Feeding problems are common in childhood. All children experience some form of picky eating. It usually coincides with developmental growth periods when the child starts to exert control and may show independence through eating habits. In some children, however, picky eating habits evolve into a pattern of feeding selectivity and may progress to an eating problem or feeding disorder that can result in poor growth, failure to thrive and malnutrition.
Problematic feeding behaviors often develop within a defined spectrum of clinical presentations. The most common and benign feeding problem is picky eating. A child who is a picky eater can be selective about many things, including variety, brand, textures, smell or presentation. The picky eater may require additional interventions but will eventually resume eating or drinking in quantities sufficient to maintain growth and development.
Prevalence
The child who does not or cannot developmentally improve may progress to more dangerous feeding behaviors, such as complete food refusal. A child who refuses to eat or is unable to eat faces short- and long-term negative consequences.1 A child with a feeding disorder is unable or refuses to eat or drink a quantity or variety of foods sufficient to meet nutritional needs and maintain proper growth and development.1
This article describes ways to approach the child who presents with feeding difficulty and provides suggestions for how to distinguish between the child who is a picky eater and the child with a feeding disorder. It also describes a practical approach for assessment and management.
Carruth et al examined a national random sample of 3,022 infants and toddlers and found that the percentage of children identified by their caregivers as picky eaters was 50% by age 24 months. This observation crossed all ages, ethnicities and household incomes.2 Other research shows that 20% of U.S. parents perceive eating as a problem with their children in general. They cite the most common difficulties as eating a limited volume and preferring liquids to food.3
The prevalence rate of feeding disorders ranges from 25% to 35% in children who develop normally and 40% to 60% in children with developmental disabilities.4-6 Feeding difficulties can be viewed on a spectrum from the most common form, the picky eater, to the more severe form, a feeding disorder. A review of the literature reveals a lack of consensus on the definitions of picky eating and a feeding disorder.7 The definition of feeding disorder in the DSM-IV is limited to weight loss for more than 1 month. The DSM-V will change "feeding disorder" to "avoidance/resistance food intake disorder." This will take into account any changes in weight in the context of nutritional deficiency and food refusal.7 A child who is a picky eater may exhibit some form of feeding disorder behavior (selectivity, volume limitation, difficult meals, food refusal) that does not affect his or her weight and usually improves over time.8 Table 1 lists red flags for the picky eater.
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The American Psychiatric Association's current criteria for feeding disorder of infancy or early childhood are persistent (at least 1 month) failure to eat adequately and associated weight loss or significant failure to gain weight. Neither symptom can be directly due to a medical condition or another mental disorder, and the onset must occur before age 6 years.8-10 The common element in this definition is weight loss associated with lack of oral intake. Table 2 lists red flags for a feeding disorder.
Assessment
A child who exhibits feeding difficulty can be challenging for the provider and family. It may not be readily apparent whether the behavior is developmentally normal and will resolve on its own, or it is problematic and will lead to long-term consequences. Assessment of the child with persistent feeding difficulty includes a focused feeding history and assessment, an evaluation of growth and nutritional status, and an understanding of how mealtime affects the family.
It is important to listen carefully to parents when they report a feeding problem. Obtain a focused feeding history that includes how long the feeding problem has been an issue, whether the child was NPO for a prolonged period of time, and whether the child received medical interventions. If the child received interventions, determine whether they centered around the mouth, such as frequent dilatations for stricture. Ask whether the child shows signs of swallowing difficulties or dysphagia; describe common symptoms of these to obtain an accurate answer. Oropharyngeal dysphagias should be considered in young children with unexplained respiratory symptoms or illness.11 Common symptoms of aspiration include persistent congestion, cough when eating or drinking, frequent upper respiratory illness, and/or pneumonia.
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Does anything aggravate or alleviate the feeding problem, such as drinking from a cup or eating more textured foods? Did the child have difficulty transitioning with feeding or other developmental tasks? Did he or she have problems with the acquisition of feeding skills? Does the child indicate hunger or demonstrate an appetite? Does he or she have chronic sensory or developmental issues?
Next conduct a review of systems that includes risk factors that may set the stage for a feeding difficulty. Ask about a history of prematurity, small size for gestational age, developmental disability, genetic or metabolic syndrome, frequent illnesses or pneumonia, and chronic illness such as gastroesophageal reflux or celiac disease. Table 3 reviews the risk factors that should raise a red flag for the child at risk for the possibility of a feeding disorder.
Evaluation of nutritional status and growth parameters will aid in the diagnosis of a feeding disorder. Consider whether the child has lost weight, is overweight, has a pattern of being underweight, or is failing to thrive. Examine the growth chart and note whether the change in the growth pattern coincides with onset of the feeding problems. Assess for any underlying chronic medical conditions that could account for the poor growth parameters. Obtaining a 24-hour or 3-day dietary recall can be useful to help identify any gross nutritional deficiencies. Remember, a child who is a picky eater usually maintains his or her weight, but a child with a feeding disorder may demonstrate changes in weight and stature. A child who is failing to thrive will lose weight first, then fall behind in height and head circumference.12
Mealtimes for the family with a child who has a feeding disorder can be stressful and complicated. It is important to determine what impact the feeding behavior may have on family mealtimes and the home environment. Ask about the typical mealtime to get a sense of the degree of frustration and angst experienced. Cultural influences and psychosocial issues such as food choices and availability of food may also affect a child's feeding disorder. Table 4 provides questions to ask parents in order to obtain understanding of family mealtime structure.
Diagnostic Testing
The diagnostic process for a child with a feeding disorder includes assessment of anatomy and rate of gastric emptying, examination of the esophagus and upper GI tract, and a complete nutritional assessment. Diagnostic tests include upper GI studies, gastric scintigraphy, upper endoscopy and a modified barium swallow study (MBSS).
The upper GI study evaluates the anatomy of the GI tract and rules out abnormalities such as malrotation and vascular rings.13 This test is often used for children who present with choking or gagging on food, food refusal, coughing and/or vomiting. Gastric scintigraphy, also known as a gastric emptying scan or milk scan, is the gold standard to assess the rate of gastric emptying.14 This test is useful in children with volume limitations or early satiety.
In a child with failure to thrive, formula intolerance or poor response to conventional medical treatment, an upper endoscopy can assess the esophagus, stomach and upper portion of the small intestines, and to obtain biopsy samples. An upper endoscopy with biopsies can differentiate gastroesophageal reflux from eosinophilic esophagitis after a child has been treated with proton pump inhibitor therapy for 6 to 8 weeks.15
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An MBSS assesses swallowing function in a child by delivering different textures (thin liquid to pureed foods). A child who presents with choking or coughing while eating or drinking or who has frequent respiratory infections may require an MBSS to assess safety of swallowing function.16
Treatment Strategies
Feeding difficulties are often treated using a multidisciplinary team approach. This approach includes the child, parent or guardian, primary care provider and (usually) medical and behavioral specialists. Before implementing a behavioral strategy for the child experiencing feeding difficulty, it is imperative to identify and treat any underlying medical pathology that may be contributing to it. This includes identifying and correcting treatable medical conditions (such as reflux or constipation), addressing any nutritional deficits (such as vitamin D and zinc) and providing nutritional supplements to ensure adequate growth and development. The expertise of a dietitian to assess nutritional intake and needs and a speech pathologist to assess and treat oral motor deficits can be helpful.
The child who is picky or selective after his or her first birthday may benefit from a multivitamin and a nutritional supplement added to milk. For the child who has slow or poor growth, a higher-calorie nutritional supplement should be recommended (Table 5). Children younger than 1 year may benefit from continuing with a 20 kcal/oz formula or concentrating the formula to a higher caloric density.17 Children older than 1 year may benefit from a higher-calorie formula or a 30 kcal or 45 kcal/oz preparation.
An infant who arches, gags, vomits or coughs while eating may be experiencing gastrointestinal discomfort. This may be a manifestation of a gastroenterologic pathology such as gastroesophageal reflux, dysphagia or constipation. The feeding presentation may be food refusal, limited volume or preference for drinking.
The child who is congested, gags, chokes or coughs when drinking may be experiencing aspiration. The feeding presentation may be food refusal, uncoordinated suck, swallow or breath pattern, or limited volume. A modified barium swallow study is useful to determine whether the child is aspirating and on what textures. Modifications should be made based on the child's ability to safely swallow a variety of textures.
The child who gags, refuses to eat more textured foods or chokes while eating and develops diarrhea may be experiencing discomfort caused by food allergies. A family history of atopy or food allergies may exist. Referral to a gastroenterologist for endoscopic evaluation or an allergist for allergy testing is recommended.
Some children may exhibit a poor appetite or an inability to recognize hunger cues. An appetite stimulant such as cyproheptadine can help improve oral intake.20,21 When a child presents with early satiety or volume limitations, the cause may be delayed gastric emptying. Medications that increase gastric motility can be useful. Offering the child several small meals throughout the day, providing 
calorie-boosting foods and ingredients, and offering high-calorie nutritious supplements can also meet the caloric needs of a child with early satiety.
A child who is a picky eater may benefit from having more mealtime structure and uniform feeding expectations. This requires significant anticipatory guidance and family support. Parents and caregivers should provide eight to 10 presentations of the same food for acceptance. Sit the child in a highchair or chair for meals. End the meals on the parent's terms (say "one last bite"), and do not allow the child to graze on food or liquids all day. These strategies improve mealtime success and help preserve a healthy parent-child relationship.20,21
The child who is highly selective or presents with food refusal may have a sensory processing disorder affecting acceptance of an age-appropriate diet. Alternating three to four bites of preferred foods with one smaller bite of nonpreferred foods is one strategy to improve oral acceptance. Having the child involved in simple meal preparations or food play may encourage him or her to touch, smell and taste nonpreferred foods.
Sequential oral sensory approach is a rehabilitative program for children with a sensory processing disorder. It is used to increase a child's comfort level by exploring and learning about taste, texture, smell and consistency.21
Patience, Persistence Needed
Feeding difficulties in children can range from picky eating to feeding disorders. A multidisciplinary approach is often necessary for the diagnosis and treatment of underlying medical conditions, behavioral interventions to encourage oral acceptance and mealtime structure, and nutritional supplements to ensure caloric intake.20-23 Understanding the complexity involved in determining and treating a feeding disorder in a child can help the clinician support and educate the family and child during a stressful period.
References
1. Unlü G, et al. Developmental characteristics of children aged 1-6 years with food refusal. Public Health Nurs. 2008;25(1):2-9.
2. Carruth BR, et al. Prevalence of picky eaters among infants and toddlers and their caregivers' decisions about offering a new food. J Am Diet Assoc. 2004;104(1 Suppl 1):S57-S64.
3. Charlotte CM, et al. How do toddler eating problems relate to their eating behavior, food preferences, and growth? Pediatrics. 2007;120(4):e1069 -e1075.
4. Byars KC, et al. A multicomponent behavioral program for oral aversion in children dependent on gastrostomy feeding. J Pediatr Gastroenterol Nutr. 2003;37(4):473-480.
5. Tobin S, et al. The role of an interdisciplinary feeding team in the assessment and treatment of feeding problems. Building Block For Life newsletter. 2005;28(3):1-11.
6. Frield D, et al. Correlates of specific childhood feeding problems. J Paediatr Child Health. 2003;39(4):299-304.
7. Kreipe R, Palomaki A. Beyond picky eating: avoidant/restrictive food intake disorder. Curr Psychiatric Rep. 2012;14:421-431.
8. Bryant-Waugh R, et al. Feeding and eating disorders in childhood. Int J Eat Disord. 2010;43(2):98-111.
9. Cathey M, Gaylor N. Picky eating: a toddler's approach to mealtime. Pediatr Nurs. 2004;30(2):101-107.
10. American Psychiatric Association. Eating disorders. In: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. Washington, D.C.: American Psychiatric Association; 2000: 263-267.
11. Lefton-Greif M, et al. Long-term follow-up of oropharyngeal dysphagia in children without apparent risk factors. Pediatr Pulmonol. 2006;41(11):1040-1048.
12. Chatoor I, et al. Failure to thrive and cognitive development in toddlers with infantile anorexia. Pediatrics. 2004;5:e440-e447.
13. Young R, Philichi L. Diagnostic studies. In: Clinical Handbook of Pediatric Gastroenterology. St. Louis: Quality Medical Publishing Inc.; 2008: 238-242.
14. Smith DS, et al. Diagnosis and treatment of chronic gastroparesis and chronic pseudo-obstruction. Gastroenterol Clin North Am. 2003;32(2):619-658.
15. Furtura GT, et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology. 2007;133(4):1342-1363.
16. Boesch RP, et al. Advances in the diagnosis and management of chronic pulmonary aspiration in children. Eur Respir J. 2006;28(4):847-861.
17. Hendricks KM, et al. Growth failure. In: Manual of Pediatric Nutrition, 3rd ed. Hamilton, Ontario: BC Decker Inc; 2000; 414-426.
18. Homnick D, et al. Long-term trial of cyrpoheptadine as an appetite stimulant in cystic fibrosis. Pediatr Pulmonol. 2005;3(40):251-256.
19. Nasr S, Drury D. Appetite stimulant use in cystic fibrosis. Pediatr Pulmonol. 2008;43(3):209-219.
20. Toomey K. Sequential oral sensory (SOS) approach to feeding. http://www.nutrition411.com/tkcenter/article.php?ID=K-0621
21. Kerwin ME, Eicher PS. Behavioral intervention and prevention of feeding difficulties in infants and toddlers. J Early and Intensive Behavioral Intervention. 2004;1(2):129-140.
22. Piazza CC. Assessment and treatment of feeding problems in children with autism. Association for Inside Behavioral Analysis International Newsletter. 2010; 2:3. http://www.abainternational.org/ABA/newsletter/IBAvol2iss3/presenters/Piazza.asp
23. Bachmeyer MH. Treatment of selective and inadequate food intake in children: a review and practical guide. Behav Anal Pract. 2009;2(1):43-50.