Case Challenges

Picky Eating and Food Aversion, From Typical to Extreme

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


April 04, 2016

Follow-up Visit: Jaden

The pediatric ENT specialist discovered that only the anterior tie was clipped initially; a submucosal (posterior) tongue-tie and scarring were causing significant restriction in motion that were probably affecting Jaden's ability to eat age-appropriate foods. A release procedure, followed by stretches to prevent scarring, were prescribed. Jaden's mother described immediate improvement in efficiency of breastfeeding and a reduction in pain.

In the context of the worry cycle, identifying the feeding challenge (whether real or perceived) is critical. Any factor that causes discomfort or difficulty in getting food in the mouth, chewing, swallowing, or digesting puts the child at risk for feeding struggles. Jaden's tongue-tie was the initial challenge, and increasing pressure to get him to eat led to greater resistance. (Risk factors and etiology of feeding challenges are covered in part 1 of this series.)

The management of tongue-tie is controversial. Tongue-clipping procedures occasionally scar and result in restricted movement and function, but not all lactation consultants or feeding therapists are trained or qualified to do a thorough oral exam. A history of difficulty feeding, significant pain with breastfeeding, and continued struggles while in feeding therapy mean that a thorough oral exam and evaluation by a qualified professional are warranted.

In the past, for a "failure to thrive" diagnosis, multiple lab tests were recommended to rule out any possible medical contribution. New thinking advises ordering labs as warranted by history, exam, and clinical course.[1]

Management: Responsive Feeding for Jaden

In discussion with Jaden's feeding therapist and with his mother, the decision was made to stop feeding therapy because Jaden was becoming more resistant. Jaden was referred to a pediatric speech-language pathologist (SLP) specializing in feeding therapies. Probably because he missed out on developmentally typical experiences and practice, Jaden was found to have mild oral motor delays. Over two visits, parents were advised on the use of chewing tubes and strengthening exercises at home, as well as ways to prepare foods appropriate to his skill level.

Furthermore, Jaden's parents were supported with responsive feeding advice: Offer foods, breastfeed every 2-3 hours, and include Jaden in family meals. Jaden was probably getting significant nutrition from breast milk, and with this stressful situation, Mom was encouraged to continue breastfeeding if desired, with instructions to do so in a way that supported Jaden's appetite. Prolonged breastfeeding with difficulty eating solids is an indication to look further, rather than simply assuming that breastfeeding is the problem and advising cessation.

With Jaden's improved ability to manipulate foods in his mouth, his gagging lessened, and although he was a few months behind, his skills improved. By age 2 years, Jaden was eating as most typical (and picky) toddlers do, and had weaned off breastfeeding. He gained 2 lb in the first month after treatment and returned to his earlier growth curve, around the 50th percentile.


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