I am often asked whether a parent should take a child to be seen by a feeding therapist. This is an extremely difficult question to answer, as in the end, only a comprehensive assessment can help us identify this. Educating parents on typical development can be helpful, as often times, as parents we are unsure of what to expect. Developmental information about feeding and eating is scarce compared to gross motor skill development like rolling and walking.
While there are many difficulties that would warrant an assessment (weight loss, weight gain issues, evidence of swallowing difficulties, trouble transitioning off puree etc) this article will focus on our picky eaters or cautious eaters.
There are many terms used by professionals and parents to define a picky eater. To muddy the waters further, how we measure the severity of a picky eater varies a great deal, not only from person to person but from study to study. So many factors contribute to “picky eating” in ways we have yet to understand.
Research studies have shown between 25% and 33% of all children within their first ten years are reported by their parents to have difficulties with feeding or growth. Picky eating is experienced by infants and children universally which shows that there is a developmental component to it. It can be a phase that many children experience at certain stages of their development.
The research also shows that 1/3 to ½ of these picky eaters will outgrow this within a 2-3 year timeframe without feeding therapy while 3-10% of infants and children will continue on to have a Paediatric Feeding Disorder. In the United States, Paediatric Feeding Disorders are more prevalent than Autism and Cerebral Palsy.
Though no consensus has been established on what exactly a picky eater is, a picky eater will have feeding challenges that may last a few weeks or up to 2 years.
A picky eater:
– Will only eat about 20-30 foods
– Will only eat a limited variety and will usually eliminate whole food groups from their diet (e.g. meat/protein) or exclude certain textures (e.g. all wet mushy foods).
– Will avoid trying new foods
– Will be more likely to have a different meal to the family meal
– Will have difficulty eating foods and amounts of foods that are seen to be important for nutrition
– Will respond to eating pressure from caregivers by becoming more upset than what we would expect from their peers
– Will be more likely to eat differently in different environments (home vs education setting etc)
– Will have strong preferences about how a food is prepared and served (e.g. will only eat raw carrots not cooked carrots).
(Based on paediatric psychologist, Kay A. Toomey’s Picky Eater definition)
So what if it is more than picky eating? If it is more than picky eating a child may have a Paediatric Feeding Disorder (PFD).
PDF is defined as impaired oral intake that is not age appropriate, lasting at least 2 weeks and associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction (Goday et al., 2019). An assessment by a feeding therapist is needed to identify a PFD. It is important that these children are seen quickly and that these children and their families are supported by a team of feeding professionals. For more detailed information please head to https://www.feedingmatters.org/toolkit/pfd-fact-sheet/
The internationally recognised PFD definition has been influential in the feeding therapy world. It may also be helpful for parents and professionals to also be familiar with the definition of a problem feeder, described by Kay A. Toomey. This population of infants and children is more extreme in their feeding difficulties than picky eaters. They require feeding intervention, with research showing only 8% will remit without intervention.
A problem feeder is a child who demonstrates significant and often extended challenges with feeding/eating patterns characterized by:
1. Long duration of feeding difficulties (> 2 years) and/or
2. Severity of feeding difficulties which exceed that of a picky eater that includes
a) A very restricted food range (~10‐15 foods)
b) Very strong food likes and dislikes (not just preferences)
3. Refusal to try new foods (pretty much at all)
4. Probable growth and/or nutrition problem/s
5. Some type of skill deficit very likely (motor and/or oral‐ motor)
6. Learned avoidance behaviours are significant enough to cause family disruption at meals and/or limit child’s ability to eat with others
The question for parents still remains, will my picky eater’s difficulties resolve by themselves or do they require intervention? The bottom line is, we don’t know. Though a comprehensive feeding assessment can get us closer to the answer. If your little one presents with difficulties like those of a problem eater or a child with a Paediatric Feeding Disorder, it is highly recommended that your child receives feeding therapy.
With all this in mind, I am a huge advocate for seeking support when you just have that gut feeling something isn’t right. Feeling supported and heard in your journey of parenthood is incredibly powerful and important.
Often a number of professionals will become involved in supporting you and your child with a feeding difficulty. In order to complete a comprehensive feeding assessment the nutritional, psychosocial, feeding skill and medical domains need to be considered. Finding a team that has experience in paediatric feeding is essential. This may be a speech pathologist, an occupational therapist, a dietitian, a paediatrician etc.
Written by Jamie Williams – Paediatric Speech Pathologist
– Toomey, K.A., and associates, 2021. Picky Eaters vs Pediatric Feeding Disorder (PFD) vs Avoidant Restrictive Food Intake Disorder (AFRID): Differential Diagnosis Decision Tree
– Goday PS, Huh SY, Silverman A, et al. Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework. J Pediatr Gastroenterol Nutr. 2019;68(1):124- 129. doi:10.1097/MPG.0000000000002188.
– Kovacic K, Rein, ScM LE, Bhagavatula P, Kommareddy S, Szabo A, Goday PS, Pediatric Feeding Disorder: A Nationwide Prevalence Study, The Journal of Pediatrics (2020), doi: https://doi.org/10.1016/j.jpeds.2020.07.047.
– National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention