I’m sure you have heard this before.
“He’s just a picky eater.”
“She will grow out of it.”
“Just feed them what you feed the family. They will get hungry enough to eat it.”
These are just some of the things parents tell me they have been told about their child’s feeding issues. We have come up with a quick way to determine if eating issues go beyond picky, towards having a diagnosed feeding disorder.
This is called Avoidant Restrictive Food Intake Disorder (ARFID) in the Diagnostic and Statistical Manual 5 (DSM 5). When evaluating a child for a feeding disorder, these are some of the behavioral characteristics you may see.
| Questions | Picky Eaters | Feeding Disorder |
| Food Groups | 1-2 foods per food group | Missing food groups
(always vegetables, often protein and fruits also) |
| Selectivity – Brand & Container
|
Eat any kind of brands family buys | Only eats one specific brand for certain foods.
Will only eat certain foods if they see them in the box/container |
| Textures | Can eat a variety of textures | Leans towards only purees or crunchy foods |
| Food Refusal | Mild, verbal | Screaming, throwing food vs passive anxious behaviors |
| Eating socially, in public | Can eat at a restaurant, Friends house, parties | Bring food from home, Eat before going out, Don’t go out to eat |
| Influences | Because friends eat it, to get a favorite food | No interest in what others are eating, don’t care about rewards of any kind |
| Mealtime Stress | Mealtimes are relatively stress-free | Parents report significant stress at mealtimes. |
Let’s look at these topics in more detail
- Food Groups
- Picky eaters usually eat a few foods from all the food groups
- Children with feeding disorders are often missing food groups
- Most children don’t eat vegetables
- Proteins are often left out, (except for chicken nuggets and peanut butter) and we worry about iron deficiency.
- Fruits are hit or miss, depending on the child’s sensory preferences
- Food Selectivity
- Picky eaters can eat foods of different brands, or cooked in different ways. They don’t care if the containers or characters change
- Instead, children with feeding disorders are very specific to certain brands of food, want foods cooked in certain ways, or will only eat foods that come in a particular container (Yogurt only in a tube, applesauce only in a pouch, Elsa has to be on the box).
- This makes buying foods very difficult, causes many families to go to more than one store, or stock up on certain foods, hoping their child doesn’t get tired of this food before they run out.
- Textures:
- Picky eaters eat a variety of textures across food groups.
- Children with feeding disorders tend to have specific texture preferences, often crunchy foods
- Some children who prefer purees or have never advanced to other textures, especially those over two.
- This could be because of a delay in the onset of foods offered, especially in preemies.
- Children who have had medical complications, like G-tube feeding, being intubated, trach dependent, who have not had solid foods.
- Children with strong gag reflex when solids were offered.
- Children with a history of aspiration, or structural difficulties.
- Could also be related to GI distress including reflux and an allergic condition called Eosinophilic Esophagitis (EoE). This requires further assessment and evaluation by gastroenterology.
- Food Refusal:
- Picky eaters tend to be a little whiny about non-preferred foods, or have occasional and mild disruptive behaviors at mealtimes
- Children with feeding disorders have more severe disruptive behaviors, including screaming, running away from the table, and throwing food. It causes distress for everyone at the table and interferes with general family meals.
- Children who are anxious may have more passive behaviors, like slowly pulling away from the food, flushing red, fidgety-ness, or sadness and tears.
- Eating in Public:
- Picky eaters can participate in mealtimes at birthday parties, find food to eat at a friends’ house or restaurant.
- Parents of children with feeding disorders often tell me they bring food with them whenever they go out, feed them before they go, or don’t go out to eat at all. These children will often avoid going places where food will be present.
- They also have trouble eating at school, even if they bring a preferred lunch.
- Social Influences:
- Picky eaters will usually eat their peas to get ice cream or try something new because a friend has tried it and liked it.
- Children with feeding disorders don’t tend to care about others are eating. They often say, “That is not my food, it’s your food.”
- They will not try new foods just because they see other children eating
- They also aren’t swayed by rewards. It doesn’t seem to matter what is offered, it doesn’t get them to try new food, let alone like it.
- Mealtime stress: If parents think mealtimes are stressful, it is worth additional attention.
Other things we notice with children with feeding disorders include
- Food jags – getting stuck on one food for a long time
- Dropping foods out of their diet for no particular reason
- Unable to sit for meals, due to difficulties with seeing others eat or smelling their food
- Hypersensitive smell and gag reflexes
- Make decisions about food based on how they look, and not how they taste.
Oftentimes, these behavioral issues occur in the context of other sensory issues, oral motor delays, and dysphagia. It is important to evaluate all aspects of the feeding disorder. Having a team of therapists, including occupational therapy, speech therapy, nutrition, and psychology can be helpful to do a comprehensive evaluation.