Navigating the spectrum of food refusal in children with IgE-mediated and non-IgE-mediated allergies

08 May 2024

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

Get access to our exclusive articles.