20 November 2017

Busting the myth that kids won’t starve themselves

Clinical Nutrition Paediatrics

Sarah is six years old and has been your patient since she was an infant.

Her mother Rachel has an anxious temperament and has become increasingly concerned with Sarah’s limited dietary intake. Each time Rachel attends your practice she mentions that meal times are stressful, that she has to prepare separate meals for Sarah and that she doesn’t think Sarah is eating at school.

You examine Sarah, she is growing well, her weight for height is tracking along the same section of the growth curve as she was in infancy. You advise Rachel that fussiness is normal and that if she just persists Sarah will eventually grow out of it.   

Sound familiar?

Feeding difficulties in childhood are common, with up to 30% of children reported to struggle with some type of feeding or growth issue, and around 5% reported to have a serious feeding or growth problem.1,2

Although prevalence estimates for older adolescents and adults are currently lacking, it Is clear that at least a proportion of children do not grow out of their difficulties incorporating a wide variety of foods into their diet, and continue to have a highly restricted dietary intake as adults.3

Lack of a consensus definition to identify problem feeders and the frequency of picky eating in young children has led to “fussiness” being labelled as typical development, resulting in high thresholds for determining whether intervention may be beneficial.

Out of necessity, there has been a focus on failure to thrive and growth parameters as the main indicators of whether intervention is required, however, these indictors alone fail to identify all problem feeders, limiting opportunities for early intervention.


Feeding difficulties are often markers of co-morbid medical or developmental issues and are associated with higher levels of familial stress and concurrent and future psychopathology, such as anxiety and depression.4

Children presenting with adequate growth and overall calorie consumption may still be at risk of medical compromise or other negative broader health difficulties. For example, although children may be able to eat sufficient calories by consuming large amounts of their preferred foods, they may be nutritionally compromised with regard to micronutrient intake, affecting their overall health and development.5

Adolescents and adults with feeding disorders report impaired social functioning, such as being unable to attend school camp, birthday parties, sleepovers and restaurants because of their restricted diet, as well as reporting a profound negative impact on their self-esteem.

Parents of children with picky eating are also at higher risk for depression as a result of the impact of their child’s feeding issues,6 and report “not being heard”, or their concerns being negated and minimised, as one of their key experiences of help seeking, which is likely to further exacerbate parental stress.7

Higher levels of parental stress are also associated with higher risk for negative mealtime interactions at both extremes; more intrusive interactions (e.g. yelling) and more permissive interactions (e.g. less structure),8 both of which are associated with poorer feeding outcomes for problem feeders.

Healthcare providers are therefore encouraged to intervene at a lower threshold and refer for further assessment and support when restricted eating behaviour is reported, even in the absence of inadequate growth markers.

Feeding difficulties are usually the result of a combination of organic and behavioural factors


A whole-child, broad picture assessment is recommended in considering whether a child may have a feeding disorder or problematic feeding behaviour.

Children (and adults) with feeding disorders are likely to present with an unwillingness to try new foods and/or refusal to try unfamiliar foods, leading to a highly restricted range of intake (usually less than 20 foods); and exclusion of whole nutritional food groups or texture types from their diet.9

Families of problem feeders are likely to report constant battles at mealtimes, that the range of accepted foods decreases over time, and that the child is rarely able to eat the same meal as other members of the family, or in some cases even come to the table.10

Delayed transitioning through the expected stages of feeding development (e.g. introduction of purees or solids) should also be considered a marker for possible feeding problems as this likely indicates sensory integration or oral motor skills difficulties.10 When the difficulties with feeding persist past school-age, the impact on social functioning, family interactions and self-esteem should also be assessed in determining whether intervention is warranted.

For older children, adolescents and adults, feeding disorders can be distinguished from eating disorders (such as anorexia nervosa) based on the cause of the restricted intake and the types of food eaten as part of the patient’s regular diet. Individuals with feeding disorders also usually have earlier onset of symptoms, with 75% of adults with feeding difficulties reporting onset of these issues in early childhood.3

A key feature of anorexia nervosa, and other eating disorders, is a disturbance in the way one’s weight or shape is experienced and undue influence of weight and/or shape on self-esteem. Individuals with feeding disorders are usually not concerned about weight gain, and usually restrict their intake due to the sensory features of the food, poor oral motor skills, dysphagia, or fear of choking or vomiting.

As a result, bland white foods often make up the bulk of their diet while fruits and vegetables are often excluded.


Feeding difficulties are usually the result of a combination of organic and behavioural difficulties.11

Children will not eat, even if they are hungry, if eating is a negative experience (e.g. due to pain) or if they do not have the skills to successfully manage the food.12 

Medical conditions that are likely to make eating a painful or aversive experience are commonly associated with feeding difficulties. Gastroesophageal reflux disease is highly comorbid, as are food allergies/intolerances, and constipation/diarrhoea. Neurological conditions, cardiopulmonary conditions and congenital abnormalities have also been shown to co-occur at high rates.13, 14

Children with autism spectrum disorder and other developmental disorders (including Down syndrome and cerebral palsy) are at higher risk of developing feeding disorders than other children;13 as are children born prematurely.

Given the broad range of co-occurring conditions that leave children at  higher risk for the development of feeding issues, a comprehensive medical assessment is likely to be beneficial to assist in understanding why eating may be a negative experience for the child. Unless co-occurring medical conditions are identified and managed, even with intervention, children are unlikely to increase their intake, as eating will continue to be an aversive and painful experience for them.

A micronutrient assessment is also likely to be beneficial even if the child has sufficient macronutrient intake. Children with feeding difficulties have been shown to have insufficient fat intake, and fibre intake substantially below the recommended dosage, as well as inadequate levels of zinc, iron, vitamin E and potassium.15


Intervention for feeding disorders usually comprises medical management of relevant co-morbid conditions (such as reflux) and behavioural interventions, such as the Sequential Oral Sensory Approach to the feeding disorders. In this approach, the feeding issue is viewed as a skills deficit rather than a behavioural problem. Graded exposure is used to introduce a variety of foods while assisting the child to develop the skills required to progress through the hierarchy of sensory and oral-motor steps towards the successful eating of new foods.

Given typically developing children without feeding problems take approximately two to three years to develop all the relevant feeding-related skills, treatment for feeding disorders is often long term, particularly for children with more severe presentations.

Families reporting less severe presentations of picky eating may also benefit from increased support, education and less intensive behavioural intervention, particularly when there are high levels of parental stress associated with the child’s eating behaviour.

Reducing parental stress at mealtimes for children with less severe feeding difficulties is likely to produce more positive mealtime interactions and therefore a better environment within which the normal processes of feeding skill development can occur.

Given the complexity of feeding disorder presentations, children (and adults) presenting with picky eating or problem feeding are best managed by a multidisciplinary or transdisciplinary team, which may be compromised of professionals from a range of disciplines, depending on the specific presentation of each individual and the identified factors that are likely contributing to their difficulties.

Professionals involved in the management of feeding difficulties may include:

• General practitioner and/or paediatrician: to provide care co-ordination, medical assessment and management

• Occupational therapist: to provide sensory integration assessment and management

• Speech therapist: to provide assessment and management of oral motor skills and swallowing

• Psychologist: to provide assessment and management of family functioning and the mental health needs of each family member

• Dietitian: to assess and manage micronutrient deficiencies and excesses

• Other allied health or medical specialist e.g. gastroenterologist, dentist, physiotherapist, ENT specialist

As it can be difficult for families to co-ordinate treatment across multiple care providers, where possible it is recommended that you refer to a dedicated feeding clinic that can provide multidisciplinary assessment and management of feeding disorders within the one location.

Health professionals involved in dedicated feeding clinics are also more likely to have cross-discipline knowledge about the management of feeding issues, limiting the total number of care providers the family needs to engage with.

Dr Amy Talbot is a clinical psychologist and director of The Talbot Centre for Eating Behaviour in Northwest Sydney, where they have a dedicated multidisciplinary feeding clinic.


1. Dubois L, Farmer A, Girard M, Peterson K, Tatone-Tokuda F. Problem eating behaviors related to social factors and body weight in preschool children: A longitudinal study. IJBNPA. 2007;4:9. 

2. Olsen EM, Petersen J, Skovgaard AM, Weile B, Jorgensen T, Wright CM. Failure to thrive: the prevalence and concurrence of anthropometric criteria in a general infant population. Arch Dis Child. 2007;92:109–14.

3. Wildes JE, Zucker NL, Marcus MD. Picky eating in adults: results of a web-based survey. Int J Eat Disord, 2012 May;45(4):575-82.

4. Zucker N, Copeland W, Franz L, Carpenter K, Keeling L, Angold A, et al. Psychological and psychosocial impairment in preschoolers with selective eating. Pediatrics, 2015 Aug;136(3):e582. 

5. Carruth B, Ziegler P, Gordon A, Barr S. Prevalence of picky eaters among infants and toddlers and their caregiver’s decisions about offering a new food. J Am Diet Assoc. 2004;104(1):S57-S64.

6. Pridham K, Steward D, Thoyre S, Brown R, Brown L. Feeding skill performance in premature infants during their first year. Early Human Development. 2007;83(5):293-305.

7. Thomlinson EH. The lived experience of families of children who are failing to thrive. Journal of Advanced Nursing. 2002;39(6):537-545.

8. Gueron-Sela N, Atzaba-Poria N, Meiri G, Yerushalmi B. Maternal worries about child underweight mediate and moderate the relationship between child feeding disorders and mother-child feeding interactions. J Pediatr Psychol. 2011 Aug;36(7):827-36. 

9. Carruth BR, Skinner JD. Revisiting the picky eater phenomenon: neophobic behaviors of young children. J Am Coll Nutr, 2000;21(2):88-96.

10. Toomey KA, Sundseth Ross E. SOS Approach to Feeding. American Speech-Language Association. 2011:82-87.

11. Bryant-Waugh RL, Markham L, Kreipe RE, Walsh BT. Feeding and eating disorders in childhood. IJED. 2010;43(2):98-111.

12. Mason SJ, Harris G, Blissett J. Tube feeding in infancy: implications for the development of normal eating and drinking skills. Dysphagia. 2005;20(1):46-61. 

13. Field D, Garland M, Williams K. Correlates of specific childhood feeding problems. J Paediatr Child Health. 2003 May;39(4):299-304.

14. Cornwell SL, Kelly K, Austin L. Paediatric feeding disorders: Effectiveness of multidisciplinary inpatient treatment of gastrostomy-tube dependent children. Children’s Health Care. 2010;39(3):214-231.

15. Butte NF, Fox MK, Briefel RR, Siega-Riz AM, Dwyer JT, Deming DM, et al. Nutrient intakes of US infants, toddlers, and preschoolers meet or exceed dietary reference intakes. J Am Diet Assoc. 2010;110(12):S27-S37.