eating requires both parents and health care professionals to be realistic in their expectations. Families need to understand that changes may take months to happen and need to be realistic about the time frames around this.  Advice given to families and young people for restrictive eating should be patient-centred and specific to the young person to ensure they grow and thrive into adulthood despite their challenges around food.