Picky Eater or Problem Feeder?

When kids don’t want to eat, we call them a “picky eater.” It’s stressful and frustrating. And, it can be a more serious issue, which is where the term “problem eater” enters the scene.

As a clinician, the first thing I do is to determine if the child is a picky eater or a problem feeder. Picky eating, while stressful and challenging, carries less of an immediate health risk to the child than does problem feeding. “He’ll will eat when he’s hungry” does not apply to kids who are problem feeders.

For both picky eaters and problem feeders, the traditional approach of “de-sensitization,” (forcing kids to take a bite, withholding privileges based on food consumption, and requiring kids to eat all of the food on their plate before offering preferred foods) can lead to increases in food aversions and selectivity, increased power struggles, and overall increased levels of anxiety and upset, not just surrounding food…which for a problem feeder can mean severe nutritional deficit and medical complications. For kids who are problem feeders, simply engaging them in food preparation and positive interactions with food, is not sufficient. Problem feeders need a thought out, targeted and multi-faced intervention plan that incorporates un-learning negative associations, building foundation skills and physiological processes that are lacking in other physical areas of function, and compensating for weaknesses to facilitate child success.

So what is a picky eater and how does one know when it turns into problem feeding?

Kay Toomey, PhD and author of the SOS Approach to Feeding says that problem feeding is characterized by the following:

• Restricted range or variety of foods, usually less than 20 different foods
• Foods lost due to food jags are NOT re-acquired
• Cries and “falls apart” when presented with new foods
• Refuses entire categories of food textures
• Almost always eats different foods than the family
• Adds new foods in more than 25 steps
• Persistently reported by parent as a “picky eater” across multiple well-child check-ups

Picky eating is characterized by:

• Decreased range or variety of foods that will eat = 30 foods or more
• Foods lost due to “burn out” because of a food jag are usually re-gained after a 2 week break
• Able to tolerate new foods on plate and usually can touch or taste a new food (even if reluctantly)
• Eats at least one food from most all food texture groups
• Frequently eats a different set of foods than the rest of the family, but usually eats with the family
• Will add new foods to repertoire in 15-25 steps on Steps to Eating Hierarchy
• Sometimes reported by parent as a “picky eater” at well-child check-ups

My most recent favorite resource for help with picky eating AND problem feeding is Susan Roberts, MDiv, OTR/L and author of “My Kids Eat Everything.”

The next step, once severity of the problem is determined, is to rule out medical cause for the behavior. Hidden gastrointestinal issues, food allergies and sensitivities, gastroesophogeal reflux (GERD), mineral and vitamin deficiencies, or congenital oral differences such as tongue tie, tongue thrust, and dental problems, may all contribute to, cause difficulty with or changes to eating behaviors. Even a child without known medical or developmental problems or children with a history of problems from infancy or toddlerhood that seem to have resolved, may still experience any number of the above. Additionally, children with or without medical diagnosis may still experience physical reasons for food aversion and avoidance.

Once medical cause has been ruled out a nutritional consult is imperative, for parents of problem feeders. A registered dietitian and nutritionist (not just a nutritionist) is skilled at establishing the minimum daily nutritional requirements for a child based on their individual needs. This information may serve as a baseline for knowing where to start in establishing an intervention plan for improving eating behaviors. For parents of picky eaters, a nutritional consult may seem optional vs. imperative, but having a concrete understanding of minimal nutritional requirements may alleviate stress on the part of a parent and also help to establish realistic expectations for how to approach the problem. It is important to note, that even a child who eats a large number of foods or eats a large quantity of food, may still be at risk for nutritional deficits and all children need proper nutrition in order to optimize their growth, development, and learning potential.

Finally, the next step is to keep a food journal for a week (including weekends). The food journal should be kept over the course of a typical week, in order to give an accurate snapshot of what a child’s true intake really is. It is easy to overestimate or underestimate when emotions are involved. Parenting a child with picky eating patterns or problems in feeding is definitely emotional, and the stress that is caused by prolonged problems in feeding may bias a parent report. The food journal should include:

• EVERY item a child puts in their mouth (not just what they swallow) and the list may be divided each day according to what is consumed (swallowed) and what is tried (put in the mouth).
• Eating behaviors (i.e. plays with food but doesn’t eat it, throws it across the room, screams and cries when said food is presented, threw up 1/2 hr. after eating, took 3 bites, eats only with video playing). The eating behaviors may give clues to the root of the picky eating challenge and also contributes to an accurate picture of what mealtime is like in your house.
• Include as many specific details as possible. For example, include brand names if there are strong brand preferences, if you cut the food into small pieces state that, and if the child only eats a certain food on a certain color of plate or day of the week, state that too. The more specific, the better because it results in a more targeted intervention plan that has more potential for success.