Is It More Than Just a Phase? Picky Eating Versus Problem Feeding

Article by: Lindsay Johnson, MS, OTR/L

Arguably the most complex aspect of child development, the term “feeding” encompasses all of the skills required to ingest an appropriate variety and quantity of solids and liquids for nourishment. While the development of feeding skills may appear to be a natural process, part of our basic survival instincts, it is much more complicated than meets the eye! There are multiple factors that influence feeding development: anatomy, reflexes, oral motor skills, sensory processing, gut and digestive function, motor coordination, behavior/motivation, and the environment. Knowing this, it may come as less of a surprise that an increasing number of children and families are running into obstacles related to feeding. Research has shown that 25-40% of all children have some form of a feeding disorder, and that number increases to 80% of children within the special needs population (Manikam & Perman; 2000). 

Parents and caregivers are faced with the highly challenging responsibility of teaching the skills needed for feeding, exposing kids to various food groups/tastes/textures, and ensuring adequate nutrition, but are often limited by: insufficient education for recognizing typical versus atypical feeding development and how to continuously support typical development (timing is critical!), the emergence of poor mealtime habits shaped by busy schedules and a societal trend away from “family style” meals, underlying systemic factors such as reflux, constipation, or unidentified food allergy or intolerance, or financial barriers (fresh, less-processed food is more expensive!).

What can we do about it? 

Firstly, it is critical to understand the difference between “picky eating” and “problem feeding,” and to recognize that the picky eating stage is not only TYPICAL, but it is EXPECTED. Around 18-24 months, even the child that would “eat anything” up to that point may suddenly start to refuse their offerings. This is a normal and often inevitable stage of development. It coincides with an increased understanding of their world and their ability to say “No!” (a child’s favorite word, right?). However, many parents/caregivers are not adequately informed and prepared for this difficult stage, and may unintentionally prolong it or exacerbate the formation of undesirable patterns of behavior/habits surrounding food and meals. Consistent exposure to a wide variety of foods in conjunction with behavioral management strategies (listed below) can support a more positive relationship with food as well as reinforce normal, healthy eating patterns. Not all strategies will work for all children, but I encourage you to give them a try, modify them toward your individual child’s unique personality, and start to THINK in terms of behavioral management during this stage.

How do we distinguish a picky eater from a problem feeder?

Signs of problem feeding include:

  • Baby: difficulty latching onto the breast; gagging or choking on lumpy foods even after several exposures; refusing new foods or certain textures; “stuck” on pureed food; lack of interest in eating; weight loss or poor weight gain.
  • Toddler: refusing new foods; acceptance only of similar textures or colors of food; eliminating one or more major food groups (e.g., protein, dairy, grains, fruit, vegetables); eating fewer than 20 different foods; subtracting previously enjoyed foods and never regaining them; crying or having a tantrum when new foods are presented; going days without eating; family stress at mealtime due to toddler’s eating patterns; poor response or no noticeable effect from trialed behavioral management strategies; consistent refusal across contexts (many kids will eat better with non-primary caregivers or outside the home).

How can we help children THROUGH the picky eating stage?

Here are some “Dos and Don’ts” regarding the management of picky eaters! This list is by no means comprehensive, but a great start to building your toolbox of strategies:

DODON’T
Offer preferred AND novel/non-preferred foods at each meal and snack. Allowing them to select ONE component may help as it informs you of which food will be the “motivator.”Allow your child to select every component of the meal or become their “short order cook.”
Utilize “First ____, Then ____” to alternate 1 bite of a non-preferred followed by a preferred (can gradually increase the expectation to 2 bites, then 3 bites, and so on).Let the child “fill up” on preferred foods/snacks/drink since they are less likely to eat new foods if their appetite isn’t strong enough (remember, milk is very filling!).
Include 3-4 food groups at each meal and 2-3 food groups at snack. Remember, EXPOSURE to food is key!Offer the same foods at each meal/snack on a daily basis, as this is more likely to result in food deletions. 
Engage in shared meals/snacks whenever possible, as this promotes a positive social experience surrounding food. Consider including the child in the food preparation/cooking process!Cook completely separate meals for your child/children every day (although sometimes this is required due to schedule and is OK). 
Modify the presentation of a preferred food (i.e. change up the temperature, shape, brand, serving vessel, utensil, etc.) to promote flexibility of food acceptance.Give in to “demands” regarding presentation (ex. For the child who only wants their fruit whole, you could explain that, “Sometimes the fruit will be whole, and sometimes cut, but it will taste the same.”).
Set an achievable, concrete expectation (ex. “Eat 3 more bites since you are 3 years old, and then you may be finished.”) and celebrate with the child when they achieve it! Can make a token board with stickers or drawn smiley faces to depict fulfillment of expectation.Set too high of an expectation that cannot be upheld (ex. “Eat everything on your plate or we’re canceling your birthday party!”).
Consider games that can be played to increase exposure to different foods/textures/concepts without the pressure to eat it (ex. Place red pepper sticks onto lines on paper to form the outline of a house; Use red pepper sticks to “paint” with ranch dressing; Blind taste-test game to guess the food).Interpret the initial reaction as the “final judgment.” It can take the brain 6-10 trials (I teach 10 trials) of a food to interpret it in order to determine whether or not they like it.
Add new foods to diet by “scaffolding” off of preferred flavor/texture profiles (ex. If they like apple, they will likely enjoy pear; If they like crunchy snacks, they may prefer crunchy/raw veggies to cooked veggies, or crunchy meat like bacon).Expect a totally unique flavor/texture profile to be accepted/enjoyed on the first try, and don’t forget that MIXED TEXTURES are more complex and challenging (ex. Pizza, soup, Stage 3 baby food).
Track your child’s diet in a daily food log if you have concerns.Wait to seek help if you suspect your child’s picky eating is evolving into problem feeding.
Please note that the picky eating stage can last through 6 years old and beyond, and so whatever strategies work for you will likely change or be advanced along the way. If, however, you observe more prolonged or more severe/extreme behaviors surrounding food, this could indicate that there is something else going on.

How is a feeding dysfunction/disorder assessed and treated? 

Occupational Therapy and Speech-Language Pathology practitioners play a vital role in comprehensive assessment and treatment of feeding disorders across the lifespan. One or both disciplines may be indicated, depending on the case and focus of treatment. Our goals are to help the families we serve understand the complexity of feeding, discover the underlying barriers to successful feeding, and establish treatment objectives as a collaborative effort in order maximize patient outcomes. However, the most important component of treatment will always be…YOU, the family! Successful resolution of feeding disorders will require that families be willing to play an active role in making/establishing CHANGE. We understand this is not an easy endeavor, and therefore will work together to implement gradual and feasible changes that support progress toward your goals. 

As with any other aspect of development, the earlier you seek and establish the right supports for your child’s feeding, the better the outcomes will be. If you have any concerns or questions, please don’t hesitate to contact our office regarding feeding therapy, and visit your primary care provider to request a referral. We look forward to working with you!

Manikam, R. & Perman, J.A. (2000). Pediatric feeding disorders. Journal of Clinical Gastroenterology, January (1), 34-46. doi: 10.1097/00004836-200001000-00007.

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