Sensory Food Aversions in Infants and Toddlers
Sensory Food Aversion (SFA) or picky eaters” and the importance of distinguishing between children who experience minor food aversions and those for whom their reluctance to eat may become a serious feeding problem. Many studies reported, 25-30 percent of parents are concerned that their child is a picky eater. Researchers have found that many picky eaters have sensory food aversions that cause them to eat only certain types of food. SFA is the most common feeding disorder seen in Picky Eater and grow Up Clinic Jakarta Indonesia.
Sensory Food Aversions is one of the most common feeding disorders during the first 3 years of life, when young children are transitioned to self-feeding, and when issues of autonomy and dependency have to be negotiated between parents and child. “Picky eaters” and the importance of distinguishing between children who experience minor food aversions and those for whom their reluctance to eat may become a serious feeding problem.
Sensory aversion of food: child eats mostly carbs, milk, cheese and only certain color (white or close to white), sometimes crunchy food: dry cereal (if cereal gets wet in milk, it will be rejected), pizza and chips. The child drinks juices from closed container, so this child does not see color. Since parents started introducing and re-introducing new textures, foods, the child started exploring each piece of food very carefully (visually, then touch and smell) before making decision. Any colored food, vegetables, fruits create tantrums. Children with SFA consistently refuse to eat certain foods because of taste, texture, smell, and/or appearance. This is different from children who refuse to eat a particular food one day, but eat it the next. Food aversions are common and vary in severity – some children refuse only a few specific foods and others refuse entire food groups, such as vegetables, fruits or meats. While SFA can affect people of all ages, it becomes evident when young children are introduced to baby and table food. Now this child tolerate touching colored food and removes it with hand. Child presents with tongue protrusion, decreased awareness/oral-motor control.
The sensitivity to taste, texture or the smell of foods runs in families. Just as peoples’ vision can vary, so can the ability to taste. Studies have found that in general, people fall into three groups: non-tasters, tasters and super tasters. Super tasters have the largest number of taste buds on their tongues; therefore, foods have a much stronger taste, making many foods unappealing for them and often causing SFA.
Sign and Symptoms
Children with SFA have reactions to certain foods that can be as mild as grimacing or as severe as gagging, spitting out the food or even vomiting. After experiencing the initial reaction, children with SFA usually refuse to continue eating that particular food and can become very distressed if forced to do so. In fact, after a bad experience, some children tend to generalize and refuse foods that look and/or smell like the aversive food. For example, children with an aversion to peas may generalize the dislike to include all green vegetables. Many children with SFA also are reluctant to try new foods for fear of having another episode, such as gagging or vomiting. Instead, they may eat a limited number of foods that they know are safe and will not cause a reaction. Some children are so sensitive that they will refuse to eat any foods that touch other foods on their plates, while others eat only foods of specific brand names or from a specific restaurant. For example, some children with SFA will eat only chicken nuggets if they come from a specific fast-food chain.
Children with sensory food aversions selectively refuse to eat certain foods related to the taste, texture, smell, and/or appearance of these particular foods. However, they eat better if they are offered preferred foods. This feeding disorder usually becomes apparent during the early years, when infants are introduced to various types of baby food and table food. Typically, when specific foods are placed in the mouth, the aversive reactions range from grimacing and spitting out the food to gagging and vomiting. After an initial aversive reaction, the children often refuse to eat any more of that particular food and frequently they generalize to other foods that seem to remind them of the aversive food (eg, refusing to eat any green vegetables after having had an unpleasant experience with spinach). However, since most children experience these aversive reactions when they are young and preverbal, they only express reluctance and fear to try certain foods, and they are often unable to explain why they are scared. Although many children may refuse to eat a few foods, some children generalize to the point that they refuse whole food groups (eg, vegetables, fruits, meats). Parents often report that these children are limited to very few foods, that they refuse to try any new foods, and in extreme cases, that they insist that one food should not touch another food on the plate, or that they accept food only if it is prepared by a certain company (eg, McDonald’s chicken nuggets or Domino’s pizza).
If a child with SFA refuses to eat foods from an entire food group, such as vegetables or meats, his or her diet may lack vitamins, minerals and/or proteins that are important for a child’s health. In addition, if children reject foods that require significant chewing, such as meats or hard vegetables, they may fall behind in oral motor development because of the lack of experience with chewing. Delayed motor development can lead to difficulty with articulation. There also may be long-lasting implications of SFA. It can cause older children to avoid social situations, such as birthday parties, sleepovers or summer camp, that require them to eat in front of others because they are embarrassed they aren’t able to eat the same foods as their peers.
If children refuse many foods or whole food groups, their limited diet may lead to specific nutritional deficiencies (eg, protein, vitamin, zinc, or iron deficiencies). If children refuse foods that require significant chewing (eg, meats, hard vegetables, or fruits), they may fall behind in their oral motor and language development. The children’s refusal to eat various foods may also create conflict within their families, and, as the children get older, they may avoid social situations because of their embarrassment that they cannot eat various foods like their peers. Since sensory food aversions are common and occur along a spectrum of severity, the diagnosis of a feeding disorder should only be made if the food aversions result in either nutritional deficiencies, oral motor delay, family conflict, or social anxiety.
In addition to their sensitivity to certain foods, many of these children experience problems in other sensory areas as well. Parents may recall that as toddlers these children did not like to walk barefoot on sand or grass, that they did not like their hands to get “messy,” that they objected to labels in their clothing, that they were reluctant to change from long pants to short pants, or that they were very sensitive to odors or loud noises. Frequently, these difficulties in other sensory areas improve with age, but some children continue to struggle with these hypersensitivities as they get older.
Other authors have referred to this eating disorder as “selective eating,”“choosy eaters,”“picky eaters,” and “food neophobia.”19 Some studies have explored whether taste sensitivities are heritable, and various models of genetic transmission have been suggested, such as multilocus and multiallele models, a two locus model, and specific changes on gene . Other studies have postulated that certain aspects of the eating environment, such as exposure and the social affective context in which the food is offered, can have a strong influence on food preferences and shape-selective food refusal. In summary, these studies suggest that both genetic predispositions and the eating environment have an effect on children’s food preferences.
- The first priority of treatment has to be directed toward the nutritional adequacy of the children’s diet. If the diet is deficient in specific nutrients (eg, protein, vitamins, zinc, or iron), supplementation with these specific nutrients should be initiated. However, these children often have difficulties in taking specific supplements and it may be necessary to explore different flavors or start with a small amount to allow them to get used to the taste or texture of the supplement. This supplementation is very important in order to alleviate the parents’ anxiety about the children’s poor diet, and to allow the behavioral program to proceed.
- Current Treatment includes: general sensory integration techniques, brushing protocol, chewy tubes, massage, nuk brush, blowing bubbles, verbal/tactile cues for lips closure and tongue movement. Any additional suggestions for treatment besides waiting for maturation of somato- and neuro-sensory systems
- Since these children are usually fearful of trying new foods, making them hungry, coaxing them, threatening them, or punishing them are usually ineffective in helping them overcome their fear of new foods. On the contrary, these interventions usually make them more anxious and more reluctant to try new foods. Although many children cannot explain why they are scared to try new foods, they express fear verbally and in body language, and some of them become combative if they are forced to eat new foods. Consequently, treatment needs to address their fearfulness. In clinical practice, several children have responded well to being rewarded with points for their courage in trying each bite of a new food of their choosing. When reaching 10, 30, and 50 points, the children earn increasingly larger rewards. The emphasis on having courage distracts from the food itself and increases the confidence and self-esteem of these children. However, some children are so anxious that medication should be considered to manage their anxiety and to facilitate the behavioral intervention. Unfortunately, no controlled treatment studies for this eating disorder are available.
Disabled children suffer not only from their primary disease, but also from other complications, including food refusal. The purpose of this study was to elucidate the relationship between these conditions and food refusal in disabled children. The effectiveness of feeding therapy in treating food refusal was also examined. The study subjects were 67 disabled children (35 boys and 32 girls; mean age at initial examination: 6.5 years, SD: 6.0 years) who attended the Nippon Dental University Hospital between April 2004 and August 2008. Of them, the 13 subjects who were diagnosed as those who refused food received feeding therapy combined with desensitization therapy for hypersensitivity. Approximately 20% of the subjects showed food refusal symptoms. Primary disease, respiratory impairment and gastroesophageal reflux were not causes of food refusal in this population. There was a significant relationship between food refusal and hypersensitivity (p = 0.021). After receiving feeding therapy, six of the seven subjects with hypersensitivity but without dysphagia at initial examination recovered from food refusal. Food refusal did not significantly correlate with tube feeding. Hypersensitivity and/or tube feeding may induce food refusal. For subjects with these conditions, feeding therapy combined with desensitization therapy is effective in achieving recovery from food refusal.
Parents of children with autism spectrum disorder (ASD) frequently report child food refusal based on characteristics of food. Our study sought to determine whether parent report of food refusal based on the characteristics of food was greater in children with ASD than in typically developing children, associated with a greater percentage of foods refused of those offered, and associated with fruit and vegetable intake. A modified food frequency questionnaire was used to determine overall food refusal as well as fruit and vegetable intake. Parent-reported food refusal related to characteristics of food (eg, texture/consistency, temperature, brand, color, shape, taste/smell, foods mixed together, or foods touching other foods) was compared between 53 children with ASD and 58 typically developing children aged 3 to 11 years in the Children’s Activity and Meal Patterns Study (2007-2008). Children with ASD were significantly more likely to refuse foods based on texture/consistency (77.4% vs 36.2%), taste/smell (49.1% vs 5.2%), mixtures (45.3% vs 25.9%), brand (15.1% vs 1.7%), and shape (11.3% vs 1.7%). No differences between groups were found for food refusal based on temperature, foods touching other foods, or color. Irrespective of ASD status, the percentage of foods refused of those offered was associated with parent reports of food refusal based on all characteristics examined, except temperature. Food refusal based on color was inversely associated with vegetable consumption in both groups. Routine screening for food refusal among children with ASD is warranted to prevent dietary inadequacies that may be associated with selective eating habits. Future research is needed to develop effective and practical feeding approaches for children with ASD.
1. If child has gagged or vomited while eating a certain food:
- Do not offer that food again.
- Continue eating the food and other foods your child may not like so that he or she can see you eating and enjoying these foods. Young children want to do what their parents are doing. However, you should not try to coax your child into eating these foods. The harder you try, the harder he or she will resist.
- Give your child foods he or she can tolerate, while still incorporating all food groups. •
2. If child grimaces after eating a certain food, offer your child the food later, but do not force the issue or your child will likely become anxious.
3. Children with SFA will eat foods they prefer. If your child resists eating broccoli, offer another green vegetable, such as green beans.
4. These tips are for children who consistently refuse to eat certain foods. Children with SFA appear anxious or fearful of the foods they dislike. This is different from children who refuse to eat a particular food one day but eat it the next day as a way to exercise control over a parent.
- Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
- Chatoor I. Feeding disorders in infants and toddlers: diagnosis and treatment. Child Adolesc Psychiatr Clin N Am. 2002;11(2):163-183.
- Timimi S, Douglas J, Tsiftsopoulou K. Selective eaters: a retrospective case note study. Child Care Health Dev. 1997;23(3):265-278.
- Rydell AM, Dahl M, Sundelin C. Characteristics of school children who are choosy eaters. J Genet Psychol. 1995;156(2):217-229.
- Marchi M, Cohen P. Early childhood eating behaviors and adolescent eating disorders. J Am Acad Child Adolesc Psychiatry. 1990;29(1):112-117.
- Pliner P, Loewen ER. Temperament and food neophobia in children and their mothers. Appetite. 1997;28(3):239-254.
- Morton CC, Cantor RM, Corey LA, Nance WE. A genetic analysis of taste threshold for phenylthiocarbamide. Acta Genet Med Gemellol (Roma). 1981;30(1):51-57.
- Olson JM, Boehnke M, Neiswanger K, Roche AF, Siervogel RM. Alternative genetic models for the inheritance of the phenylthiocarbamide (PTC) taste deficiency. Genet Epidemiol. 1989;6(3):423-434.
- Kim U, Jorgenson E, Coon H, Leppert M, Risch N, Drayna D. Positional cloning of the human quantitative trait locus underlying taste sensitivity to phenylthiocarbamide. Science. 2003;299(5610):1221-1225.
- Tamura F, Kikutani T, Machida R, Takahashi N, Nishiwaki K, Yaegaki K. Feeding therapy for children with food refusal. Int J Orofacial Myology. 2011 Nov;37:57-68
- Hubbard KL, Anderson SE, Curtin C, Must A, Bandini LG. A comparison of food refusal related to characteristics of food in children with autism spectrum disorder and typically developing children. J Acad Nutr Diet. 2014 Dec;114(12):1981-7.
- Penanganan Terkini Sensory Food Aversions
- Pediatric Reference: Feeding Difficulties, Food Aversion and Eating Disorders
- Sensory Food Aversions in Infants and Toddlers
- Cause of Food Aversion
- The SOS (Sequential Oral Sensory) Approach to Feeding in Food Aversion
- Classification of Food Aversions
- Common myths: Food Aversions in Children
- Food Aversions and the Gut-Brain Connection
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