Why isn’t feeding development tracked in the Red Book?

ResearchDr Melissa Bujtor12 min read

At a glance

1

Learning to eat is part of child development, involving physical, sensory, cognitive, emotional and social skills.

2

The Red Book does not routinely follow feeding development as a distinct, integrated developmental process.

3

Normal growth does not necessarily mean eating is going well. My research found that early selective eating was more consistently associated with poorer dietary quality than with differences in growth.

4

Feeding development deserves greater recognition, with opportunities to identify difficulties earlier and support children as they learn to eat.

Throughout childhood, children gradually develop the physical, sensory, cognitive, emotional and social skills involved in eating, yet we do not routinely follow this progression as a distinct area of development.

In England, parents are given a Personal Child Health Record, commonly known as the Red Book, to record how their child grows and develops: their weight, their first words, their first steps. But while we carefully follow many aspects of childhood development, the broader process of learning to eat receives comparatively little attention.

A few years ago, I began questioning why this was the case. I am not alone in asking: organisations such as Feeding Matters in the United States, and researchers internationally, also describe feeding as part of child development (Goday et al., 2019). What I wanted to understand was what this could mean for children in the UK. Nutrition provides the energy and essential nutrients that underpin children’s growth, brain development, movement and learning. Without adequate nutrition, the very processes that support the developmental milestones we monitor can be affected (Prado and Dewey, 2014; Cusick and Georgieff, 2016). Yet we pay comparatively little attention to how children develop the skills needed to eat and obtain that nutrition.

Why do we follow how children learn to walk and talk so carefully, but not how they learn to eat? What might we be missing when children experience difficulties developing those skills?

WISE

Those questions became the starting point for a broader piece of work exploring how feeding development could be better understood, recognised and incorporated into the way we follow children’s health. They also informed my research into the relationship between early selective eating and children’s nutrition and growth as they reach school age.

What do I mean by feeding development?

We tend to think of eating as something children simply do. They are born needing food, learn to take milk, move on to solids and eventually eat many of the same foods as the rest of the family. But learning to eat is considerably more complex.

Although babies are born with reflexes that enable them to feed from birth, eating becomes an increasingly complex and learned activity as they grow. New abilities emerge through physical maturation, experience and opportunities to practise, with feeding skills continuing to develop throughout childhood (Scientific Advisory Committee on Nutrition, 2018; Pados, Thoyre and Park, 2018).

Feeding development is the process through which a child gradually acquires the physical, sensory, cognitive, emotional and social skills involved in eating.

Think about what is involved in eating a single meal. A child needs to recognise and respond to hunger and fullness, coordinate their posture and movements, manage food in their mouth, chew and swallow safely, process different tastes, textures, smells and appearances, communicate their needs and participate in the social experience of eating. These abilities involve multiple, interacting aspects of development, including feeding skills, nutritional needs and the child’s relationships and experiences around food (Black and Aboud, 2011; Goday et al., 2019).

During adolescence, increasing independence, changing nutritional requirements, social relationships and developing identities bring new influences to food choices and eating experiences (Neufeld et al., 2022). Our relationship with food continues to evolve into adulthood as we establish routines, acquire new skills and adapt to changing circumstances.

Although feeding development continues throughout life, early childhood provides important foundations for later eating skills and experiences. Understanding and monitoring how these foundations develop creates opportunities to recognise emerging difficulties and support children as they acquire the abilities involved in eating.

For some children, acquiring feeding skills is relatively straightforward. Others need more time, different experiences or additional support. For a smaller group, feeding difficulties are more persistent or complex.

These difficulties may be associated with medical conditions, differences in feeding skills, sensory processing or significant distress around eating. Some children may meet the criteria for Paediatric Feeding Disorder (PFD), which recognises the interaction between medical, nutritional, feeding-skill and psychosocial factors (Goday et al., 2019). Others may meet the criteria for Avoidant/Restrictive Food Intake Disorder (ARFID), where restricted or avoidant eating results in significant nutritional, physical or psychosocial consequences (American Psychiatric Association, 2022).

Feeding difficulties can affect far more than the range of foods a child eats. They may compromise nutritional adequacy and growth, affect physical health and emotional wellbeing, and contribute to anxiety or distress around food. Their impact can extend into family relationships, friendships, school and social activities, making everyday experiences such as eating lunch with classmates, attending birthday parties, going on school trips or sharing a family meal difficult or overwhelming.

Understanding feeding development also means looking beyond the child and their eating difficulties. How children learn to eat is shaped by their biology, health, sensory experiences, temperament and developmental abilities, alongside their relationships, family circumstances, culture, food security and opportunities to experience different foods (Scientific Advisory Committee on Nutrition, 2023; World Health Organization, UNICEF and World Bank Group, 2018).

Feeding development is therefore not simply about the acquisition of individual skills. It is a process shaped by the interaction between the child, their environment and their experiences of eating.

The Red Book: why aren’t we following feeding development?

Although the Red Book includes feeding advice and some feeding-related milestones, feeding development is not currently presented as a distinct, integrated developmental domain comparable to movement or communication. Health visitors already talk with families about feeding at key reviews, and the Healthy Child Programme and national guidance recognise the importance of nutrition, eating skills and identifying feeding difficulties early. What is missing is a way of bringing the developmental aspects of feeding together, so that how children learn to eat can be followed over time in the same way as other areas of development (Royal College of Paediatrics and Child Health, n.d.; Harlow Printing, 2026; Department of Health and Social Care, 2026; NICE, 2025; Scientific Advisory Committee on Nutrition, 2023).

There are important clinical reasons to consider this gap. Feeding difficulties in early childhood have been associated with broader developmental concerns, particularly when they persist (Putnick et al., 2022). Significant difficulties with eating are also not always apparent from growth measurements or nutritional status. Children may experience considerable anxiety, distress and restrictions in everyday activities without obvious physical consequences (Dinkler et al., 2025).

A child can be growing as expected and still be experiencing significant difficulties with eating.

We follow children’s movement, speech and communication because recognising developmental difficulties early allows us to understand their needs and offer support while skills are still emerging. Early identification creates opportunities to address difficulties, support development and potentially lessen their impact on other aspects of a child’s life (Lipkin and Macias, 2020; NICE, 2016).

The same principle deserves consideration in feeding development. Recognising difficulties as they emerge may allow families to receive guidance and support before avoidance, anxiety or restrictive eating patterns become more established. It may also help identify children whose feeding difficulties are affecting their participation in everyday life and their overall functioning, even when their growth remains within expected ranges.

The Red Book could provide a practical starting point. Including feeding development alongside other developmental domains could help parents and healthcare professionals follow how eating skills emerge and change, recognise concerns and consider when additional support might be helpful. This would not mean imposing rigid milestones or treating normal developmental differences as disorders. Rather, it would give feeding development a place within the routine conversations we already have about children’s growth and development.

Whether a more structured approach to following feeding development would improve early identification and longer-term outcomes requires further research. But applying the principles of developmental surveillance to how children learn to eat offers an important opportunity to explore.

My research: looking beyond the growth chart

Nutrition is fundamental to children’s growth, brain development and health throughout childhood. Its importance during early development is well established, including its role in brain development and its potential influence on health across the lifespan (Barker, 2007; Prado and Dewey, 2014; Cusick and Georgieff, 2016).

Yet nutrition and feeding development are not the same thing. Nutrition concerns the energy and nutrients a child receives, while feeding development concerns how they acquire the skills and experiences involved in eating. The two are closely connected, but understanding one does not necessarily tell us about the other.

This distinction informed some of my recent research, in which I explored whether picky or selective eating during the first five years of life was associated with differences in children’s nutrition and growth during the school years.

My systematic review brought together findings from 15 longitudinal studies, representing ten cohorts and more than 40,000 participant observations. By examining research that followed children over time, I wanted to understand whether early differences in eating were associated with nutritional consequences that might not necessarily be apparent from a child’s growth.

Systematic review findings: dietary and nutritional differences were more consistently observed than overt growth impairment. Click the image to view it full size.

What did the research find?

The clearest finding was that early picky or selective eating was more consistently associated with poorer dietary quality than with differences in growth.

Children identified as picky or selective eaters in early childhood tended to consume less fruit and vegetables and had lower reported intakes of several important nutrients, including fibre, iron, zinc and vitamin A. Yet their overall energy intake was often similar to that of other children, and many continued to grow within expected ranges.

Differences were generally more pronounced where picky eating persisted over time. Although some studies identified modest differences in height, body composition or weight, the findings for growth were less consistent than those for dietary intake.

These findings need to be interpreted carefully. The studies examined associations rather than cause and effect, and nutrient intake was generally assessed through dietary measures rather than confirmed through biochemical testing. The evidence was also concentrated in a relatively small number of cohorts, with differences in how picky eating was defined and measured.

Importantly, the review focused specifically on picky or selective eating, rather than the full range of feeding skills and developmental feeding difficulties. It therefore contributes only one piece of a much broader puzzle.

Why does this matter?

The findings highlight an important distinction: a child may consume enough energy to support growth without necessarily receiving the full range of nutrients they need.

The findings do also provide some reassurance. Early picky eating does not inevitably lead to poor growth or serious nutritional problems. However, where difficulties persist or a child’s range of accepted foods becomes increasingly restricted, there may be good reasons to look more closely at their dietary intake and experiences of eating.

For me, this reinforces the importance of considering nutrition and feeding development together. Growth measurements and dietary assessments provide valuable information, but a fuller understanding of children’s nutritional health also requires attention to how they are learning to eat, the difficulties they may encounter and how those experiences change over time.

Where this goes next

My research explored one part of a much broader question: how children learn to eat, and how feeding development relates to their nutrition, growth, overall development and functioning.

We already have considerable knowledge about the physical, sensory, cognitive, emotional and social processes involved in eating. An important next step is to understand how these processes develop and interact throughout childhood and adolescence, including the different pathways children may take, and how that knowledge could inform routine developmental monitoring.

There is an opportunity to bring this existing knowledge into practical use, helping parents and healthcare professionals better understand feeding development, recognise emerging difficulties and support children as they learn to eat. Further research can build on these approaches, strengthening the evidence, evaluating their usefulness and informing how they develop over time.

These questions continue to inform my clinical and research work, and I welcome opportunities for further research, collaboration and discussion with others who share an interest in this area. If this is an area of interest to you, please do get in touch.

Ultimately, it brings me back to the question I began asking a few years ago:

Given that adequate nutrition provides the energy and essential nutrients children need to grow, move, learn and develop the very skills and abilities we routinely monitor, why do we recognise learning to walk, talk and communicate as important parts of childhood development, but not the development of the skills children need to eat and obtain that nutrition?

WISE

Feeding development deserves a more prominent place in how we understand and follow children’s health. Not simply because some children experience difficulties, but because eating is about so much more than meeting nutritional needs.

It is about discovering new tastes, enjoying familiar favourites, sharing meals, celebrating together and feeling part of family and social life. It is about curiosity, pleasure, independence and connection.

Learning to eat is one of the many ways children discover and participate in the world around them. And every child deserves the opportunity to develop that relationship with food in a way that works for them.

WISE From Dr BujtorUnderstand feeding. Support its development.Coming soon →

References

Related reading

Dr Melissa Bujtor is a HCPC Registered Dietitian and AfN Registered Nutritionist (RNutr), and a paediatric feeding specialist. She works with children and young people across the full spectrum of feeding and eating difficulties, from sensory-based differences through to more complex restriction and disordered eating. Trained in multiple evidence-based approaches including the SOS Approach to Feeding, she is also a Trustee of The Feeding Trust UK.

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