Case Challenges

Picky Eating and Food Aversion, From Typical to Extreme

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

Disclosures

April 04, 2016

Follow-up Visit: Andrew

At the return visit 4 weeks later, you review the additional history obtained from his previous pediatrician. Solid foods were started at age 4.5 months to try to get him to gain weight. His mother told the pediatrician that "getting him to eat was always a struggle." He never liked being spoon-fed. Andrew is pickier than his older brother and "can't gain weight." Other than the pouches, he prefers mostly carbohydrates (pasta with butter, crackers, rice, breads, cookies, cakes). His mother serves organic chicken nuggets most evenings "to get some protein in him."

The list of foods Andrew has eaten, in addition to PediaSure, includes some cheeses, breads, crackers, canned mandarin oranges, bananas (which he no longer eats), hot dogs, corn, peas with butter, applesauce, waffles, pancakes, grilled cheese sandwiches, scrambled eggs, pears with peel (but only sliced), and 2% milk. He accepted more foods until he was about age 18 months, when he regularly began refusing previously accepted foods. He likes most desserts, refuses new foods, and whines until he is given one of his preferred foods. His parents eat dinner after the kids are in bed.

Andrew snacks on crackers or food pouches whenever he wants, and tends to eat more if distracted by TV. His mother can get a few bites of vegetables in if she bribes him with dessert. A brief video of a meal shows him throwing banana slices and screaming in his high chair. His mother brings him a pouch of pureed fruits and vegetables and lets him down from his chair.

Andrew's weight and growth are stable from the previous visit, and the records from his former pediatrician show consistent growth. A previously obtained serum iron level was normal. With no history or exam indicating other problems, further laboratory work is not indicated at this time.

Management: Helping Andrew's Parents Feed Well

Address Andrew's mother's worries about his growth and protein. Growth charts are not "report cards," although many parents believe that the 50th percentile is better than 25th percentile. Andrew's growth is steady and probably healthy for him, with no other concerning history or physical findings.[1,2,3] From milk, cheese, and peanut butter, he is getting enough protein, which a simple calculation confirms.[4] (At age 1 to 3 years, children need 0.55 g of protein per pound of body weight each day.) If Andrew's mother remains concerned, or needs more information or reassurance, she can visit a pediatric dietitian, although it is unlikely to be covered by insurance.

Let Andrew's mother know that trying to get her son to eat more or gain more weight is not productive (as she has observed), and could make matters worse.[5,6,7] Appetite varies for typical toddlers and preschoolers, who tend to eat more at some meals and snacks and less at others.

Andrew: Responsive Feeding

Responsive feeding, operationalized through Satter's Division of Responsibility in Feeding (DOR), is considered "best practice" in childhood feeding.[5,8,9] The DOR states that parents are responsible for what, when, and where their children eat, and the child is responsible for how much is eaten. Problems may arise with feeding when a parent pressures a child to eat more or less, or different foods, or the child is allowed to decide what, when, and where to eat.

When faced with picky eating concerns, follow these steps:

  • Perform a thorough history and examination;

  • Order lab tests only as indicated;

  • Uncover and address parental worries;

  • Reassure parents appropriately; and

  • Support families with referral as needed and information on responsive feeding.

Medical reasons for low food intake or difficulties absorbing nutrients must be considered; these include gastroesophageal reflux, celiac disease, allergies, and inflammatory bowel disease.[1]

Tips to help Andrew's parents feed in a responsive way:

  • Stop pressuring Andrew to eat more or different foods.

  • Offer regular meals and planned sit-down snacks every 2-4 hours, and offer only water between most meals and snacks.

  • Offer the pouches with meals and snacks, and transition to more developmentally appropriate choices at most eating opportunities.

  • Have Andrew join the family table. Removing the high chair (which he associates with negative experiences) may help. A booster seat or seating with a footrest helps children settle.

  • Limit meals and snacks to 20-30 minutes, and limit eating on the go. This also reduces choking risk.

  • It is unlikely that Andrew needs a liquid supplement for nutrition, and if his mother is comfortable doing so, she can stop giving liquid supplements altogether or incorporate them into meals and snacks;

  • Encourage his parents to eat meals with Andrew as often as possible. Family meals (one adult eating with a child counts) expose children to a variety of foods and are linked with many health and wellness benefits.

  • Serve a wider range of foods, not just the foods he eats now. Offer balanced and filling snacks, such as whole grain crackers with peanut butter and sliced pears. If he eats little for one meal, he will soon have another opportunity.

  • Offer small amounts of new foods, because there is likely to be more waste initially.

  • Serve child-sized portions of dessert with the meal. Bribing with dessert is likely to backfire as well.

  • Send his mother home with handouts and resources that explain and support responsive feeding.

At a nurse visit to recheck height and weight 2 months later, Andrew was on a stable growth trajectory. The family eats five evening meals together each week. The kids like family-style meals, and everyone enjoys meals more.

Andrew is described as eating a little bit more. He is "still pretty picky," but he is eating a better variety of foods, including turkey lunchmeat and canned baked beans. Andrew's brother is also benefitting, trying several new foods.

Summary: Andrew

Andrew's history illustrates typical picky eating, behaviors that affect roughly 1 in 3 children. The feeding history hints at pressured feeding from the start. Andrew was started on solids early in an effort to increase weight gain, probably before he was ready. He became progressively picky at around age 18 months. He eats a variety of textures, with no indication of oral/motor or swallowing difficulties. Such phrases as "get him to eat" or "get a few more bites in," as well as allowing him to regularly eat in front of screens, suggest less-than-optimal feeding, as do parental frustration and Andrew's misbehavior at the table. His steady growth, typical development, unremarkable medical and family history, and normal physical exam are all reassuring.

Figure. The Worry Cycle © Courtesy of Katja J. Rowell, MD.

The "worry cycle" (Figure) is a useful visual for the dynamic process operating in many families with picky eaters. In Andrew's case, his parents and first pediatrician worried that Andrew was "too small" at the 25th percentile for weight and 50th percentile for height. Efforts to try to get children to eat more tend to result in less intake over time.[5,10,11,12] Coercive feeding practices often "work" to get a few bites in initially, but soon begin to backfire, leading to less intake of fruits and vegetables and increased risk for poor growth.[5]

The misguided worry that Andrew was too small and wasn't getting enough protein motivated his mother to get him to eat, prepare his favorites, and allow him to eat whenever he wanted—three common mistakes that sabotage appetite. Kerzner and colleagues[5] aptly describe the danger of misperceived challenges: "Even mildly affected children whose anxious parents adopt inappropriate feeding practices may experience consequences."

Misperceptions, or worries about intake, nutrition, and weight, frequently lead to counterproductive feeding. Food power struggles are likely to backfire with such strong-willed and independent children as Andrew, causing them to eat less. Temperament is often a contributing factor.

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