When children are picky eaters or refuse to eat, as parents, it truly rocks your world. You may worry there is something wrong that could lead to poor growth and abnormal development. It may also cause feelings of guilt, that you did not do a good job, or you failed your child. Feeding problems not only involve the child, but the whole family. 

Normal feeding and swallowing

Normal feeding and swallowing are essential to your child’s growth and are important developmental milestones. Feeding is also a social event, allowing the child to interact with both family and peers. 

Feeding is a complex process that involves close interaction between a child’s internal systems (central nervous, skeletal, and gastrointestinal) and external environment. When typical feeding development is disrupted, disordered eating behaviors may begin, and without treatment, can develop into a feeding disorder. 

How common are childhood feeding problems?

Many parents are concerned about their child’s ability to eat. When a child eats too little, has a limited diet, has a fear of food and/or eating, or actively refuses to eat, parents recognize a feeding issue. They may be quick to label the child as a “picky eater.” In some cases, the problem may be a parent’s misunderstanding of the child’s normal feeding development. 

Feeding and swallowing problems are common, occurring in:

  • 25 to 35 percent of typically developing children
  • 40 to 70 percent of premature infants 
  • up to 85% of those with neurodevelopmental disabilities and chronic illness. 

For most children, this is only a phase and part of normal development.

What causes feeding disorders?

There are some common conditions that cause pain and discomfort and may impact a child’s feeding:

  • Oral lesion: dental problems, oral mucosal disorder, tongue tie
  • Gastroesophageal Reflux Disease (GERD): this condition causes heartburn, recurrent vomiting, abdominal pain
  • Constipation: bloating, abdominal pain, feeling of fullness; cycles of good and bad eating
  • Inflammatory bowel conditions: celiac disease, IBD, other autoimmune conditions
  • Eosinophilic esophagitis: a condition marked by dysphagia; heartburn, abdominal pain, vomiting

In addition, failed interaction between infant and caregiver can also result in significant feeding problems. They evolve out of a misunderstanding of the cues an infant provides and how the caregiver interprets those cues. 

Is it “picky eating” or a feeding disorder?

It may be difficult for a parent to know whether a child is just a picky eater or is experiencing a feeding disorder. Children who refuse food quickly learn that parents will provide better tasting, preferred foods, along with more attention. A parent learns that the child will not eat unless a favorite food is offered. Then the parent begins to only offer favorite foods to ensure the child is eating.

It helps to think of feeding issues in different categories:

  • Transient neophobia/picky eating. This resolves in a healthy child whose refusals have been addressed with appropriate caregiver response.
  • Avoidant restrictive food intake disorder (AFRID). This condition occurs in a child of any age, without a body image issue or desire to lose weight, who avoids food. It results in poor growth, malnutrition, nutrient deficiencies, and a need for nutritional supplements.
  • For children with autism spectrum disorder, feeding problems are also common, and may be the first symptom of autism. This condition is linked to highly selective eating with rigid preferences to food type, color, temperature and how it is presented. Children on the autism spectrum often eat a “beige” diet that is mostly carbohydrates, such as bread, pasta, cheese, graham crackers, and milk, which can lead to increased risk of discomfort or constipation, malnutrition and nutrient deficiencies. 

Warning signs and symptoms of feeding disorders

Parents should be aware of the warning signs and red flags associated with feeding issues and feeding disorders. Those include:

  • poor weight gain
  • weight loss
  • signs and symptoms of pathologic anxiety that needs treatment
  • recurrent choking, difficulty swallowing (dysphagia) or pain when swallowing (odynophagia)
  • recurrent fevers, cough, or chest pain
  • recurrent vomiting (especially not associated with feeding); or vomiting blood
  • diarrhea and blood in the stool
  • developmental delays, physical abnormalities, or neurodevelopmental anomalies
  • skin conditions such as dermatitis or eczema that may indicate food allergies

Tips for parents to help manage feeding

Eating is a set of behaviors that can be altered. Parents can help manage their child’s feeding issues and develop better feeding habits using the following strategies:

  • Offer structured meals at regularly scheduled times.
  • Do not allow “grazing” between meals – this allows the child to be most hungry.
  • Leave two to three hours between meals to create the cycle of hunger and fullness.
  • Offer non-preferred foods in very small portions. Try mixing or pairing them with a food your child prefers. Praise your child for touching, smelling, licking, mouthing, chewing, or swallowing food to reinforce the positive behavior.
  • Limit mealtimes. Allow 30 minutes for big meals and 15 to 20 minutes for snacks. Any food that is not eaten during this time is taken away and no additional food is offered. This may cause parents to worry that the child will go hungry but can be comforted knowing the child will eat again in a few hours. It is important to be patient, create a routine, and let your child know that mealtime is limited. 
  • Use ignoring or brief “time-outs” if your child shows negative behavior such as pushing or batting away food, gagging or vomiting. A parent can look the other way or show no reaction as this will help to lessen the negative behavior.
  • In select cases and under the guidance of a physician, the use of appetite stimulants may be appropriate.

When to get treatment for feeding disorders

It is important for a parent to identify any signs of picky eating and discuss them with their child’s pediatrician. The doctor will perform a complete medical evaluation along with a discussion with parents to understand what issues a child may be having and if there are any physical issues that may be causing feeding difficulties. The physician will discuss what mealtimes are like and what symptoms the child is exhibiting. For some children, especially those with chronic conditions, interventional strategies and the help of pediatric experts may be necessary. 

Children who fear feeding

Some infants may cry at the sight of the bottle or food. They arch their body, resist feeding and refuse to open their mouths. The cause of these behaviors may be a traumatic feeding experience in the past such as choking, vomiting, procedures/placements of tubes, or force feeding. Some infants are known as “dream feeders” because they only feed when half asleep, without a stressful environment. For these children, the strategy is to remove the trigger or stress and avoid force feeding. More intensive feeding therapies with experts may be needed.

Neophobia – the fear of trying new foods

Some children have a fear of trying new foods, also known as neophobia. This usually occurs when a child is moving from liquid to solid foods, between ages one and five. In general, neophobic children refuse to eat foods based on texture, consistency, color, or smell. The child’s initial rejection of the food can change with repeat opportunities to try it. It is not associated with a physical cause and typically resolves when parents use the following strategies: 

  • disguise the food with a familiar flavor 
  • use role models: mother enjoying the food is the best example for a child
  • continue to present the food, at least ten times

Expert help for feeding disorders near you

It is important for parents to understand that feeding difficulties are quite common in young children and they have the potential to compromise nutrition, growth, and cognitive development. The good news is that most feeding problems are developmental and transient – if handled in the appropriate way. Knowing how feeding problems begin and evolve will help parents to see early signs and get help. 

For persistent feeding problems or an evolving feeding disorder, we can help. The Feeding Program at Hasbro Children's Hospital has a multidisciplinary team which include gastroenterologists, nutritionists, speech and language pathologists, occupational therapists and behavioral psychologists who can provide expert evaluation and tailored treatment. 

Carolina S. Cerezo, MD

Carolina Cerezo, MD, is the division director of the Pediatric Gastroenterology, Nutrition and Liver Diseases and director of the Feeding Program at Hasbro Children's Hospital. She is certified in pediatric gastroenterology and nutrition.