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• Dr.Tugume Elias
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• 24 February, 2025

Understanding why children refuse food

Child Food Refusal: Causes, Diagnosis, and Management

Introduction
Child food refusal is a common concern among parents and healthcare providers. While it is often part of a child’s natural exploration of food, in some cases, it may indicate underlying medical or psychological conditions that require intervention. Understanding the causes, classifications, and management of food refusal can help prevent nutritional deficiencies and feeding disorders.

Classification of Food Refusal
Food refusal can be broadly classified into two main types:
1.    Active Refusal: The child actively resists food by crying, turning their head, spitting out food, or vomiting when forced to eat.
2.    Passive Refusal: The child appears indifferent to food, allowing it to be placed in their mouth but letting it fall out without chewing or swallowing.
Another classification based on etiology includes:
•    Primary (Psychological) Anorexias:
o    Simple anorexia due to poor feeding habits.
o    Psychic anorexia caused by hypersensitivity or psychological distress.
o    Psychogenic anorexia linked to social conflicts (e.g., parental disputes, overprotection, neglect).
•    Secondary Anorexias:
o    Caused by organic diseases such as infections, gastrointestinal disorders, metabolic diseases, renal or endocrine conditions, and neurological disorders.
o    Medication-induced anorexia from antibiotics, anticonvulsants, or immunosuppressants.

Etiology of Food Refusal
Food refusal in infants may stem from a combination of genetic, environmental, and behavioral factors. Key contributing factors include:
•    Developmental Changes: Transitioning from breastfeeding to solid foods.
•    Parental Feeding Practices: Force-feeding, rigid meal schedules, and inappropriate food choices.
•    Sensory Issues: Hypersensitivity to food textures, flavors, or temperatures.
•    Medical Conditions: Digestive disorders (GERD, celiac disease), infections, or deficiencies (iron, vitamins A, C, D).
•    Psychological Factors: Anxiety, depression, or a history of stressful feeding experiences.

Epidemiology
Food refusal is reported in up to 20-30% of healthy children and 80% of children with developmental disorders. Picky eating is particularly common in children under three years old, with most cases resolving naturally.

Diagnosis
Proper diagnosis requires:
•    Medical History: Assessing feeding patterns, growth trends, and potential underlying illnesses.
•    Physical Examination: Checking for signs of malnutrition, developmental delays, and gastrointestinal or respiratory conditions.
•    Laboratory Tests: Blood tests, stool analysis, and imaging studies when organic diseases are suspected.
Red Flags Indicating Organic or Behavioral Issues:
•    Chronic vomiting, diarrhea, or blood in stools.
•    Dysphagia or difficulty swallowing.
•    Weight loss or failure to thrive.
•    Extreme food selectivity or food fixation.
•    Anxiety or distress during feeding.

Treatment Approaches
The management of food refusal depends on its cause and severity. Treatment strategies include:
1. Medical Treatment
•    Address underlying conditions such as infections, gastrointestinal diseases, or metabolic disorders.
•    Nutritional supplementation for deficiencies.
•    Avoid unnecessary medications, though appetite stimulants like cyproheptadine may be considered in severe cases.
2. Nutritional Management
•    Establish structured meal schedules and avoid frequent snacking.
•    Increase food variety and caloric density in cases of malnutrition.
•    Provide micronutrient supplements if needed.
•    Consider enteral feeding in severe malnutrition.
3. Behavioral Therapy
•    Positive Reinforcement: Rewarding desirable eating behaviors.
•    Desensitization: Gradually introducing new foods.
•    Environmental Modifications: Creating a calm mealtime setting and avoiding distractions.
•    Parental Guidance: Educating caregivers on appropriate feeding techniques.

Conclusion
Food refusal in children is often benign and resolves with time, but persistent cases require careful assessment to rule out medical or psychological conditions. A multidisciplinary approach involving pediatricians, nutritionists, and psychologists is essential for effective management, ensuring the child receives adequate nutrition for optimal growth and development.

Compiled by Tugume Elias "Sostine"

Med. Sup. | Anesthesiologist | Pediatrician
Prof. Ms Anes. & Crit. Care | Adv. Ms Clin. Peds.