Pediatric feeding disorder
Until recently there has been no universally accepted definition of picky eating even within the scientific or medical community. That has meant that no one can say a picky eater has exactly xyz traits. Or that to be classified as a picky eater a child needs to do x or not do y.
Therefore, even though there may have been quite a bit of research into eating challenges, often it was comparing oranges and apples as each study used its own definition of what fussy eating was or wasn’t.
Not having a definition also introduces challenges medically as doctors could not determine for sure what was and was not a problem.
This is part of the reason that picky eating has not been recognised in the same way as other childhood challenges like struggles to read or talk.
Picky eating is also less straightforward than other childhood challenges as there are times when behaviour could be either normal or problematic. For example, it is developmentally normal for children to be neophobic (refuse unfamiliar foods) as it’s a built in safety mechanism. However, it is also not ‘normal’ for that food refusal to either narrow a child’s diet to a few foods or to last for years.
Unfortunately, ‘it’s just a phase’ has become the catch-all for picky eating and is frequently used even when it’s entirely inappropriate:
– A child who never took to solids and has always struggled to eat, is not in a phase.
– An 8 year old who eats 10 foods and has done for years, is not in a phase.
– A child with sensory sensitivities who avoids whole food groups, is not in a phase.
New definitions for picky eating
There are a variety of terms that apply to children who obviously face eating challenges. ARFID (Avoidant Restrictive Food Intake Disorder) was introduced into the DSM-5 in 2013 (the diagnostic manual for mental health issues) as an ‘eating disorder’ diagnosis for extreme picky eating. Read about it here:
However, ARFID is a psychiatric diagnosis and so not necessarily a fit for many children. It also does not always sit comfortably for either parents or those who work with children who struggle to eat. I myself, have often wondered whether its been a useful diagnosis for a host of reasons.
A ‘feeding’ disorder rather than an ‘eating’ disorder appeared to be more accurate for many children.
Thus, in 2019 a group of experts from multiple disciplines working with children with eating challenges collaborated on a new diagnosis – Pediatric Feeding Disorder (PFD).
Doctors to dieticians to psychologists to gastroenterologists created PFD as a universally recognised term, one which is part of the ICD (International Classification of Functioning, Disability and Health) that is a framework used by the World Health Organisation (WHO) *.
What does the new diagnosis mean?
Hospitals in Australia and NZ are familiar with the ICD classifications so it should become an accessible diagnosis over time. Unfortunately, there is often considerable time-lag between a new diagnosis and wide-spread acknowledgement even within medical circles.
It will probably take quite a few years before recognition of PFD filters through to the majority of GP’s and even then, there may be resistance to accepting feeding challenges as a serious complaint.
Historically they have been seen as something that is best left to resolve itself organically.
Unfortunately, more and more research demonstrates that many children just do not grow out of their eating challenges. Just last year Auckland University found that 25 – 33% of children will struggle with a feeding disorder and 3-10% will have severe or persistent problems. That is 3-10% of ALL children.
Further, that children could have an ‘established’ feeding problem by the age of 4. Rather than this being a ‘phase’, even before school extreme picky eating could be an issue that is not going to resolve itself without support.
Also, 14% of children with a persistent feeding problem will experience worsening problems over time. Rather than ‘growing out of’ their challenges, they will see them getting more pronounced.
All of these statistics fit with the patterns I see working with over 100 families a year.
Definition of a feeding disorder
According to the medical literature, feeding disorders require a thorough assessment of 4 domains:
– Feeding skills
These domains are closely related and interact with one another. For example, a lack of oral motor skills may lead to picky eating which mean poor nutrition and the inability to attend social occasions comfortably.
Historically diagnoses have been done by a specialist in one area and therefore potentially some of the ongoing challenges in other parts of a child’s life have been missed.
As the parent of a selective eater, it is easy to see how there are frequently more global challenges than just a limited diet. It is also obvious that resolving problems may need attention to more than just one narrow issue.
For example, I frequently work with families where a child has sensory challenges that make some foods uncomfortable. This may lead to a diet that excludes whole food groups, and also has a knock-on effect into discomfort with, for example, sleepovers.
Definition of a feeding disorder
“Impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction”.
Having a specific diagnosis that addresses all 4 domains that are of relevance in feeding disorders means that professionals can all be ‘on the same page’. It also means that over time, hopefully, the narrow way eating challenges are commonly looked at is broadened.
It means that as a parent, you have specific criteria you can look at to explain to your healthcare provider what exactly is happening for your child.
Unfortunately, the definition, although listed in the ICD, does not appear on the medical reference sites that GP’s commonly use to look up disorders or issues. Until this is the case, and it is more commonly recognised, there may be little additional awareness of picky eating challenges.
You can, however, use the information about PFD to be better informed and potentially have better results from requests for help.
Feeding and functioning
Eating is complex. It requires interaction between the nervous system, the muscles, the skeletal system, the digestive system, and multiple organs. In order to do this efficiently a child needs to acquire and master skills. If there is a challenge in any of the areas supporting competent eating it can increase the risk of a feeding disorder.
When more than one system is not working well it can exacerbate challenges. With children’s eating there is also the added complication of the caregiver-child relationship, which can also help or hinder!
The new definition of PFD also advocates using the ICF (International Classification of Functioning, Disability, and Health) framework. This complements the ICD-10, emphasising a wholistic understanding of a feeding disorder and looks at the fact that not eating widely can be dysfunctional and disabling.
Not being able to eat competently generates environmental and social barriers, like not being able to go on a school camp and impacting on family and community life. Being able to function in everyday situations and not be excluded, is important for quality of life.
It can also increase stress on parents.
PFD therefore sets out describe the effects of the eating challenge on function.
The 4 domains of PFD
The definition states that intake of nutrients by mouth – that is inappropriate for the age of the child – happens for at least 2 weeks and is associated with at least one of the following:
1. Medical dysfunction – where there is:
a. Cardiorespiratory compromise during feeding. For example, a child struggles to breathe properly when eating.
b. Aspiration or recurrent aspiration pneumonitis. Which is when food is being breathed in rather than going towards the GI tract.
2. Nutritional dysfunction – which is shown by any of:
b. Specific nutrient deficiency or a significantly low intake of any or more nutrients due to a limited diet
c. Necessity for supplements or non-oral feeding to maintain nutritional intake and /or hydration.
3. Feeding skills dysfunction – shown by any of:
a. Requiring the texture of food or drink to be modified
b. Needing modified feeding position or equipment
c. Requiring modified feeding strategies
4. Psychosocial dysfunction – shown by any of:
a. Avoidance behaviours when being fed
b. Inappropriate caregiver management of child’s feeding and/or nutrition
c. Disruption of social functioning in a feeding context
d. Feeding disrupting the child-caregiver relationship
Also, that none of these have the body image focus of ‘traditional’ eating disorders or are due to lack of food or cultural practices.
Looking through the list, it is easy to see how selective eaters can easily tick a few boxes. For example, older children who eat from pouches, or those who can’t go to camps or sleepovers.
It is also relatively common for parents to tell me eating challenges affect their relationship with their child. Or, that they need to give their child vitamins as they are not eating widely and well.
In the ICF framework disability is defined when feeding challenges interact with personal and environmental factors and result in limitations on activities or participation. So, for example, a child cannot fully participate in daycare or school activities, or routines need to be altered to accommodate the child.
I know many parents who have had to go on trips or camps to ensure their child is able to eat. PFD in the teen/older years can impact on social relationships and employment.
One of the 4 domains assessed for a diagnosis of PFD.
There is a lot of medical detail listed under this heading and so if your child has a developmental delay or other medical challenge it is worth delving into this in more detail.
Children who have a disorder of appetite signalling.
The category also covers neurodevelopment disorders which are associated with PFD, specifically Autism Spectrum Disorder.
The second domain assessed for PFD.
PFD often means low quality, quantity and/or variety of food and drinks consumed. Children are therefore at risk for malnutrition, overnutrition, micronutrient deficit toxicity (from too many of one vitamin in supplements) and dehydration.
Malnutrition – when nutrients ingested cannot meet nutritional requirements causing lack of energy, protein or micronutrients that can impact on growth, development and health.
Malnutrition affects 25 – 50% of children with PFD. It’s most common when a child has chronic disease or neurodevelopment disorders.
A limited diet can create other problems. For example, excluding whole food groups like fruit and veg may cause a micronutrient deficiency even though a child is eating enough food.
The 3rd domain assessed for PFD.
Illness injury or developmental delays can affect feeding skills.
There is quite a bit of detail around children who have medical challenges beyond feeding, but that impact upon feeding.
Oral sensory functioning can affect or limit the number of foods and drinks accepted. There is also quite a bit of detail discussing both this and oral motor functioning (something that impacts on the ability to eat or drink effectively and efficiently).
Some signs these may be a factor are gagging, problems swallowing, food dropping from the mouth, overstuffing the mouth, lots of chewing, gulping, food left in the mouth, breathing in food, and sensitivities to texture, flavour, temperature, or appearance of foods.
Dysfunction is where feeding skills are not safe, age appropriate and efficient.
Unsafe – may be choking, breathing in food, or other negative feeding signs like gagging, vomiting, fatigue or refusal.
Delayed feeding skills – might mean a child cannot eat/drink age-appropriate food textures or liquids. For example, needing food pureed or smooth. A child may also struggle with self-feeding or using utensils. And/or need special feeding equipment, positioning or strategies to help them eat.
Inefficient feeding – could be overlong mealtimes (over 30 minutes) or not eating enough at a meal. Children may need altered textures, special strategies or equipment or supplements.
The final domain assessed within PFD.
Aspects of the environment, or circumstances of the caregiver or child can negatively affect feeding, and contribute to the development and maintenance of PFD.
Problem feeding behaviours can develop. When things are going wrong, and compromises are being made parents know and so this is a commonly reported challenge.
Developmental factors, mental and behavioural health problems, social factors or environmental factors whether in the child and/or the caregiver can affect feeding. Any of these individually can cause dysfunction and frequently there is an interaction between more than one factor.
Delays in motor skills, language, socialisation, and cognition can all impact on feeding. Unfortunately, this also often results in a gap between what a child is capable of and what a caregiver expects in the feeding area. Feeling as though a child ‘should’ be doing something and they are not can mean adopting feeding tactics that are inadvertently detrimental.
Mental & behavioural health problems
Mental and behavourial issues, whether in the child, the caregiver or the relationship can affect feeding and eating. In the child, mood disorders, anxiety, disordered thinking, or a dysregulated temperament can disrupt feeding. In parents stress and/or other mental health challenges may alter feeding interactions. In turn dysfunctional feeding may result in eating challenges which then produce more issues in feeding.
These may be cultural expectations or interactions caregiver-child which impact on mealtime behaviour. For example, caregivers may not manage problem behaviour well, or not read hunger cues effectively and thus interrupt competent eating.
A distracting feeding environment, such as watching TV or using devices, can inadvertently contribute to the development of PFD. As can inappropriate feeding behaviour like providing preferred foods when other options are refused, or not having a mealtime schedule. A shortage of food may also affect how and what is fed and in turn affect eating.
Unfortunately, many of the factors described above impact on feeding and can cause, maintain or exacerbate PFD. Many of them, however, are the result of lack of knowledge, support, and/or desperation. When feeding is not going well and eating is a necessity compromises naturally get made and many of these inadvertently prevent competent eating and/or worsen challenges.
PFD usually manifests as one of the following:
1. Learned feeding aversions – not unsurprisingly, when a child continually has pain or discomfort during feeding they do not enjoy eating. Over time a child will find ways to avoid the discomfort, for example, refusing many foods. When this reduces the discomfort these coping strategies become habit.
2. Stress and distress – whether in the child and/or the parent these cause negative emotions and dislike of meals.
3. Picky eating – or food ‘overselectivity’ which is where the variety of foods is limited and new foods are not tried, despite the ability to eat more widely. Also, children may not progress to foods appropriate to their age, for example, eating purees beyond babyhood.
4. Grazing – children frequently eat and drink small amounts through the day and so never feel hungry and so often eat less.
5. Inappropriate strategies – making inappropriate compromises/using inappropriate strategies to increase food and nutritional intake. Many of these are ‘maladaptive’ so although they may work short-term, they exacerbate problems. For example, providing only favourite foods, hand-feeding older children or using a bottle beyond infancy.
Looking through the list above you may recognise your child or yourself in some of the descriptions. If so, it’s important to evaluate whether you feel this is something you are able to work on yourself to improve feeding or whether you need external support.
A feeding expert can usually look at what’s happening and identify areas you can make changes, yielding positive results, very quickly. They can also give you practical strategies to use that are specific to you and your child.
You can also use this article as the basis of a conversation with your GP. If you recognise many of these in your child’s feeding you can make a list and explain to the doctor what is going wrong and how this is part of a medical condition and not a ‘phase’ or a ‘parent induced problem’.
If you have any questions after reading this, please feel free to get in contact with me. I will respond personally to anyone who needs additional support – email@example.com
*Pediatric Feeding Disorder
Goday, Praveen S.; Huh, Susanna Y.; Silverman, Alan; Lukens, Colleen T.; Dodrill, Pamela; Cohen, Sherri S.; Delaney, Amy L.; Feuling, Mary B.; Noel, Richard J.; Gisel, Erika; Kenzer, Amy; Kessler, Daniel B.; Kraus de Camargo, Olaf; Browne, Joy; Phalen, James A
Journal of Pediatric Gastroenterology and Nutrition 68(1):p 124-129, January 2019. | DOI: 10.1097/MPG.0000000000002188
Judith, MA Cantab (Cambridge University), Post Grad Dip Psychology (Massey University), is an AOTA accredited picky eating advisor and internationally certified nutritional therapist. She works with 100+ families every year resolving fussy eating and returning pleasure and joy to the meal table.
She is also mum to two boys and the author of Creating Confident Eaters and Winner Winner I Eat Dinner. Her dream is that every child is able to approach food from a place of safety and joy, not fear.
Learn more about Judith here: https://theconfidenteater.com/about/