Food refusal can be referred to feeding difficulties or picky eating habits of infants and children, which can develop into eating disorders.¹ During the 2024 AAAAI Annual Meeting, Dr. Rosan Meyer, a specialist in pediatric nutrition from the United Kingdom provided an overview of the topic, discussing its prevalence, risk factors and triggers.¹

The definition of food refusal has been broad and lacks consistency, with varying terminologies and diagnostic criteria.¹ A systematic review of 10 publications focusing on food refusal in individuals with food allergies found that 11-12 different diagnostic tools and terminologies were used to describe this behavior.¹ Due to the lack of a unified definition, reported rates of food refusal in the general population vary significantly.¹ A recent systematic review based on 21 studies reported a prevalence ranging from 5.1% to 70.1%.¹ According to the ALSPAC study, the prevalence of food refusal is 10% at 24 months, increases to 15% at 38 months, and then decreases to 14% and 12% at 54 and 65 months, respectively.

Food refusal can be categorized into three levels: mild, moderate, and severe.¹ Mild food refusal is common in children who simply do not enjoy certain foods, potentially leading to micronutrient deficiencies.¹ Children with food allergies may exhibit moderate food refusal, avoiding specific food categories and increasing the risk of micronutrient deficiencies and growth issues.¹ Severe food refusal involves avoiding a majority of foods and food categories, often attributed to sensory integration disorders and avoidant restrictive food intake disorder (ARFID).¹ These children often experience significant weight loss and nutritional deficiencies, and may rely heavily on oral nutritional supplements and enteral feeding.¹ They also commonly face psychosocial functioning problems.¹

Compared to children with non-immunoglobin E (IgE)-mediated food allergies, the prevalence data of food refusal among children with IgE-mediated allergies were relatively limited.¹ Overall, 30%-40% of children with non-IgE-mediated food allergies experienced feeding difficulties, accompanied by a higher incidence of symptoms such as abdominal distension (p<0.002), vomiting (p<0.0001), weight loss (p<0.0001), constipation (p<0.0001) and rectal bleeding (p=0.025) compared to their healthy counterparts.¹ In particular, children with food protein-induced enterocolitis syndrome (FPIES) have a significantly higher reported incidence of feeding difficulties compared to those with IgE-mediated food allergy (52.0% vs. 22.3%; p<0.0001).¹ Of note, the diagnosis of ARFID can be challenging due to its overlapping symptoms with eosinophilic esophagitis (EoE).¹

Understanding the risk factors and triggers for food refusal is crucial for prevention.¹ Common maternal risk factors for food refusal included age, education, smoking habits and social class.¹ Male infants with lighter birthweight, lower sucking patterns, genetic variation in taste and reduced exposure to early tastes and textures may be at higher risk of developing food refusal.¹ Parental reactions, such as poor modeling of dietary intake and parental pressure during eating, can also contribute to its development.¹ In terms of triggers for food refusal, they are represented by the acronym STOMP (S: size concerns related to the child's growth; T: transitions in feeding from breastmilk to bottle milk or from pureed to textured foods; O: organic diseases like allergies and vomiting episodes; M: mechanistic feeding practices that impose strict eating schedules disregarding natural hunger and satiety; P: post-traumatic events such as allergy-induced anaphylaxis or non-allergy related choking or gagging).¹

In conclusion, food refusal encompasses a spectrum of abnormal eating behaviors often observed in children with food allergies.¹ A proactive approach is necessary to minimize its impact.¹ Recognizing and addressing risk factors and triggers are crucial for prevention and early intervention of food refusal.¹