The Picky Eater and Feeding Difficulties

Children with feeding disorders aren’t just picky eaters. These disorders can signal the presence of underlying medical and developmental issues. Picky eating is a common behavior with children. There is no universally accepted definition of picky eating. There’s also no agreement on the best tool to identify it. Whether parents are wondering whether their child or children are merely going through a temperamental phase, or may be experiencing something more serious, it’s important to be able to recognize the signs of feeding disorders. That way, infants and children with potential feeding difficulties can receive the help they need to eat without pain, discomfort or fear.

Causes of picky eating may include early feeding difficulties, pressure to eat, and late introduction of lumpier foods at weaning. The consequences for a child who is a picky eater includes poor variety of foods in their diet and a lack of different nutrients important for growth and development. This could include children having low intakes of vitamins, iron and zinc from low intakes of meat, fruits and vegetables, which are of particular concern. Low intakes of dietary fiber, as a result of limited/no fruit and vegetables are associated with constipation. There may be a small subgroup of children where picky eating does not resolve itself. These children may be at risk of thinness during adolescence, developing an eating disorder or becoming an adult who is a picky eater. These children need to be identified at an early age to enable support, therapy, monitoring and advice to be offered to parents.

Up to 80 percent of children with developmental disabilities or medical and behavioral difficulties display feeding disorders, according to a study from World Psychiatry. Feeding disorders can progress to increased developmental delays, behavioral disorders, feeding difficulties and poor growth. Difficulties with psychosocial issues also can develop, interfering with family dynamics during mealtimes and with socialization with peers. Strategies for avoiding or improving picky eating with children include repeated exposures to unfamiliar foods, parental modeling of eating fruit and vegetables and unfamiliar foods, and creating positive social experiences around mealtimes.

Feeding therapy helps children learn how to eat or how to eat better.  Feeding therapists are usually occupational therapists (OT’s) or speech and language pathologists (SLP’s).  Some dietitian/nutritionists provide direct treatment, but more often provide support with additional services for some children to manage any weight or growth concerns when it is necessary. Occupational therapy and speech therapy often have cross over and frequently work together when children have feeding difficulties.

No matter what their background, it is important to note that “feeding” is a specialty within a specialty.  Not all OT’s and SLP’S are trained in pediatric practice, and not all pediatric therapists have advanced feeding therapy education and practice either. Feeding therapy often happens on a weekly basis, but can be every other week or once a month during a scheduled block of time, usually 30-60 minutes long. Most often, this time is spent teaching your child how to eat new foods (if they have a very limited diet) or how to eat (if they don’t know how to chew or manage food in their mouth).

Depending on the child’s underlying difficulties, you may see your child participating in sensory integration/registration activities or completing exercises to strengthen the muscles they need for eating.  Exercises will often include activities like blowing bubbles, making silly faces, or using whistles. They may also be placed on a “sensory diet”, which may include incorporating certain kinds of stimulatory foods, such as crunchy, salty, spicy or chewy. It could also involve heavy work and/or movement based activities such as using suspended equipment, wheelbarrow walking or pushing a scooter while lying on their tummy, as well as being put on a sensory brushing program called the Wilbarger brushing protocol.

Generally speaking, feeding therapy is extremely helpful and strongly recommended if your child or children are having difficulties actually eating.  This is most common with children that have special needs or medical challenges that may make it physically difficult for them. Many children may already be receiving occupational therapy and/or speech therapy for other issues besides feeding difficulties.

Is feeding therapy for picky eaters though? In order to answer that question you need to know that not all picky eaters are created equal. It’s a blanket statement that is used to describe any child that basically has food preferences or perhaps doesn’t like vegetables. It may also include children that gag or even throw up at the sight of new foods and only have 4-5 foods that they regularly eat. Feeding therapy is recommended for more extreme picky eaters that have a very limited diet and stress around trying new foods. Obviously, feeding therapy isn’t necessary for all of them.

As you can imagine, there are different types of approaches to feeding therapy. Some you may be comfortable with and some possibly not.  Remember that it is always okay to ask what type of approach they are using to help your child.  There are dozens of different approaches that would be too much to cover in this post, but the majority can be summed up into two different categories:

  • Behavioral – This method being the more traditional method of feeding therapy uses a reward system for new foods eaten. Children could receive a toy, sticker, or play time on an I-Pad or video game for taking a bite of a new food. They would receive additional rewards for additional bites of food. These rewards should be slowly phased out with time, although that isn’t always the case.
  • Child directed – This is a more modern approach and parents are more involved with this type of treatment. The focus is on addressing the underlying cause of the problem (i.e. sensory, medical, etc.). While this approach may take longer to see results initially, there is research that supports the effects are longer lasting.  

Children receiving occupational therapy from a therapist well versed in feeding difficulties is your ultimate goal. They can provide strategies and solutions to various challenges you may be having with your child or children’s feeding issues. Ultimately, starting therapy as early as possible and addressing the underlying issues is ideal for helping children who are picky eaters and/or have feeding difficulties…at least in this humble occupational therapist’s opinion!