Following my last post about picky eaters, parents should know that there is a more severe level of picky eating, which has been termed problem feeding. In the medical community, it is often diagnosed as “feeding difficulties”.
Problem feeders have the following behaviors:
- Young infants who refuse bottle or breast, or drink a small amount then refuse. This results in a decreased overall volume consumed, and eventually weight loss and dehydration.
- Toddlers and children who eat less than 20 foods.
- Kids who “lose” foods that they once ate, and do not resume eating them even after a few weeks break. Eventually they may be down to 5-10 foods.
- Kids who refuse certain textures altogether.
- Kids who scream, cry, and panic over touching, smelling, or tasting a new food.
- Kids who are unwilling to try almost any new food even after 10+ exposures.
Why do some kids become problem feeders?
- Gastroesophageal reflux disease (GERD), chronic constipation, delayed gastric emptying, dysphagia
- Food allergies
- Sensory processing disorders, autism
- Complications related to premature birth, including history of intubation and/or feeding tube
In these cases, the child forms “oral aversion” associated with the pain and discomfort they feel/felt as a result of eating or swallowing. This association is made very strongly in the young developing brain, and in the case of problem feeders, overrides hunger. Oral aversion becomes a protective mechanism, which is why they panic over eating new foods. Problem feeders can be underweight or overweight as a result of their rigid food choices, depending on what type and how much food they eat.
The big difference between picky eaters and problem feeders:
Eventually, a picky eater will come around to eat some type of food they are presented with outside of their usual repertoire, if they are hungry enough. A problem feeder will not respond to hunger cues to meet their needs with the food options presented to them if it is outside of their “accepted” foods. Problem feeders will go on a food “strike”, even if it results in dehydration and malnutrition.
Problem feeders need assessment and feeding therapy, which can be effectively achieved with a multidisciplinary team, such as at North Shore Pediatric Therapy. NSPT has occupational therapists, speech therapists, and dietitians to work through sensory, oral-motor, and nutritional deficits as well as mealtime behaviors. We also have social workers for additional support and behavior guidance. If you are concerned that your child is a problem feeder or a picky eater, contact our facility for an evaluation.
The picky eater phenomenon is not uncommon, and can be quite challenging and stressful for parents.
Picky eaters have the following characteristics/behaviors
- Eat a limited number of foods (20-30).
- Avoid classes of foods such as red meat or green vegetables.
- May reject foods they previously accepted, but will re-accept these foods after a two-week break.
- Will try some new foods after being exposed to the food several different times.
- Will touch and play with new foods, although they may not eat it at first.
- Picky eaters usually eat enough to support growth within normal ranges. (1, 2)
How To Encourage Your Picky Eater, To Eat More:
To alleviate some stress, first examine if your expectations for your child’s eating is realistic. Kids are naturally wary of new things (think “stranger danger”), including new foods. Their first reaction to something they have never seen, smelled, touched or tasted before is to not trust it. Do not be discouraged if your child doesn’t love hummus, spinach, and salmon right away. It takes an average of 8-15 exposures to a new food before the child will actually eat it (2). Also, toddlers and teens particularly want to exert their sense of control and opinion, including what they will (and won’t) eat. In other words, sometimes a strong-willed child will refuse to eat what you want them to just because it gives them control over that aspect of their environment.
Typically developing young children will eat according to their innate hunger and satiety cues. That is, they will eat what they need when they are hungry and not when they are satisfied. Imagine how you might feel if you were full from dinner, and someone comes at you with a spoonful of food telling you to take another bite. Imagine you are really full, and the thought of taking another bite makes you sick. Now this person starts yelling at you and threatening to punish you. How would you feel? It can be difficult to let go and trust your child’s appetite. Your job as the parent is to provide healthy meal choices, regular mealtimes and snacks, and a positive eating environment without toys or TV.
Finally, using bribes like “one more bite and you can have dessert”, and punishments such as “you can’t play outside if you don’t finish your plate” are not effective in the long run. Doing these things negates children’s natural ability to eat what they need. It also creates a negative, untrustworthy dynamic between the child and the caregiver at the table. Picky eaters will continue to thrive and meet their nutrition needs when provided an optimal mealtime environment. A dietitian at North Shore Pediatric Therapy can counsel families to help picky eaters.
However, there is a difference between a picky eater and a problem feeder. Problem feeders have more rigid food preferences, a dwindling number of accepted foods, and will refuse food (and drinks) that are not part of their repertoire to the point of malnutrition. These children require more intensive evaluation and therapy, and benefit from multidisciplinary treatment available at North Shore Pediatric Therapy. I will further discuss problem feeders in my blog next week.
- Carruth BR, Skinner J, Houck K, Moran III J, Coletta F, Ott D. The phenomenon of “picky eater”: a behavioral marker in eating patterns of toddlers. J Am Coll Nutr 17:180-186, 1998.
- Carruth BR, Ziegler PJ, Gordon A, Barr SI. Prevalence of picky eaters among infants and toddlers and their caregivers’ decisions about offering a new food. J Am Diet Assoc. 2004 Jan;104(1Suppl1):s57-64.
It is often assumed that eating is a natural instinct children are born with and that difficulties in this area are rare. Not so. Various studies into feeding disorders have identified a wide variety of prevalence statistics. It is known that some children are at an increased risk for feeding difficulty; those who are born prematurely, experience early medical complications, or children with neurological disorders. But even for children without any medical or developmental diagnoses, feeding may be a very tricky skill to acquire.
Currently available data suggests the incidence of children who experience feeding difficulty is as follows:
- Manikam & Perman, 2000: Pediatric feeding disorders are common. 25% of children are reported to present with some form of feeding disorder. This number increases to 80% in developmentally delayed children.
- Lewinsohn et al 2005: up to 45% of children at 36 months of age exhibit some “picky eating” as defined by food refusal, or accepting food one day and denying it another.
- Emond, Emmett, Steer, & Golding, 2010: This study compared the eating habits of children diagnosed with Autism to a sample of typically developing children at multiple ages. Children with ASD experienced feeding difficulty much more frequently and to a greater degree. Using a parent-completed questionnaire, typically developing children were identified as “very choosy” eaters as follows:
- o 15 months: 5.4%
- 24 months: 9.5%
- 38 months: 15.5%
- 54 months: 13.9%
Parents of picky eaters, the underlying message here is: you are not alone. If your child is experiencing feeding difficulty, seek out the advice of a professional- your pediatrician, an occupational therapist, speech-language pathologist, and nutritionist are among the qualified individuals who can help you to better understand and navigate the factors that impact your child’s feeding abilities.
Emond, A., Emmett, P., Steer, C., & Golding, J. (2010). Feeding symptoms, dietary patterns, and growth in young children with autism spectrum disorders. Pediatrics, 26, 337-342.
Lewinsohn et al. (2005). Prblematic eating and feeding behaviors of 36-month-old children. International Journal of Eating Disorders, 38, 208-219.
Manikam, R., & Perman, J. (2000). Pediatric feeding disorders. Journal of Clinical Gastroenterology, 30, 34-46.
A recent study from The Journal of Pediatrics discovered that children with Autism Spectrum Disorders are more likely to be picky eaters and may be at risk for suboptimal nutrition¹. Children with Autism Spectrum Disorders were found to have increased occurrences of food refusal and more limited food repertoires. Other research has estimated that one third of mothers felt their infant had feeding difficulties in the first four months of life and one in four mothers at routine pediatrician visits expressed concerns with their child’s feeding skills². The statistics show nearly 25% of typically developing children and 80% of developmentally delayed children will demonstrate characteristics of a feeding disorder³. Read more