‘Picky Eating’: How to Introduce New Foods to Children with Autism

Selective eating is a common problem in children with autism, with many only eating foods of a certain colour (e.g. white foods), or rejecting particular foods due to their texture or smell. This highly-restricted diet can cause a range of health problems, including nutritional imbalance, poor gut health, and weight management issues.

In this article, we explore the challenges of a selective diet, and how parents and carers can ensure their child is getting the healthy balance they need from their food.
 

For 8-year-old Tom, mealtimes are a ‘white food only’ zone. Tom, who is on the autism spectrum, has difficulties with sensory processing and integration. Over time, he has steadily rejected all other food types and is now so restricted in his diet, he will only eat five foods: fish sticks, chicken nuggets, mashed potatoes, white rice, and white bread-and-butter sandwiches.

Tom violently rejects the other types of food his father tries to offer him. This means dinnertime tantrums are common, making family meals exhausting and overwhelming for everyone. While Tom’s parents have all but given up trying to introduce new foods for the sake of peace, they are worried about the fact that Tom is not eating a healthy, balanced diet. 
 

So what could be behind Tom’s unwavering insistence on white foods? Research shows that children on the autism spectrum are more likely to eat a narrow range of foods and have a greater number of feeding problems than those without autism[1]. This may be due to ritualistic and repetitive behaviours, as well as sensory processing issues. What’s more, children with both autism and sensory issues are more likely to reject foods based on their colour, texture and smell[2].

For example, children with autism may only want to eat:

·       white or yellow foods

·       foods with either a crunchy or smooth texture

·       foods that are either salty or bitter

·       foods that have either a sweet or sour flavour

If your child is restricting their diet in this way, it is likely to be limiting their nutritional intake and can lead to a range of other significant medical problems – including developmental delays, issues with weight management (being either overweight or underweight), gastrointestinal problems, and chronic diseases such as obesity and diabetes[3].


White Food Woes

The problem is, the white foods in our diet tend to be the ones that are highly processed. In fact, white flours are used to make many of our popular ‘treat’ foods, such as crackers, breads, biscuits, pasta and cakes.

In order to obtain the white flour, naturally-brown whole grains are stripped of their nutrient-dense husks, meaning white rice and wheat lack fibre and essential vitamins. When eaten in high quantities, the nutrient deficiency occurring in white foods can impact gut health and nutritional balance.

And there’s more bad news! In addition to their lack of naturally-occurring nutrients, many of these white processed foods also contain added sugar to provide more flavour. 
 

The Challenge: Introducing New Food Groups in Selective Eaters

If you’re attempting to introduce a new food to a child with autism, we know it can be a difficult and exhausting exercise. To ensure a safe and effective outcome, it’s important to work with your health team. Before you get started, you might want to consider the following: 

1.     Has your doctor checked whether there is a medical reason for your child not eating a certain food?
Sometimes, children with autism have painful gut symptoms which may be exacerbated by certain foods. In addition, mouth ulcers, food intolerances and allergies can all cause pain, which can prevent a child from eating or impact their relationship with food. 

2.     Has your health team (e.g. speech pathologist or dietitian) completed a motor skills check to confirm your child is able to chew and swallow comfortably?

3.     Is your child’s eating problem based on a difficulty or a preference?

 

Engaging a Dietitian to Establish a Balanced Diet For Your Child  

A dietitian is a health professional who is specially trained in nutrition and eating behaviours. They can help to develop strategies and tools that make it easier to introduce new food and improve your child’s nutritional balance.

A dietitian will work with you and your family to understand your goals, then create a practical action plan to achieve the desired outcomes. By exploring current eating habits and food types, the dietitian can develop an understanding of behaviour, motivations and incentives, as well as learning what works in your specific situation, i.e. for your family and your child.

There are many strategies which can assist in creating learning opportunities for your child around healthy food choices; a dietitian will aim to build a new and positive relationship between your child and their food.

Introducing new food to people with autism takes time and patience. Here are some of the ways a dietitian might approach the introduction of new food for a child with autism:

1.     Introducing a new colour or texture can require many exposures – a child may need to see, touch and smell the new food multiple times before they are willing to taste it.

2.     Games and child’s play will help to introduce new food in a fun way, without the pressure to taste straight away.

3.     Food is a powerful way for a child to control their environment. By presenting your child with options, they can maintain this control and make choices for themselves. For example, the dietitian may ask “which one of these three foods would you like to try today?”.

 

As little Tom loves playing with dinosaurs, he and his dietitian used different foods as props for his dinosaur play. Tom gradually accepted touching and feeling the lettuce and broccoli, and was ok with grapes being in his space. As cauliflower was white, Tom allowed it to be mashed into his potatoes. Later, he accepted a banana in his lunch box, then some lettuce in his sandwich, and after another two weeks, a slice of tomato. Six months later, Tom had increased his food groups significantly and had even lost enough weight to be in the healthy range. Meanwhile, Tom’s mum and dad are relieved that he is getting a nutritional balance – and mealtimes are no longer an uphill struggle!


If you’re concerned about unhealthy eating habits in your child with a disability, our qualified dietitians are here to help, from meal planning and nutritional analysis to advice on healthy eating. Learn more about our dietitian services, which are supported by your NDIS funding.

 

 

References: 

Bandini, L.G., Anderson, S.E., Curtin, C., Cermak, S., Evans, E.W., Scampini, R., Maslin, M. and Must, A., 2010. Food selectivity in children with autism spectrum disorders and typically developing children. The Journal of pediatrics157(2), pp.259-264.

Baranek, G.T., Boyd, B.A., Poe, M.D., David, F.J. and Watson, L.R., 2007. Hyperresponsive sensory patterns in young children with autism, developmental delay, and typical development. American Journal on Mental Retardation112(4), pp.233-245.

Johnson, C.R., Turner, K., Stewart, P.A., Schmidt, B., Shui, A., Macklin, E., Reynolds, A., James, J., Johnson, S.L., Courtney, P.M. and Hyman, S.L., 2014. Relationships between feeding problems, behavioral characteristics and nutritional quality in children with ASD. Journal of Autism and Developmental Disorders44(9), pp.2175-2184.

Sharp, W. G., Jaquess, D. L., Morton, J. F., & Herzinger, C. V. (2010). Pediatric feeding disorders: A quantitative synthesis of treatment outcomes. Clinical Child and Family Psychology Review, 13(4), 348–365.

 

 

[1] Bandini et al, 2010; Johnson et al, 2014

[2] Baranek, 2007

[3] Sharp, 2010

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COULD GLUTEN OR DAIRY BE CAUSING YOUR GUT PROBLEMS?

 

Did you know that people with autism are more likely to suffer from gastrointestinal (GI) problems[1]?. 

While it’s still unclear whether GI problems cause autism, or whether people with autism are simply more likely to have GI problems (without a known cause), one prominent theory is called leaky gut syndrome. Leaky gut leads to absorption of incompletely digested proteins causing an overstimulation of the immune system in the bloodstream [1]. Resulting in inflammation of the gut lining of the intestine and  increased permeability, making it easier for elements to pass through into the blood stream and travel to the brain and tissues[2].

Examples of proteins that can be incompletely digested include:

·       Gluten: Such as cereals, wheat and barley

·      Casein: Found in milk and dairy products

As not all the protein from these substances is broken down, some parts remain and cause uncomfortable gut symptoms. Gut symptoms can include abdominal pain, gas, bloating, chronic constipation, chronic diarrhoea and loose stools [ 2] . In addition, this process of poorly digested proteins can have a similar effect to opioid drugs, leading to a range of issues including repetitive behaviours, lack of concentration, and a worsening of GI problems and other typical autism symptoms.

Although there’s not currently enough research to fully explain the relationship between these foods and the resulting symptoms, a number of studies have found that switching to a gluten-free/casein free diet (GFCF) can significantly improve behaviour, development and health in people with autism[3]. However, following a gluten-casein elimination diet can lead to nutrient deficiencies and is not recommended as a general treatment for ASD. For those who wish to trial this diet will need to be closely monitored by a dietitian [3 & 4].

What is Gluten Intolerance?

Gluten is a protein found in foods such as wheat, barley, rye and oats.

Symptoms of gluten intolerance can include gut disturbances, such as:

·       Bloating

·       Flatulence (excessive wind)

·       Diarrhoea or constipation

·       Stomach cramps

·       Nausea and vomiting

·       Abdominal pain

In turn, these uncomfortable gut symptoms can lead to other problems, including:

·       Fatigue

·       Weakness

·       Anaemia

·       Weight loss

·       Problems with bowel movements

·       Irritability

·       Smelly stools

·       Delayed growth or puberty

 


How Can You Manage Gluten Intolerance?

For people who are very sensitive to gluten, even tiny crumbs of gluten can cause stomach upsets. The only way to completely avoid all the symptoms of gluten intolerance is to follow a strict gluten-free diet. This will enable the gut and the lining of the intestine to heal and return to normal.

Before switching to a gluten-free diet, it’s important to seek medical advice to determine the cause of your symptoms. In many cases, these symptoms may not be caused by gluten specifically.  Some GI problems can be a result of a decreased level of certain digestive enzymes such as disaccharidases, gluccomylase, lactase and sucrose, thus predisposing to disorders associated with starch metabolism, carbohydrate malabsorption and intestinal disorders [2]. It may then be beneficial to follow a low FODMAP diet to identify if GI symptoms are resulting from irritable bowel syndrome.

Therefore it is essential that before cutting out gluten from your diet that you are properly diagnosed as it may be unhealthy for you to follow a gluten free diet. Please be sure to seek medical advice or speak to a specialist dietitian. The good news is, a simple blood test or allergen test can assist with diagnosis of coeliac disease.
 

Dietitian Services for Gluten Intolerance

When commencing a gluten-free diet, a dietitian can help you meet your goals by designing a food plan, and ensuring you are aware of which foods contain gluten and what you can substitute these with. You might be surprised at just how many ‘everyday’ foods contain gluten!

A dietitian will also help you track and monitor your symptoms, in order to evaluate the results of your dietary changes.

What is a casein free diet?

Casein is the main protein found in cow’s milk, cheese, yoghurt and ice cream.  There are two major genetic variants of beta-casein A1 and A2. A1 beta-casein has been found to release the opioid peptide upon digestion “increasing the opioid drug like effect” where A2 beta-casein does not or if it does it does at a much lower rate. Some research has shown that once casein is eliminated from the diet improved behaviour soon follows [5] .

Symptoms of casein intolerance can include:

·      Gut inflammation

·      Abdominal pain

·      Bloating

·      Behavioural issues

Dietitian Services For casein free diet

When switching to a casein-free diet, it’s important to work with a dietitian who can help you understand what steps you need to take. A dietitian can also help with designing a meal plan and guidelines to ensure you’re still getting enough calcium for healthy bones and teeth, which is particularly important for children.

Plus, a dietician will help you track and monitor your symptoms, in order to evaluate the results of your dietary changes.

Are you concerned about gut and behavioural problems in someone with autism? Our dietitians can help you find out whether these are caused by a gluten or lactose intolerance, and assist you in taking the next steps to achieve your goals. Learn more about our dietitian services, which are supported by your NDIS funding. 

 

For people who are lactose intolerant, the milk sugars are only partially digested in the small intestine. The lactose that’s left behind is broken down and fermented by bacteria in the intestine, leading to symptoms of lactose intolerance, including:

·       Bloating

·       Flatulence (excessive wind)

·       Diarrhoea

·       Stomach cramps

·       Abdominal pain

·       Smelly stools


How Can You Manage lactose Intolerance?

If you are diagnosed as lactose intolerant, changing to a lactose-free or low-lactose diet can help to avoid the symptoms of your condition.

While most dairy products contain lactose, some have lower levels of lactose than others. The following dairy foods all contain lactose:

·       Milk, milk solids and milk powder

·       Cow and goat's milk

·       Whey protein

·       Most flavoured milks and smoothies

·       Milk-based ice-creams

·       Cheesecake

·       Cheese

·       Yoghurt

·       Cream


 

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DINNERTIME DILEMMAS

Addressing Disruptive Eating Behaviours in Children With Autism

Eating a varied diet is essential for our health. However, unhealthy eating behaviours in children with autism can result in a very restricted diet, which in turn can lead to nutritional imbalance, health problems and behavioural issues.

While each child is different, in this article, we look at the common food challenges facing children with autism, and the services available to help you improve your child’s eating habits and minimise mealtime stress.

Meet Rachel. Her daughter Katie, who is on the autism spectrum, has a difficult relationship with food. Mealtimes are stressful, as Rachel struggles to meet Katie’s very specific needs – the same fork, the same chair, the same food, over and over again. Rachel is exhausted and worried about Katie’s health – she’s underweight and seems more prone to sickness than her other children. 

And if eating at home is difficult, eating out is almost impossible. Finding healthy food options for Katie is a challenge, and her behaviour becomes increasingly disruptive the hungrier she gets. As a result, Katie is no longer invited to other children’s homes. 


As a parent or carer of a child with autism, Rachel and Katie’s story might sound very familiar. For while most of us are enticed by the smells, textures and colours of different foods, this is often not the case for children with autism. Perhaps, like Rachel, mealtimes in your household have become battlegrounds of stress, disruption, anxiety and conflict – not only for your child, but the entire family.

If so, you’re not alone. In fact, 49-89% of children with autism eat fewer foods and have a lower nutritional intake, due to a combination of ritualistic behaviours (e.g. needing to use a particular utensil or have food presented in a certain way) and sensory processing issues.

Autism and Disruptive Eating: The Behavioural Cycle

Demanding or refusing particular foods is common in children with autism. For example, your child may only want to eat the following food types:

  • White foods, e.g. white bread, pasta, chicken nuggets, fish sticks etc.
  • Foods without any smell
  • Foods with a particular texture

Introducing new foods can be a huge challenge. Aside from impacting your child’s health, this can also limit social options and flexibility – eating out at a restaurant can be a nightmare! 

This becomes a vicious cycle.

The Effects of Poor Eating Habits on Children’s Health

Restricted diets can have a number of significant health impacts on children with autism.

Children who have long-term reduced nutritional intake are more likely to have a slower growth rate, developmental delay and further medical conditions or ill-health

Children with autism and nutritional imbalances have a greater chance of experiencing food intolerances, weight management problems, infections, behavioural issues and sleep disturbances.

They are also more likely to suffer from poor gut health and bowel problems. This can cause significant gastrointestinal symptoms, such as diarrhoea, constipation and flatulence. In addition, nutritional imbalances can impact the absorption of nutrients, making the imbalance even worse.

Rachel is determined to reduce mealtime stress so that her family can eat together happily. She’d really like Katie’s health to improve so she can attend school regularly, and is worried about gut problems like constipation, which has resulted in hospitalisation in the past.

Rachel decides to engage the services of a dietitian, which is supported by her NDIS funding. The dietitian works with Katie and her family to understand and analyse her eating habits and patterns. Seeing that Katie is only eating white foods, the dietitian is able to identify the nutrients that are missing from her diet. She also looks at what works well, such as how Rachel can encourage Katie to eat, and what motivates Katie to engage in positive eating behaviour.  


How a Dietitian Can Help to Improve Your Child’s Eating Behaviours

It’s very important to address nutritional imbalances in children with autism as soon as possible. Early intervention - at a time when children are growing and developing habits for their future - can be critical for long-term health. 

A dietitian is a health professional who is specially trained in nutrition and eating behaviours. They can analyse your child’s current nutritional intake and identify what nutrients or food elements may be missing. They will also consider your child’s environment, family dynamics, and sensory sensitivities and behaviour, to establish solutions that work for everyone involved.

A dietitian may work with your family to establish clear goals and then create a plan of action to achieve these goals. This could include: 

  1. Understanding what is missing from your child’s diet, such as fibre for gut health, and essential vitamins and minerals. Suggestions can then be made for food or supplements to develop a nutritional balance.
  2. Identifying food intolerances, such as gluten or dairy, which may be impacting your child’s ability to eat a variety of food. This requires education and training to understand options.
  3. Establishing routine behaviours around mealtimes, such as eating as a family to model healthy eating behaviours. Recommendations can be made to slowly introduce variations in the routine, allowing for more options around food types and eating venues.
  4. Developing strategies to introduce new foods for children with sensory integration issues. This may be assisted by games and learning opportunities designed specifically for children. 

Each session with your dietitian will aim to improve your child’s nutritional intake and health, make mealtimes more manageable, and reduce medical symptoms such as gastrointestinal problems as soon as possible. In doing so, steady progress will be made towards your child’s and family’s goals.

Working with their dietitian, Rachel and Katie found that the white foods Katie was eating lacked fibre and many other nutrients essential to her health. They learnt which foods contained fibre naturally and slowly introduced these one at a time. Through some carefully designed games and a few toy animals, Katie started to play with a ‘jungle’ of lettuce, which helped to introduce her to a new food and colour. 

The rest of the family helped too, by committing to a family dinner five nights a week in order to establish healthier eating behaviours. And when Katie ate all of her dinner, she was allowed to watch 30 minutes of her favourite TV show before bed – a very attractive reward!

Over time, Katie’s gut symptoms began to resolve and she became more regular. She started to eat more food groups, and explore different colours and flavours. Katie was happier, mum Rachel was less stressed, and mealtimes become a more enjoyable experience – so much so that last Friday night, the whole family even got the chance to out at their local Italian restaurant!

 

If you’re concerned about unhealthy eating habits in your child with a disability, our qualified dietitians are here to help, from meal planning and nutritional analysis to advice on healthy eating. Learn more about our dietitian services, which are supported by your NDIS funding.  

 

 

 

References:

Bandini, L.G., Anderson, S.E., Curtin, C., Cermak, S., Evans, E.W., Scampini, R., Maslin, M. and Must, A., 2010. Food selectivity in children with autism spectrum disorders and typically developing children. The Journal of pediatrics157(2), pp.259-264.

Johnson, C.R., Turner, K., Stewart, P.A., Schmidt, B., Shui, A., Macklin, E., Reynolds, A., James, J., Johnson, S.L., Courtney, P.M. and Hyman, S.L., 2014. Relationships between feeding problems, behavioral characteristics and nutritional quality in children with ASD. Journal of Autism and Developmental Disorders44(9), pp.2175-2184.

Kawicka, A. and Regulska-Ilow, B., 2013. How nutritional status, diet and dietary supplements can affect autism. A review. Roczniki Państwowego Zakładu Higieny64(1).

Kuhlthau, K., Orlich, F., Hall, T.A., Sikora, D., Kovacs, E.A., Delahaye, J. and Clemons, T.E., 2010. Health-related quality of life in children with autism spectrum disorders: Results from the autism treatment network. Journal of autism and developmental disorders40(6), pp.721-729.

Ledford, J.R. and Gast, D.L., 2006. Feeding problems in children with autism spectrum disorders: A review. Focus on Autism and Other Developmental Disabilities21(3), pp.153-166.

Seiverling, L.J., Hendy, H.M. and Williams, K.E., 2011. Child and parent variables associated with texture problems in children’s feeding. Journal of Developmental and Physical Disabilities23(4), pp.303-311.

Sharp, W. G., Jaquess, D. L., Morton, J. F., & Herzinger, C. V. (2010). Pediatric feeding disorders: A quantitative synthesis of treatment outcomes. Clinical Child and Family Psychology Review, 13(4), 348–365.

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