For parents of food allergic children mealtimes can be a daily problem. But a dose of expert knowledge can go a long way. At AAA:s invitation, Assistant Psychologist Lucy Spicer and Paediatric Dietitian Rebecca Brocklehurst, from the Children’s Allergy Service, Evelina London Children’s Hospital, took to the stage in the Learning Theatre of the Allergy & Free From Show, Olympia on July 5 to reveal some good ways to manage meal times.

Typical feeding development in children

 Feeding is a non-negotiable part of everyday living and essential for us to survive. It typically happens three times a day and is bound in cultural and societal values. It is usually at the centre of celebrations, eg  Birthday cake, Christmas Dinner and Eid . Feeding is considered as a highly pleasurable and social activity and so abnormal feeding behaviours can have a detrimental impact on the caregiver and the child ‘s quality of life .

      Feeding is a learned behaviour that occurs in a predictable, sequential progress ion that involves motor skills, sensory systems, behaviour, psychosocial components and communication. Typic al feeding development is where the child acquires feeding skills through observation and practice, usually from the care giver paired with developmentally appropriate food choices i.e.purees and in supportive environments. In healthy infants and toddlers, development of feeding skills occurs from 0 -24 months with individual validation in gaining the fine motor skills needed to be able to eventually self-feed.

      There is now increasing recognition of food allergy as another condition associated with feeding disorders. In a young child with suspected or confirmed food allergy, where at least one food group is already being restricted, fussy eating and feeding difficulties are likely to have a considerable impact on eating habits and food intake. Eating followed by feelings of satiety reinforces continued eating on the part of the child and re in forces the care giver to continue the typical, successful mealtime process. Conversely, eating followed by vomiting, abdominal pain or oral discomfort rein forces feeding avoidance and conditions the care giver to alter mealtime’s practices in search of success.

Causes of feeding difficulties in children with food allergies, including the role anxiety and sensory sensitivities can play:

 Anxiety can play a role in food refusal in children with allergies. Some children may exhibit food refusal based on a fear related to previous uncomfortable or painful experiences. This anxiety may “spill over” to foods that have not been identified as allergens yet. This may provoke anxiety nonetheless because of novelty, similar characteristics to an allergenic food, or unfamiliarity resulting from selective avoidance of that food. This may manifest in aversive behaviours around feeding including; excessive spitting out of food, crying/irritability at feeding time, eating extremely slowly, retching at the sight of the bottle or spoon, apparent difficulty in swallowing, throwing and pushing/hiding food away. These behaviours can understandably make mealtimes and feeding stressful for the caregiver and in turn mealtimes may feel like a ‘battle’.

      Parental anxiety regarding accidental exposure to food allergens and how it may serve as another reinforcer for inflexibility and food refusal in some children should also be considered. Parental anxiety may be communicated to the child verbally or non-verbally, with facial expression, tone of voice, and actions communicating fear to the child regarding food items or even environments in which food is present. For example, when at a birthday party, a parent may anxiously stand over the child to ensure they don’t come into contact with allergenic food. These levels of anxiety may serve as another reinforcer for inflexibility and food refusal in some children.

      By not being able to not expose the child to a variety of tastes due to necessary avoidance for foods, some children with allergies may not develop an oral motor pattern for feeding consistent with his or her chronological age, advancement and chewing. lf a child has oral motor skills below what is expected for their age, as a consequence of a lack of exposure to certain textures, caregivers may continue to present age typical foods, which if attempted by the child may result in gagging and vomiting (secondary to gag), which may then further reinforce food refusal and bring skill progression to a halt.

What difficulties might you see in a child who finds the sensory experience of feeding difficult?

More sensitive and actively avoids:

  • Prefer beige foods:
  • Covers nose
  • Avoids touching food
  • Loud environments avoided
  • Avoids change

      The strategies for sensory sensitivities in relation to feeding difficulties are outlined in more detail below and would include messy play to help children become more familiar with textures they find challenging. A meal planner to help children who prefer routine and predictability and find change difficult. Quiet mealtimes with minimal distractions will be helpful for children who find eating in a loud environment more uncomfortable.

Identifying factors that may be contributing to feeding difficulties:

 It is important to consider why a child might have feeding difficulties. The feeding difficulties we see in our clinics are more than ‘fussy feeding’ and the children/young people have very restrictive diets. A child may have feeding difficulties just because of their allergies and the negative experiences associated with this i.e. early experience of discomfort from food, having allergic reactions from foods, always being ‘suspicious’ of food and therefore food brings little enjoyment and may be a source of anxiety for the child. However, there may  also  be   other   factors contributing to the feeding difficulties including; sensory problems i.e. a dislike for certain textures and a hypersensitive gag, dysphagia (a disordered swallow) , rigid thinking style i.e. desire for predictability and sameness and repetitive behaviours, medical conditions that may affect appetite i.e. cardiac and renal or/and a history of abnormal sensory input i.e. being tube fed, having surgery or recurrent bout of tonsillitis .

      If a child has feeding diffiulties and is not interested in food or it causes significant anxiety, it can be extremely difficult for the caregiver and family. Feeding difficulties may impact on the family so that it is challenging to eat out at restaurants or with the family; siblings may copy the behaviour of the child with feeding difficulties, at mealtimes, several meals may have to be prepared every day. It can cause parental anxiety around worries about the child ‘s weight or their growth or nutritional adequacy. Mealtimes may be effortful and take a long time and parents may worry about their child not eating all day at school.

What do feeding difficulties look like?

  • Eating a very restricted range of foods or textures (selective eating) or asking for food
  • Avoiding/ refusing to sit down for meals or needing distraction (e. TV) to eat
  • Turning away, pushing the spoon away etc.
  • Anxiety/ disgust e.g. gagging or vomiting at the sight / smell / taste of food
  • Eating very small amounts
  • Refusing to self-feed
  • Spitting out food
  • Crying / screaming at mealtimes
  • High anxiety over new foods
  • Negotiating and/or using distraction techniques to avoid eating

Strategies for managing feeding difficulties and introducing new foods:

 What can maintain feeding difficulties at mealtimes:

  • Pressure to eat
  • Using food as a reward
  • Restricting access to preferred foods
  • Grazing, where there is no routine around mealtimes
  • Fixed idea about the “right” foods are, instead think of all food as food
  • Mealtimes taking too long (>20- 30 mins)

Tasting times/tasting ladder:

 Tasting times are a common strategy we use for children who are worried about trying new foods. This involves scheduling in a time once or twice a week for a child to ‘try’ a new food. We recommend the child picking a new food, this might be similar to a food that they already accept (see food chaining). The child may like to go to the supermarket to choose the new food with their parent/caregiver. The principle of tasting times is that it is kept low pressure and that progress is likely to be slow. It is an opportunity for children to gain experience with unfamiliar foods in a familiar setting and that new foods will hopefully gradually become more associated with preferred foods through repeated presentation.

      A further way to support tasting times is to use a ‘tasting ladder’. This is for children to have the opportunity to explore foods without any expectation or pressure to eat the unfamiliar food. This is where the process of ‘trying’ a new food down into smaller steps and helps to keep levels of anxiety low. A tasting ladder can be used to help a child feel successful at trying new foods by completing each step:

      Looking at the food-touching the food smelling the food – touching the food to the lips – kissing the food – holding the food in the mouth-chewing the food swallowing the food.

Messy play with food:

Messy play can be a really helpful strategy for children who are tactile sensitive, by helping them to desensitize from certain textures. It is a way to introduce foods in a non-threatening way, away from mealtimes. During messy play, there should be no expectation or encouragement for the child to eat the food but if the child tries the food on their own agenda, praise should be given,

      The foods should be graded on what the child can tolerate i.e. hard and dry textures like cereal are easier than wet and sticky textures like custard. You can also have fun with foods in other ways i.e. cooking or baking together or creating games out of food i.e. fruit bowling and finger painting with The agenda is to keep food playful.

Food Chaining:

Food chaining is a really good strategy to introduce and identify new foods for children to try. It is where a preferred acceptable food is matched as closely as other foods with similar sensory properties i.e. a different brand of French fries or trying a potato waffles if a potato smilie is accepted. It is likely to take multiple attempts, using the tasting ladder as a guide for the child to eventually accept the new food. By choosing a new food that is similar to an already accepted food, it helps to keep anxiety levels low as it is similar to something that is already in the child’s repertoire of foods.

Food Jagging:

Food jagging is where a child may get stuck on eating certain foods repeatedly. After some time, a child may get tired of this food and then may drop it or move on to a different food. This can often be seen as a complete rejection of the food. However, the previously preferred food may be able to be reintroduced over time, using the tasting ladder. To counteract food jagging, setting a menu where preferred foods are rotated may help to prevent this pattern.

Meal planner:

Children often respond very well to routine and knowing what to expect. A weekly meal planner can be used to plan the daily routine of three meals and two snacks that fits around the family’s lifestyle. By pooling all of the children’s food together, even if their variety is very limited, the parent can then decide when each food will be offered so that they are not consistently having the same meals. For example, if a child only eats two types of cereal, this can be offered on alternate mornings. Creating more variety at different mealtimes helps to prevent food jagging. It can also help with parental anxiety so that they feel more reassured that there is more variety in their child’s diet.

Nutritional Considerations for children with allergies:

 The main treatment at present for managing food allergies, is a patient specific elimination diet, avoiding offending food allergens and manipulating the diet to ensure the child gets achieves an adequate nutritional intake.  Some of the most common food allergies include cow’s milk, hen’s egg, wheat, soya, fish, peanut and tree nuts. Some children may have to exclude multiple allergens. These foods contribute essential nutrients and elimination can impact the nutritional status of a child. Some recent data indicates that around 9% of children with food allergies (non lgE and lgE mediated) within tertiary allergy services are affected by growth stunting. Cow’s milk elimination in particular has been identified as a risk factor. Furthermore, picky eating behaviours and feeding disorders can further contribute to the child ‘s restricted dietary intake.

There are many simple practical strategies that can be implemented to optimize the nutritional intake of a child with foods allergies and feeding difficulties, some are detailed below:

  1. Choose free/from alternative products that provide optimum nutrition. Many of the milk alternative drinks g. soya, oat, coconut, nut, contain varying amounts of energy, protein and micro nutrients. For younger children choosing a higher calorie milk alternative (50- 64kcal/100ml), with a higher protein content (1-2.7g/100ml) is preferable.
  1. Choose milk and dairy alternatives with added Many of the dairy free yogurts, custards and some dairy free cheeses are now fortified. For some children it is also useful to choose a milk alternative with added iron and/or iodine, in particular children taking a vegetarian/vegan diet or those having to avoid dairy and fish/ seafood due to their allergies. Some wheat/gluten-free cereals are also fortified with micronutrients including iron. Check the nutritional information on the packet.
  1. Meals/snacks can often be made more energy/protein-dense with the addition of some extra vegetable based spread/oils, dairy-free cream (e. oat, soya, coconut), avocado, pureed beans/lentil/pulses, pure nut butters (if your child has been advised to eat nuts). For example try mixing a tablespoon of dairy-free cream or teaspoon of nut butter into porridge OR a tablespoon of pureed lentils into a tomato-based pasta sauce can help to increase the energy/protein content of the meal, without the child having to eat a larger portion.
  1. The department of health recommends that all children aged 1-4 years should take a daily supplement of 10mcg/ 400IU vitamin D. Consider the type of presentation they are more likely to accept e. chew, drops, liquid, spray.
  1. Try to offer your child preferred and accepted foods at mealtimes and new foods separate to meals.

If you are concerned about the child’s weight, growth or nutritional status, please speak with your child’s dietitians or health care professional.

Case study of a child with feeding difficulties and allergies:

Freddie was referred to our joint Dietitian and Psychology clinic with his mother. He was a 15-year-old male with Autistic Spectrum Disorder, who had an allergy to peanuts diagnosed at 3 years old. He had a longstanding very limited repertoire of foods that we would accept coupled with a low hunger drive. He had a preference for beige, dry and country foods. We asked for a food diary on a typical day was dry toast or crumpet for breakfast. For lunch, he would take in a lunchbox consisting of Swedish crackers, dry crunchy biscuits, breadsticks and rye crackers. Like breakfast, for dinner, he would either have dry toast or a crumpet. His snacks would either be crisps or chocolate. His mother reported that within the family there had been a general acceptance of Freddie’s feeding pattern. His preferred foods were always available to him and new foods were offered in a low-pressure manner and they accepted if Freddie refused to try. The hopes of Freddie’s mother from the clinic was to have support in thinking of ways to expand Freddie’s range of foods. Freddie was also willing for us to implement strategies but shared that he didn’t see the point in expanding his range of foods.

      The maintaining factors that kept Freddie eating the same foods and a lack of motivation to change was his preference for sameness and predictability and so he had the same foods every day, this helped to reduce his anxiety as there were no unfamiliar, new foods. Due to his sensory sensitivities he had a preference for dry, beige, crunchy foods rather than more challenging wet, sticky, textures such as yoghurt which would have been anxiety-provoking for him. Because of the rigid thinking style, associated with his Autism diagnosis, he didn’t see the point in changing what he eats and was happy with what he was already eating. He therefore avoided any exposure to new foods by only stick to his safe foods and this was accommodated by his family as his mother said that they had given up on trying to challenge him to expand his range of foods.

      During his clinic appointment, we shared the strategies of tasting times accompanied by the tasting ladder for him to try at home. After a discussion with Freddie about what might be motivating for him to try these strategies, he identified that he wanted to have better nutrition for his health. We talked about the benefits of healthy eating, what nutritional benefit each food provides, the importance of having food from different food groups and the importance of eating larger quantities of foods to ensure he has energy for the school day. This discussion for what was motivation for Freddie was to try and increase his flexibility of thought around having a wider range of foods i.e. more choices for breakfast and for what went in his lunchbox. The foods he identified that he wanted to try were a satsuma, broccoli and jam.

      When we saw Freddie at his next appointment he reported that he had set up tasting times once a week to try the new foods he had identified as wanting to try. Freddie was always in control of choosing the new foods he wanted to try and gave a lot of thought to each food he picked . He picked things that were textually very different to his safe foods ie a satsuma and picked them instead on their nutritional benefit i.e. Vitamin C. To help contain his anxiety of trying a new food he would have an in-depth discussion with his mother about what the sensory experience might be like i.e the texture, what would happen with the liquid when he bit into the satsuma. Freddie used a rating scale to predict before he tried a food on how much he thought he would like it and again after he had tried it. He felt that moving up the steps on the tasting ladder created more anxiety for him and instead he preferred to put the food straight into his mouth. He reminded himself that he needed to try the foods multiple times to know if he liked it or not.

      In our last clinic appointment, we reviewed the progress that Freddie had made. He had done really well at trying the new foo ds he identified including, jam, broccoli, a satsuma and milk. Another fantastic outcome was that he was now finishing his lunch box at school in order to have more energy for the school day, when previously he would just pick at the contents in it.

      We discussed how Freddie could carry this amazing progress forward and he planned to create a food schedule (tasting times) to keep tr yin g new foods and that if he felt that he had a set back and was reluctant to try new  foods, he  would overcome this by talking to his m u m, about the barriers he was experiencing to trying. In Freddie’s own words he stated ” l have made very good progress. I scheduled all the things I would like to try at St Toms’ Hospital and try the foods at home. Also, I have used a different way of thinking when trying new foods”.

This article was first published in Allergy Newsletter No. 126 Summer 2019