Case Challenges

Picky Eating and Food Aversion, From Typical to Extreme

Katja J. Rowell, MD; Jenny H. McGlothlin, MS, CCC/SLP


April 04, 2016

Healthy Feeding

In all cases of picky eating or food aversion, perform a thorough history and medical exam. Obtain further testing as indicated. Treat medical, sensory, or oral motor needs. Reassure families as indicated by exam and history, and address worries directly. Refer to other specialists as indicated.

Many children with typical picky eating, or even with more involved picky eating, do not need specialist care if parents are able to implement responsive and supportive feeding and the child is not getting worse. Help parents with anticipatory guidance for common problems, and offer resources. With picky eating, from typical to more extreme, reducing anxiety (child and parent), supporting routine meals and snacks every 2-4 hours with water in between, encouraging family meals without pressuring children to eat more or different foods, and offering repeat exposures to a variety of foods supports healthy feeding.

A variety of therapeutic approaches to clinical pediatric feeding struggles are available, ranging from behavioral modification to sensory-focused therapies that are generally provided by SLPs or OTs. An SLP can offer oral motor evaluation, therapies, and exercises to help with oral and swallowing delays or dysfunction. Behavioral therapies and therapies to address anxiety are likely to help if anxiety or obsessive-compulsive disorder are contributing factors, or after an aversive event, such as vomiting or choking. Some programs use a more "child-centered" approach, incorporating responsive feeding and the DOR[5] in treatment with sensory and oral motor skill-building (an example is Marsha Dunn Klein's Get Permission approach).

Much research in the field is hampered by a lack of consistent diagnostic criteria, lack of blinded research with controls, use of outcomes other than the achievement of typical eating, and short length of follow-up. Research is ongoing to better provide evidence for decision-making. The lack of consensus as to best treatment practice is frustrating for parents and doctors alike.[16]

When a child is not improving, therapy increases anxiety, conflict or power struggles arise, and intake and variety are not improving, it may be prudent to help parents find other support. Additional resources are found in the Table.

Table. Feeding Resources for Parents and Clinicians

Resources for Parents
Sole-Smith V. When your baby won't eat. New York Times Magazine. February 4, 2016.

Rowell K, McGlothin J. Helping Your Child With Extreme Picky Eating. Oakland, Calif: New Harbinger Publications; 2015. a

Ellyn Satter Institute. Ellyn Satter's Feeding With Love and Good Sense II [DVD]. b

Satter E. Child of Mine. Boulder, Colo: Bull Publishing; 2000.

Satter E. Secrets of Feeding a Healthy Family: How to Eat, How to Raise Good Eaters, How to Cook. Kelcy Press; 2008.

Fraker C, Fishbein M, Cox S, Walbert L. Food Chaining: The Proven 6-Step Plan to Stop Picky Eating, Solve Feeding Problems, and Expand Your Child's Diet. Boston, Mass: Da Capo Press; 2007.

Bahr D. Nobody Ever Told Me (Or My Mother) That!: Everything from Bottles to Breathing to Healthy Speech Development. Arlington, Tex: Sensory World; 2010.
Support and Anticipatory Guidancec
Feeding With Love and Good Sense: The First Two Years (booklet)

Feeding With Love and Good Sense: 18 Months to 6 Years (booklet)

Satter's Feeding in Primary Care Pregnancy Through Preschool (handout)
Resources for Clinicians
Santa Clara County Childhood Feeding Collaborative

Ellyn Satter Institute d

a Authored by Dr Rowell and Ms McGlothin; they have no financial interest in any other resources included in this table.
b Information on typical feeding and development, with family videos, from birth through age 5 years.
c Reproducible handouts and booklets available in bulk.
d Resource for articles, self-directed learning, and review or pertinent research.

Recommended Reading

Jaffe AC. Failure to thrive: current clinical concepts. Pediatr Rev. 2011;32:100-107.

Kerzner B, Milano K, MacLean WC Jr, Berall G, Stuart S, Chatoor I. A practical approach to classifying and managing feeding difficulties. Pediatrics. 2015;135:344-353.

Statement from USPSTF: screening for iron deficiency anemia -- including iron supplementation for children and pregnant women. Medscape Family Medicine. May 9, 2007.

Brice J. Tongue-tie treatment solves breast-feeding problems. Medscape Medical News. October 30, 2007.

Editor's Recommendation


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