Parents, does dinner with your children feel like an episode of the popular TV show Cupcake Wars, where you are the contestant who is vying for that stamp of approval from the judges-your kids? It seems like no matter what you do, how many cute shapes you cut the food into, how many ways you can arrange it on the plate or how many "open wide for the train to go in the tunnel" games you play, you cannot get your child to eat. Is your child simply a picky eater, or could there be something more serious impacting her willingness to eat?

Feeding and swallowing development occurs as a complex sequence, with skills building on one another and becoming more refined with age. Serious feeding problems in children are often accompanied by a developmental, neurological or genetic disorder or complex medical conditions. These can include, but are not limited to: autism spectrum disorders, Down syndrome, gastrointestinal motility disorders (GI disorders), cerebral palsy or cystic fibrosis. Children with severe food allergies, experience gastroesophageal reflux disease (GERD), have structural abnormalities (cleft lip or palate), or are dependent on alternative feeds are at a higher risk for becoming a problem feeders. Those who were hospitalized for an extended time at birth or who received a tracheostomy or feeding tube, may also have difficulty transitioning to an age-appropriate feeding pattern due to oral aversion. Oral aversion is when a child has a difficult time allowing food or objects to be on or near the face. This fear can develop into a fear of food or trying new food, often referred to as food neophobia. In 2010, researchers Drs. Laurel Branen and Samantha Ramsey from the University of Idaho found that once these children work through the fear, they usually add the new food to their repertoire. Research shows that 25-45 percent of typically developing children suffer with some degree of a feeding disorder. In children who suffer from a developmental, neurologic, or genetic disorder, that number rises to 30 - 80 percent.

Picky Eaters

Not everyone likes broccoli, so how do you know if your child is simply a picky eater or if there is something more serious going on? According to research by ASHA fellow Dr. Joan Arvedson and pediatric psychologist Dr. Kay Toomey, a picky eater is classified by the following:

  • Eats a limited variety of foods, but has around 30 foods they will eat,

  • Intakes enough calories daily for growth and nutrition,

  • Can lose interest in a certain food for a period of time, but will accept it again after a few weeks,

  • Will eat at least one food from all major food groups (protein, grains, fruits, etc.),

  • Can tolerate a new food on the plate, even if they will not eat it,

  • Often eats a different meal than the rest of the family during mealtime.

Mealtimes with a picky eater can be difficult. Parents experience stress and anxiety making sure the child is receiving adequate calories while still taking in a variety of nutrients. Eating three pieces of French toast, for example, is not the same as having a balanced meal of fruits, vegetables and grains.

Problem Feeders

A feeding disorder is characterized by any difficulties eating or drinking including chewing, sucking or swallowing. Problems can be observed before, during or after a meal. Children who have not developed age-appropriate feeding skills and/or have a genetic, developmental or behavioral disorder can have difficulty during mealtime. According to the American Speech-Language-Hearing Association (ASHA) some signs and symptoms of a problem feeder can include:

  • Lengthy feeding times,

  • Trouble breathing when eating or drinking,

  • Choking, gagging or excessive crying during mealtimes,

  • Tantrums when presented with new foods,

  • Excessive drooling or spilling foods/liquids from the mouth,

  • Difficulty chewing or swallowing food,

  • Restricted variety of foods eaten, usually fewer than 20,

  • Refusal of entire categories of food based on texture or food group,

  • Frequent congestion, especially after meals,

  • Poor weight gain or weight loss.

Pediatric gastroenterologist states that critical periods for oral exploration, chewing and texture advancement are believed to exist (Udall, 2007). Children who fail to reach certain feeding milestones often have difficulty transitioning to the next stage. Positioning, types of foods, appetite and presentation can all be contributing factors to a child's feeding problem. The key is to identify what is causing the difficulty in order to begin the process of treating it.

The Next Step

If you suspect that your child's difficulties are more in line with problem feeders, there are resources and options available for you. Contact your pediatrician for a referral to a feeding therapist who can determine the specifics of your child's feeding problem. A feeding therapist is a licensed, qualified speech-language pathologist, occupational therapist or dietician who works with individuals with feeding difficulties. The process begins with a feeding and swallowing evaluation conducted in the home, or a private practice, outpatient clinic or hospital. During the evaluation, the feeding therapist will ask about your child's eating patterns and give you an opportunity to share your concerns. The therapist will then identify any structures in the child's mouth that are not performing adequately (tongue, lips, jaw, etc.) and observe your child eating and drinking. The feeding therapist will make recommendations for further evaluations if needed, as well as treatment and support. Therapy varies based on the facility but typically ranges from 30 minutes to one hour with sessions occurring once or twice a week. Treatment is most often family centered and may include various professionals on your child's team. Family involvement is a critical factor and therapists work to educate and empower the family about the child's feeding problem. Working together with family members and other professionals using an individualized approach for each child serves as the groundwork for successful outcomes. Solving your child's feeding problem may not win you a grand prize. However, it will solve the food war battles and leave you with a happier, healthier eater.

April Anderson is a speech-language pathologist at National Speech/Language Therapy Center. She works with infants and toddlers, as well as school-aged children with feeding disorders, including those transitioning from feeding tubes, with complex medical disorders and with feeding aversion. 301-493-0023;