NHD PAEDIATRIC HUB FACT FILE
Understanding fussy eating
Fussy eating is common in children, particularly during the toddler years, and can sometimes persist. It is a normal developmental phase, often called the 'neophobic stage', where children may refuse new foods or foods they previously liked. This behaviour is thought to be an evolutionary mechanism to avoid unsafe foods. Although it can be worrying, most cases resolve over time with simple strategies.
Assessment guidelines for fussy eaters
When assessing fussy eating, follow the dietetic care pathway under these categories:
1. Anthropometrics
Record weight, height, and BMI (if age-appropriate).
Plot growth on a centile chart:
Has there been weight loss, static weight, or dropped centiles?
Consider birthweight and historical growth trends.
Measure head circumference if relevant.
2. Biochemistry
Blood tests are usually unnecessary but may be considered for: vitamin D, iron, folate, ferritin and B12.
In severe cases, further testing might be needed such as looking at Vitamin A and Zinc.
Be mindful of the trauma associated with blood tests for children and where testing can be done.
3. Clinical
Check for underlying conditions impacting eating or nutritional requirements.
Assess bowel health:
Is constipation reducing oral intake?
Are they suffering with diarrhoea so have additional losses?
If their bowel habits are worrying, do they need a referral to the GP or Paediatrician for further assessment?
Review other developmental milestones (e.g., speech delays).
Has there been any past clinical conditions which impacted their relationship with food in the past? (i.e. needing an NGT tube for a period during weaning)
4. Dietary
Evaluate feeding patterns:
Are they eating regularly and following a routine?
Do they eat better in specific environments or with distractions?
Identify preferences:
Textures, colours, sensory sensitivities, or specific foods.
Consider if there are any nutritional deficiencies in their diet. Some of the main ones you may want to identify include:
Calcium such as yogurt, milk, cheese
Iron such as red meat, baked beans, fortified cereals
Vitamin D (usually sun exposure or a supplement)
Omega 3 such as oily fish, nuts, seeds and plant oils
Fibre such as fruit and vegetables
Zinc such as meats, seeds and legumes
Consider parental behaviour:
Are parents calm or forceful at mealtimes?
Are they engaging the child in messy play and food exploration?
Are they causing any anxiety at mealtimes?
Are they eating with the child at mealtimes?
Based on these suggestions and more, you would then come up with your own PASS statement and work with the family to come up with some realistic goals which are SMART-focused.
Examples of generic goals and actions for a Dietetic Plan
Food variety
Ensure Parent’s offer a variety of foods from each food group. This could include offering carbohydrates, protein, fat and vegetables for both lunch and dinner.
Small is best
Use small plates and portions to prevent overwhelming the child. Potentially use their favourite plate to try to make the mealtime more fun.
Multivitamins
Commence a suitable age-appropriate multivitamin to address some of the deficiencies you may be concerned with
Food frequency
Expose children to new foods multiple times. Select a food to introduce which is similar in colour/taste or shape so it may appear more familiar to them.
Parents at mealtimes
Reduce parental anxiety at mealtimes and ensure these are not too long.
Fortified foods
To consider swapping or adding in some fortified foods which are fortified in iron and calcium. Look at the Paediatric Hub for our spreadsheet on this.
Key strategies to help parents manage a child's fussy eating
Causes of iron deficiency range, but it’s important to detect the cause in the assessment. Possible causes include the following:
1. Establish a regular routine
Offer 3 meals and 2–3 snacks daily, spaced 2–3 hours apart.
Avoid grazing throughout the day.
Use child-sized portions (e.g., fist-sized carbs, palm-sized protein, cupped-hand vegetables).
2. Create a positive mealtime
Stay calm and avoid reacting negatively to food refusal or throwing.
Keep mealtimes to 30 minutes. Remove uneaten food without comment.
Praise good behaviour (e.g., sitting at the table, trying new foods).
Eat together as a family in a relaxed, distraction-free environment.
3. Encourage exploration and play
Allow messy eating to familiarize your child with different textures.
Offer new foods alongside familiar ones, starting with small amounts.
Make meals fun and colourful.
4. Avoid bribery or food-based rewards
Do not use dessert as a reward for eating a meal or withhold it as punishment.
If dessert is planned, serve it regardless of how much of the meal is eaten.
Use non-food rewards (e.g., stickers, playtime).
Differential diagnosis
It’s important to distinguish between: the following:
Picky Eating: A common developmental stage with normal growth patterns.
Paediatric Feeding Disorder (PFD): Eating difficulties related to medical, nutritional, or developmental issues.
Avoidant/Restrictive Food Intake Disorder (ARFID): A severe avoidance of food due to fear, sensory issues, or a lack of interest, often impacting weight and health.
For more detailed assessments, consult the SOS differential diagnosis decision tree and speak to other members of your dietetic team if you are uncertain.
Fortified foods and gluten-free fortified foods Database Table
Want to know more about fortified products in iron and calcium(including fortified gluten-free products)? We have released a brand-new database for this!
Some foods may surprise you...