“She won’t starve”

I can guarantee that if you are the parent of a picky or fussy eater, you will have heard this gem a few times. When friends and family give you advice that leaves you feeling misunderstood, it can be frustrating and even upsetting. However, to hear this message from a professional is a whole other thing.

I usually have a policy of not criticising other professionals; I’d rather put my energy into sharing evidence-based advice and supporting parents. But recently, both in the clinic and in my facebook group for parents of picky eaters, (which I co-run with Australian feeding specialist, Simone Emery)  I’m sick of hearing that concerned parents are taking their child to the pediatrician (US) or GP (UK), only to be told “He’ll eat when he’s hungry enough” or “He won’t starve”.  Even more shockingly, I’ve heard of doctors telling parents to let a child go without food for several days until they back down. As though food rejection is just an almighty battle of wills that the adult needs to be tough enough to win. 

The first thing that is wrong with the “She won’t starve” message, is that actually, she will. In my clinical experience, I have met many parents who have described how they followed this kind of advice and their child did not eat for days. This is tantamount to abuse. Don’t get me wrong, I am not criticising parents for following this suggestion. When we visit our doctors, they are in a position of power and we are usually already concerned because otherwise we wouldn’t be there. Following doctor’s orders seems like the right thing to do, and if you can’t trust your doctor, what hope is there? So I understand why people follow this advice, but I want to explain to any doctors out there why advising parents to let children go hungry is so wrong.

The following is an open letter to any healthcare practitioner who has ever told the parent of a child with food issues, “they won’t starve”. Feel free to share it with your doctor if you have been on the receiving end of this advice.

Dear Dr…

First of all, let me say that I appreciate that in many situations, services are stretched (they certainly are in the UK where I live) and it isn’t always easy to make the referrals parents might be hoping for. Secondly, I appreciate that general practitioners are by definition generalists – there is no reason why you should be an expert in feeding, that isn’t your role. I also understand that saying to parents that their child will ‘eat when they are hungry’, is a socially normal response to fussy eating. 

There are, however, a few important things medical professionals working with children, need to know about picky or selective eating. Once you are aware of these, the advice “she won’t starve” will not seem appropriate any more:

Often, children are not making a choice about refusing to eat a certain food. We may assume they are, but they are not. They are actually genuinely anxious about eating it and could no more ‘take a bite’, than an agoraphobic person could ‘just step outside’. 

Why may they be anxious about eating a new or disliked food? Well, research tells us that picky eating is ‘complex and multifactorial’ – for each child, the underlying causes may be different.  Here are some of the common causes of anxiety in relation to food:

• Sensory processing challenges

If a child struggles with the integration of sense data,  this can make eating extremely difficult. A child whose eating is very limited may need a sensory assessment by an occupational therapist, to establish the type and extent of any sensory processing issues.

• Oral motor problems

Sometimes, children may have trouble chewing or swallowing and it can be hard to assess this. A child may avoid eating foods with certain textures (or combinations of textures) because they find them physically difficult to manage or have an over-sensitive gag reflex. Oral motor problems need to be ruled out by a speech and language specialist (SLP – US, SaLT, UK).

• ASD 

Many children may not meet the threshold for a diagnosis of autism, but still exhibit some autistic traits. These children often find eating very difficult, and get extremely anxious when faced with new or disliked foods.

• Temperament

Some children are simply more cautious or sensitive than others. This is innate but could also be exacerbated by environmental factors. A child who is wary of the unfamiliar may find new foods genuinely frightening.

• Trauma

What an adult views as a trauma is not necessarily the same as what a child experiences as a trauma. Perhaps a child choked on a piece of banana as a toddler. This may have set up a negative association whereby they become very wary of eating foods they are not sure about. Perhaps they experienced repeated pain after milk feeds as a baby due to reflux. This can also lead to a fear of eating a wide range of foods.

Sometimes, several of these causal factors are at play simultaneously. And this is by no means an exhaustive list.  Whatever the cause of a child’s eating issues, it is important to acknowledge that they may be truly anxious about eating foods which are not on their ‘safe’ list.

Yes, often picky eating is a normal developmental phase which children will grow out of.  Yes, parenting and power struggles can contribute to picky eating and it is important for parents not to fall into becoming a ‘short order cook’ and getting trapped in power games. 

However, my key message is this: by the time a parent is worried enough to bring their child to see you, the chances are, they have eating problems which will not just go away. Take time to talk to the parent and ask if they feel their child is genuinely anxious about eating new and disliked food. Take time to consider whether their eating behaviours are better understood as a coping mechanism than ‘bad behaviour’. Trust parents’ intuition – we KNOW when things are not right with our children. And then make an appropriate referral so the child can be assessed and supported by the right professional.  

It is so important that children can always be confident that there will be something available that they can eat at every meal and snack (read Ellyn Satter‘s papers on eating competence and self-regulation to find out more about that) and there is no scenario where a child should be left to go hungry because nothing on their safe list has been provided for them.

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Simone Emery has kindly offered to share her resource for parents to share with GPs, which echoes much of what I’m talking about in this article. Download it here. You’ll find her post ‘Nine things not to say to the parent of a fussy eater‘ super relevant too.

So if you’re planning a trip to your doctor for some support for your child – and I advise that you do consider seeking professional help if you are worried – bring my open letter and Simone’s pdf and you will be prepared and ready to get your child the help they need.