Understanding Fussy Eating in Infants: Developmental & Clinical Perspectives
Fussy eating is a common part of early childhood, which often causes a lot of stress for families. In this article Lucy Wood explores the developmental, behavioural and clinical factors behind feeding challenges, as well as offering practice guidance on how to support parents.
Few topics generate as much discussion in the early years as fussy or avoidant eating. It is commonly asked about during health visiting reviews, GP appointments, conversations with childcare practitioners and of course amongst family or friends.
Parents are often worried about how their child can survive on such a small amount of food, or worry about the negative effects of a very limited diet. More recently there are increasing concerns about large intakes of ultra processed foods. For many families, these behaviours can cause a great deal of anxiety about growth, overall nutrition or the long-term implications and with limited input from healthcare professionals these worries can get worse over time.
Fussy eating in young children is common, with research suggesting that around 20–30% of toddlers are described by parents as picky or fussy eaters, with behaviours often peaking between 18 and 24 months.
There are some major developmental changes happening around this age that can impact feeding which are helpful to highlight as they can be hugely reassuring to a worrying parent.
Slower growth after the first year: after the first year the period of rapid growth slows and appetite tends to decrease. Food intake can become much more variable day to day which can lead to the perception of fussiness; when in reality it is more related to changes in appetite. In reality, this is normal and a positive sign that a child is listening to their hunger and fullness cues.
Increasing autonomy: around this time young children are developmentally programmed to seek out autonomy. There is often very little opportunity for genuine independence during early childhood and food can become an area they like to control – saying no, leaving the table, clamping their mouth shut and other such actions.
Food neophobia: This developmental phase, which is biologically normal literally translates into fear of new foods and is a widely accepted hypothesis with evolutionary roots. When children become more mobile, independent and inquisitive, their brain is programmed not to eat unfamiliar foods as throughout evolution these could have potentially been poisonous berries or mushrooms. Nowadays, we are more in control of our children’s movements and oral intakes, but the reflex is still present for many children.
Essentially, there is a perfect storm emerging from around 12-24 months that can appear to be fussy eating but in reality a multitude of factors are affecting the feeding and behaviour:
- Growth slows
- Appetite fluctuates
- Mobility and independence increase; sitting down to eat can be more challenging
- Food caution (neophobia) emerges
- Emotional responses are strong and immediate
Why does fussy eating happen?
Eating challenges occur for a wide range of reasons. For some children, fussy eating may follow a single event or developmental phase. For others, changes in eating habits may occur from a combination of physiological, psychological and environmental factors that disrupt their natural instinct to eat a variety of different foods.
Despite how widespread this issue is; there is still a great deal of stigma around fussy eating and parents often feel judged if their child only eats a narrow range of foods. Approaching this with care, curiosity and kindness is important; not only to build trust with a family you are working with, but helps parents to feel less burdened with guilt. Helping to unpick why a child is fussy is generally the first step in moving forwards towards greater confidence and food curiosity.
When exploring feeding concerns, it is beneficial to consider the wider context of the child’s development, health and environment. The following factors commonly influence feeding behaviour in early childhood:
Life events and environmental changes
Whether a life changing event feels positive or negative, if it feels like a major change to a child it can temporarily affect appetite and food acceptance. These may include:
- The birth of a sibling
- Parental separation
- Starting nursery or childcare
- Moving house
- Changes in primary caregiver
Young children are sensitive to change but often don’t have the communication skills to verbalise their feelings so may seek to gain more control at mealtimes by narrowing their range of foods or appearing more unsettled.
Anxiety
Anxiety may be specific to mealtimes; for example, if it is common practice for a child to be pressured to eat foods they don’t like they may come to mealtimes already anxious. Anxiety may also be part of a more generalised pattern of feelings throughout the day. Anxiety, whether generalised or food based may lead to a reduction in appetite and an increase in staying within a safety zone.
Although it is not a causative factor, parental anxiety around feeding can unintentionally worsen feeding difficulties, particularly if it leads to pressure or negotiation at mealtimes and only offering accepted foods.
Temperament
A child’s personality, or temperament, can sometimes play a significant role in feeding behaviour.
For example, children who are naturally cautious are unlikely to be the ones running to the table to try new foods. Strong-willed children are more likely to seek out autonomy, and those who are highly sensitive or emotionally reactive may show more pronounced responses if offered foods they do not want to eat.
Personality characteristics don’t only influence how a child responds when food is offered but are also likely to impact how caregivers respond. A parent of a highly emotional child or strong willed child is more likely to offer favourites in order to minimise mealtimes battles which over time is likely to further narrow their food preferences.
Often the characteristics that are hard to parent, assertiveness, sensitivity and caution, are qualities we admire in adults. Reframing these factors as personality and not behavioural or deliberately oppositional can transform responses from parents and reduce conflict at mealtimes.
Physical or gastrointestinal factors
Early life body issues, even if they are resolved, can impact a child’s relationship with food. If eating has been associated with discomfort or pain, there are more likely to be avoidant eating habits.
Exploring and identifying any current or historical physical causes of avoidant eating is important. Issues may no longer be a concern, but their impact on feeding can be ongoing.
- Constipation
- Gastro-oesophageal reflux
- Food allergy or intolerance
- Painful teething
- Previous choking or gagging incidents
Food neophobia
As highlighted earlier, food neophobia (or fear of new foods), is commonly experienced in toddlerhood. Many parents describe this as a switch going off at around 15 – 18 months with their child changing almost overnight from a curious to a cautious eater.
This cautious response to unfamiliar foods is developmentally typical, but in some children it can present more strongly and contribute to a narrowing of accepted foods over a prolonged period of time.
Neurodivergence
Neurodiverse children may experience additional feeding challenges related to:
- Preference for routine and predictability
- Difficulty with transitions
- Sensory processing differences
- Heightened anxiety
Sensory preferences
Every individual has sensory preferences, how loud they have their music, how hot they have their shower, how spicy they like their food. These are very normal human characteristics and we expect there to be differences in the types of foods enjoyed.
However, as eating is a complex sensory experience involving all eight of our senses — visual appearance, smell, taste, texture, temperature, sound, interoception, vestibular and proprioception. If a child is hyper or hypo sensitive to input for one or more of these senses we may see eating being impacted. This may present itself as challenges with texture, strong smells, sitting still to eat or a lack of understanding of hunger and fullness signals.
Sensory sensitivity does not necessarily indicate disorder; however, it can significantly influence food acceptance and contribute to selective eating patterns.
Normal Variation vs Red Flags
One of the most valuable actions a healthcare professional can take in helping families experiences feeding difficulties is distinguishing between developmentally typical behaviour and feeding patterns that may require further assessment. Having the confidence to assess when a situation simply requires reassurance and when to refer on is a key part of providing appropriate care.
Although not all cases will require onward referral, it is important to note that feeding issues rarely exist without environmental or social influences. Outdated generational feeding practices and myths as well as well-meaning but unhelpful guidance from family or friends lead to pressure driven feeding practices in many households. This means that for most children, even if their eating is developmentally normal, there is almost always the potential for healthcare professionals to have a positive impact on the feeding environment, feeding dynamics, parental expectations and long term eating habits.
Developmentally normal feeding behaviours
The following patterns are commonly seen in otherwise healthy children and are usually part of normal development:
- Variable intake from day to day
- Eating very little at one meal and compensating at another
- Initial rejection of new foods (often requiring multiple exposures)
- Strong preference for familiar or previously accepted foods
- Temporary narrowing of food variety during periods of change
- Growth tracking consistently along established centiles
- Consumption of at least one food from most food groups across the week (even if not daily)
In these cases, providing guidance and support with responsive feeding strategies are usually sufficient.
Consider further assessment if:
Further exploration or referral may be appropriate if food refusal is accompanied by:
- Faltering growth or significant centile crossing
- Persistent texture refusal beyond the expected developmental stage
- Ongoing coughing, choking, gagging with most textures, or suspected aspiration
- Extremely restricted intake (for example, fewer than 10–15 accepted foods or the omission of full food groups)
- Mealtimes that are consistently distressed or prolonged (e.g. regularly exceeding 30–40 minutes)
- Signs of oral-motor delay or difficulty chewing age-appropriate textures
- Co-occurring developmental delay or neurodevelopmental concerns
- Parents are experiencing severe anxiety that is significantly impacting feeding dynamics
Please note that this is not an exhaustive list and any child you are concerned about should be referred onto other services by the GP if they feel it is relevant. For some situations, a multidisciplinary approach may be required, involving services such as dietetics, speech and language therapy or paediatricians.
For detailed strategies on how you can manage avoidant (fussy) eating with parents, read our article Managing Avoidant Fussy Eating: Practical Strategies for Healthcare Professionals, also written by Lucy Wood.
Black MM, Aboud FE. Responsive feeding is embedded in a theoretical framework of responsive parenting. Journal of Nutrition. 2011;141(3):490–494.
Blissett J, Fogel A. Intrinsic and extrinsic influences on children’s acceptance of new foods. Physiology & Behavior. 2013;121:89–95. https://doi.org/10.1016/j.physbeh.2013.02.013
Cherif L, Boudabous J, Khemekhem K, Mkawer S, Ayadi H, Moalla Y. Feeding problems in children with autism spectrum disorders. Journal of Family Medicine. 2018;1(1):30–39.
Daniels LA. Feeding practices and parenting: A pathway to child health and family happiness. Annals of Nutrition and Metabolism. 2019;74(Suppl 2):29–42.
Farrow CV, Coulthard H. Relationships between sensory sensitivity, anxiety and selective eating in children. Appetite. 2012;58(3):842–846.
Finnane JM, Jansen E, Mallan KM, Daniels LA. Mealtime structure and responsive feeding practices are associated with less food fussiness and more food enjoyment in children. Journal of Nutrition Education and Behavior. 2017;49(1):11–18.
Gregory JE, Paxton SJ, Brozovic AM. Pressure to eat and restriction are associated with child eating behaviours and maternal concern about child weight, but not child body mass index, in 2- to 4-year-old children. Appetite. 2010;54(3):550–556. https://doi.org/10.1016/j.appet.2010.02.013
Jansen PW, de Barse LM, Jaddoe VWV, Verhulst FC, Franco OH, Tiemeier H. Bi-directional associations between child fussy eating and parents' pressure to eat: Who influences whom? Physiology & Behavior. 2017;176:101–106.
Loth KA. Associations between food restriction and pressure-to-eat parenting practices and dietary intake in children: A selective review of the recent literature. Current Nutrition Reports. 2016;5:61–67.
Rollins BY, Savage JS, Fisher JO, Birch LL. Alternatives to restrictive feeding practices to promote self-regulation in childhood: A developmental perspective. Pediatric Obesity. 2016;11(5):326–332.
Rowell K, McGlothlin J. Responsive Feeding Therapy: Values and Practice. White paper. 2020 (updated 2023). Available at: www.responsivefeedingpro.com
Satter E. Eating competence: definition and evidence for the Satter Eating Competence model. Journal of Nutrition Education and Behavior. 2007;39(5 Suppl):S142–S153.
Satter E. Child of Mine: Feeding with Love and Good Sense. 2nd ed. Boulder, CO: Bull Publishing; 2012.
Spill MK, Callahan EH, Shapiro MJ, Spahn JM, Wong YP, Benjamin-Neelon SE, Casavale KO. Caregiver feeding practices and child weight outcomes: A systematic review. American Journal of Clinical Nutrition. 2019;109(Suppl 1):990S–1002S.
Vollmer RL. Parental feeding style changes the relationships between children's food preferences and food parenting practices: The case for comprehensive food parenting interventions by pediatric healthcare professionals. Journal of Specialists in Pediatric Nursing. 2019;24(1):e12230.
Wolstenholme H, Kelly C, Heary C. ‘Fussy eating’ and feeding dynamics: School children’s perceptions, experiences, and strategies. Appetite. 2022.
Wolstenholme H. A qualitative investigation of family perceptions, experiences and management of childhood fussy eating behaviours. Doctoral dissertation. NUI Galway; 2020.
Written by Lucy Wood
Lucy has a BSc honours degree from King’s College London with additional postgraduate learning through the British Dietetic Association and has been working as a registered dietitian for 12 years both within the NHS and the private sector.
