A Functional Approach to Feeding Difficulties in Children
Purpose of Review
This review provides an approach for resolving a variety of feeding difficulties in children, ranging from normal eating behavior that is misperceived as a problem to substantial feeding disorders.
Criteria to identify pediatric feeding disorders have been thoroughly addressed in the newly established designations of avoidant restrictive food intake disorder (ARFID) and pediatric feeding disorder (PFD). These diagnostic criteria improve the accuracy of identifying, classifying, and managing significant feeding disorders in young children.
While recent definitions of feeding difficulties are particularly appropriate in multidisciplinary settings, in this paper, we advocate for a progressive approach of managing feeding problems in all clinical settings. It begins by identifying red flags indicative of serious threats to the child, screening for oral motor dysfunction, stabilizing nutrient intake, and eliminating aversive feeding practices. The next step, if eating behavior does not improve, involves strategies that target specific eating behaviors and parental feeding styles. In severe or resistant cases, referral to specialists or interdisciplinary feeding teams is advised.
KeywordsFeeding disorder Food selectivity Poor appetite Fear of feeding Picky eating
Compliance with Ethical Standards
Conflict of Interest
Kim Milano and Irene Chatoor report receiving honoraria from Abbott Laboratories for speaking at conferences related to feeding difficulties and disorders. The other author declares that there is no conflict of interest. Benny Kerzner carried out a clinical study 5 years ago to assess the ability of pediatricians to correctly classify young children with feeding problems in the office setting. The study was funded by Abbott Laboratories.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: •• Of major importance
- 1.American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub; 2013 May 22.Google Scholar
- 2.•• Goday PS, Huh SY, Silverman A, Lukens CT, Dodrill P, Cohen SS, et al. Pediatric feeding disorder: Consensus definition and conceptual framework. J Pediatr Gast Nutr. 2019;68(1):124–9 Provides interdisciplinary consensus on the definition of and criteria for identifying pediatric feeding disorders not related to distortions in body image or weight concerns. Google Scholar
- 6.Kerwin ME. Pediatric feeding problems: a behavior analytic approach to assessment and treatment. Behav Anal Today. 2003;4(2):162–75.Google Scholar
- 9.Carruth BR, Ziegler PJ, Gordon A, Hendricks K. Developmental milestones and self-feeding behaviors in infants and toddlers. J Am Diet Assoc. 2004;104:51–6.Google Scholar
- 10.Morris SE, Klein MD, Klein DM. Pre-feeding skills: a comprehensive resource for mealtime development. New York: Academic; 2001.Google Scholar
- 11.Hojsak I, Bronsky J, Campoy C, Domellöf M, Embleton N, Fidler Mis N, et al. Young child formula: a position paper by the ESPGHAN committee on nutrition. J Pediatr Gast Nutr. 2018;66(1):177–85.Google Scholar
- 16.Chatoor I. Diagnosis and treatment of feeding disorders in infants, toddlers, and young children. Washington, DC: Zero to Three; 2009.Google Scholar
- 19.•• Gibson EL, Cooke L. Understanding food fussiness and its implications for food choice, health, weight and interventions in young children: the impact of professor Jane Wardle. Curr Obes Rep. 2017;6(1):46–56 Excellent review of the contribution genetics, environment, and parental feeding practices has on food selectivity and neophobia and the resulting impact these factors have on children’s food choice and preferences. PubMedGoogle Scholar
- 24.Williams KE, Riegel K, Kerwin ML. Feeding disorder of infancy or early childhood: how often is it seen in feeding programs? Child Health Care. 2009;38(2):123–36.Google Scholar
- 27.Marí-Bauset S, Zazpe I, Mari-Sanchis A, Llopis-González A, Morales-Suárez-Varela M. Food selectivity in autism spectrum disorders: a systematic review. J Child Neur. 2014;29(11):1554–61.Google Scholar
- 34.Volger S, Sheng XY, Tong LM, Zhao DM, Fan T, Zhang F, et al. Nutrient intake and dietary patterns in children 2.5-5 years of age with picky eating behaviors and low weight-for-height. Asia Pac J Clin Nutr. 2015;26(1):104–9.Google Scholar
- 39.•• Marshall J, Hill RJ, Ware RS, Ziviani J, Dodrill P. Multidisciplinary intervention for childhood feeding difficulties. J Pediatr Gast Nutr. 2015;60(5):680–7 This study compared the effectiveness of behavioral interventions for feeding problems, specifically those using operant conditioning techniques versus systematic desensitization strategies. Both types of behavioral therapies improved diet variety and mealtime behavior when provided in structured interventions. Google Scholar
- 40.Toomey KA, Ross ES. SOS approach to feeding. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 2011;20(3):82–7.Google Scholar
- 41.Dovey TM, Martin CI. A parent-led contingent reward desensitization intervention for children with a feeding problem resulting from sensory defensiveness. Infant Child Adolesc Nutr. 2012;4(6):384–93.Google Scholar
- 48.Spungen J. Bowes & Church’s food values of portions commonly used. Baltimore: Lippincott Williams & Wilkins; 2005.Google Scholar
- 50.Johnson SL. Improving preschoolers’ self-regulation of energy intake. Pediatr. 2000;106(6):1429–35.Google Scholar
- 53.Chinuck R, Dewar J, Baldwin DR, Hendron E. Appetite stimulants for people with cystic fibrosis. Cochrane Database Syst Rev. 2014;7:1–27.Google Scholar
- 54.Sant’Anna AM, Hammes PS, Porporino M, Martel C, Zygmuntowicz C, Ramsay M. Use of cyproheptadine in young children with feeding difficulties and poor growth in a pediatric feeding program. J Pediatr Gast Nutr. 2014;59(5):674–8.Google Scholar
- 55.Spettigue W, Norris ML, Santos A, Obeid N. Treatment of children and adolescents with avoidant/restrictive food intake disorder: a case series examining the feasibility of family therapy and adjunctive treatments. J Eat Disorder. 2018;6(1):20–31.Google Scholar
- 56.•• Krasaelap A, Madani S. Cyproheptadine: a potentially effective treatment for functional gastrointestinal disorders in children. Pediatr Ann. 2017;46(3):e120–5 Review examines possible benefits of cyproheptadine related to functional gastrointestinal discomfort along with potential side effects and appropriate dosing of medication. PubMedGoogle Scholar
- 57.de Roos C, de Jongh A. EMDR treatment of children and adolescents with a choking phobia. J EMDR Pract Res. 2008;2(3):201–11.Google Scholar
- 59.Segal I, Tirosh A, Sinai T, Alony S, Levi A, Korenfeld L, et al. Role reversal method for treatment of food refusal associated with infantile feeding disorders. J Pediatr Gast Nutr. 2014;58(6):739–42.Google Scholar
- 60.Chiatto F, Coletta R, Aversano A, Warburton T, Forsythe L, Morabito A. Messy play therapy in the treatment of food aversion in a patient with intestinal failure: our experience. J Parenter Enter Nutr. 2019;43(3):412–8.Google Scholar
- 71.Maximino P, Machado RH, Junqueira P, Ciari M, Tosatti AM, de Cássia RC, et al. How to monitor children with feeding difficulties in a multidisciplinary scope? Multidisciplinary care protocol for children and adolescents. J Hum Growth Dev. 26(2):331–40.Google Scholar