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A Practical Approach To Classifying and Managing Feeding Dif Ficulties
A Practical Approach To Classifying and Managing Feeding Dif Ficulties
abstract Many young children are thought by their parents to eat poorly. Although the
majority of these children are mildly affected, a small percentage have
a serious feeding disorder. Nevertheless, even mildly affected children
whose anxious parents adopt inappropriate feeding practices may experience
consequences. Therefore, pediatricians must take all parental concerns
seriously and offer appropriate guidance. This requires a workable
classification of feeding problems and a systematic approach. The
classification and approach we describe incorporate more recent
considerations by specialists, both medical and psychological. In our model,
children are categorized under the 3 principal eating behaviors that concern
parents: limited appetite, selective intake, and fear of feeding. Each category
includes a range from normal (misperceived) to severe (behavioral and
Departments of aPediatric Gastroenterology, Hepatology, organic). The feeding styles of caregivers (responsive, controlling, indulgent,
and Nutrition, and ePsychiatry, Children’s National Medical and neglectful) are also incorporated. The objective is to allow the physician to
Center, The George Washington School of Medicine
and Health Sciences, Washington, District of Columbia;
efficiently sort out the wide variety of conditions, categorize them for therapy,
b
Pediatric Nutritional Consultant, Geneva, Illinois; cFAAP and where necessary refer to specialists in the field.
Gastroenterology, Hepatology, and Nutrition, Nationwide
Children’s Hospital, College of Medicine, The Ohio State
University, Columbus, Ohio; and dDepartment of Paediatrics,
North York General Hospital, Department of Paediatrics and Parents of young children worldwide 1980s tend to reflect the discipline of
Nutritional Sciences, University of Toronto, Toronto, Ontario, are concerned about feeding difficulties. the authors and often lack an agreed-
Canada
When asked, more than 50% of mothers upon nomenclature.8–11 Those from
Dr Kerzner developed the original concept for the claim that at least 1 of their children the pediatric medical community
current classification and after discussions with all eats poorly; this implicates ∼20% to generally focus on well-defined organic
authors refined it. He wrote the first draft and
30% of children.1–4 These perceived conditions, but do not emphasize
subsequent revisions; Ms Milano and Dr MacLean
participated in discussions and refinement of the feeding problems encompass a broad a systematic approach to behavioral
original concept, and shared in the writing of the range, from mild (so-called picky issues.8,9 Classifications from the
first draft and subsequent revisions; Drs Berall, eating) to severe (as seen in autism). psychiatric field12 focus more on
Chatoor, and Stewart participated in discussion and The pediatrician seeking to resolve behavioral problems, whose diagnostic
refinement of the original concept and commented
these concerns needs a comprehensive labels are necessarily “constructs,”
on early drafts; and all authors approved the final
manuscript. approach, one that extends beyond (ie, models devised on the basis of
the guidelines more suited for clinical observation, subject to variability,
www.pediatrics.org/cgi/doi/10.1542/peds.2014-1630
subspecialists and multidisciplinary but nonetheless affording opportunity
DOI: 10.1542/peds.2014-1630 teams, who are confronted by the more to institute appropriate therapy).
Accepted for publication Oct 15, 2014 severe end of the spectrum: the Bryant-Waugh et al,6 as well as Kreipe
Address correspondence to Benny Kerzner, BSc, so-called “feeding disorders” (Fig 1). and Palomaki,13 in excellent reviews
MBBCh, FCP, Department of Pediatric
Feeding disorders are recognized in the explaining the most recent DSM-V
Gastroenterology, Hepatology, and Nutrition,
Children’s National Medical Center, 111 Michigan Ave psychiatric Diagnostic and Statistical classification, concluded that early
NW, Washington, DC 20010. E-mail: bkerzner@cnmc. Manual of Mental Disorders, Fifth childhood feeding disorders should be
org Edition (DSM-V) and medical grouped under the umbrella term
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, International Statistical Classification of “avoidant/restrictive food intake
1098-4275). Diseases and Related Health Problems disorder.” They recognize 3
Copyright © 2015 by the American Academy of coding systems.5–7 Classifications of fundamental, aberrant feeding
Pediatrics these disorders dating back to the behaviors: children eating too little,
IDENTIFICATION OF FEEDING
DIFFICULTIES
Our approach to identifying and
FIGURE 1 managing feeding difficulties is
Pyramidal representation of young children’s feeding behaviors.
illustrated by the algorithm shown in
eating a restricted number of (moving from breast to bottle or cup, Fig 2. If a parent voices concern about
foods, or displaying a fear of eating. when complementary foods are a child’s feeding, that is sufficient to
With rare exception,14 recent introduced, or when self-feeding require constructive resolution of the
classifications have not identified begins)16–18 and guidance during issue by the pediatrician. Additional
parental misperception as a distinct these developmental phases is features that may indicate
subcategory of feeding difficulty, but particularly helpful. a dysfunctional feeding interaction
it clearly is a clinical problem needing are listed in Table 1. When it is
resolution. We concur with Davies apparent that a potential feeding
NOMENCLATURE difficulty exists, a complete history
et al15 that feeding difficulties must
An agreed-upon nomenclature is and physical examination, including
be conceptualized as a relational
fundamental for any classification. carefully done anthropometrics and
disorder between the feeder and the
The terms below, frequently used in a brief dietary assessment, are
child and that the caregivers’ feeding
the literature without uniformity, are necessary with special attention to
styles must therefore be incorporated
into the management of these
used in this article as follows: serious red flags, defined as medical
problems. Neophobia: Defined as “the rejection and behavioral symptoms and signs
of foods that are novel or unknown that require prompt attention and in
The primary care provider needs an many instances referral for in-depth
to the child.” Such rejection is seen
approach that (1) is straight forward investigation/specialized treatment.
in all omnivores and resolves with
and easy to use in the office setting,
repeated exposures.19 Organic Red Flags
(2) integrates both organic and
behavioral perspectives, (3) accounts Picky eating8,19,20: A moniker that has Probably the most critical are
for the wide spectrum of severity that inconsistent definitions and mean- indications of dysphagia and
both the child and feeder display, ings in different countries. Various aspiration (Table 1). In the nonverbal
and (4) incorporates the impact of criteria for picky eating are used by child, dysphagia and odynophagia
parenting and feeding styles. This different authors and in some cul- may present with food refusal.
article describes a comprehensive tures include “fussy” children with Features that suggest incoordinate
classification that recognizes the poor appetite.2,21 Others view it as swallowing may be overt
above issues and details a systematic a mild form of more overt sensory (eg, coughing or choking). Aspiration
screening and management sequence disturbances.12 It generally con- can be “silent” or more subtle
that allows the pediatrician to notes a mild or transient problem. (eg, wheezing). Evaluation of dysphagia
distinguish the key characteristics Although it is not considered requires identifying which phase of
of each feeding difficulty and then a “medical condition,” it requires deglutition (oral, pharyngeal, or
provide appropriate management. the attention of the primary care esophageal) is disorganized23 and is
Although our focus is on those provider. best handled by oral motor
children who resist oral feeding, the Feeding disorder8,20,22: A term con- specialists. Although generally less
practitioner should keep in mind that noting a severe problem that urgent, growth failure, diarrhea, and
well-nourished, and even obese results in substantial organic, nu- vomiting also need resolution. They
children, can have feeding difficulties. tritional, or emotional con- necessitate consideration of the full
Pediatricians should be aware that sequences. It equates to avoidant/ range of causes, which might require
feeding difficulties often emerge restrictive food intake disorder di- help from a pediatric
during a child’s feeding transitions agnoses in the DSM-V and the gastroenterologist. Be aware that
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latter group, differentiating “normal”
children with concerned parents from
children with mild, but recognizable
and treatable conditions is
challenging, but necessary.
addressed the parents’ feeding style, further down the pyramid.28 In this c Adapted from Levine et al.25
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snacks) per day with nothing but referred to as “picky eaters.” These presenting issue in some autistic
water in between. Parents must children consume fewer foods than children and should be considered
model healthy eating, adhere to the average. Wright et al3 found that as when there are questionable social
feeding schedule, and set limits for toddlers they tried the same number interactions.
mealtime behavior, including of foods as “nonproblem” eaters, but
appropriate discipline. A mealtime liked far fewer of them. Dovey et al19 Organic
“time-out” is often effective; parents noted that unlike neophobia, repeated Selective eating may be the
offer the child attention in response exposure to rejected foods tends not consequence of medical conditions
to positive eating behavior, but to result in acceptance by picky and is often seen in children with
withdraw attention by turning away eaters. These children typically grow developmental delay due to anoxia,
when the behavior is unacceptable.42 and develop normally and have chromosomal, mitochondrial, and
Growth failure associated with poor adequate energy and nutrient inexplicable causes of neurologic
appetite often necessitates enriching intakes.1,2 damage.49,50 Selectivity may be
the diet calorically including the The major concern for them is not related to hypersensitive or
addition of nutritional supplements. their nutrition,1,3,46 but family hyposensitive responses to the
Providing adequate nutrition and discord centered around coercive sensory properties of food and/or
supportive interaction with an feeding and subsequent behavioral delayed development of oral motor
experienced feeder is sufficient to consequences. Chatoor et al34 skills.51,52 Children with organic
improve the apathetic child with reported that conflict around feeding selectivity due to motor disorders
limited appetite. This may be resulted in a lower Bayley Mental tend to accept objects placed in their
achieved through early childhood Developmental Index independent of mouths, but have difficulty with all
intervention programs or child the child’s nutritional status. In textures, both liquid and solid; the
protection services; sometimes this a study of children defined by their highly selective child due to sensory
necessitates hospitalization. parents as picky, Jacobi et al2 showed processing deficits gags in
a higher incidence of subsequent anticipation of objects touching their
With organic disease, the medical
behavioral problems, including mouth and then rejects only certain
condition influencing appetite must be
anxiety, depression, aggression, and textures, mainly solid foods.49
addressed and, if possible, resolved.
Management is often complex delinquency. The problem may well
be bidirectional: poor behavior Management of Selectivity
requiring alternate feeding routes
(eg, enteral tube or intravenous feeding, prompting coercive and indulgent With misperception, educating
which further suppress appetite).43,44 feeding practices, which in turn parents to have reasonable
aggravate the behavior and may expectations and counseling them to
result in long-term problems. consistently and repeatedly expose
Children With Selectivity
children to new foods is needed.
Children who are considered to be Highly Selective Foods must often be offered 8 to
selective range from those who are Here the consequences are severe 15 times without pressure to achieve
eating appropriately for their stage of enough to consider it a feeding acceptance.1 In the mildly selective
development (misperception) to disorder. These children limit their child, other simple techniques may be
sensory-related aversions to organic diet to ,10 to 15 foods.47 Chatoor12 needed, such as “hiding” pureed
disease. refers to these children as having vegetables in sauces, using “dips” to
“sensory food aversions”: a refusal to enhance flavor, modeling eating,
Misperception
eat whole categories of foods related giving foods appealing names,
Neophobia is frequently misperceived to their taste, texture, smell, involving children in food
by parents as inappropriate temperature, and/or appearance. This preparation, and presenting it in
selectivity. However, it is a normal problem can interrupt development attractive designs.53–56 In contrast,
behavior that begins at the end of the of normal oral motor skills. Some of the highly selective child frequently
first year of life, peaks between 18 to these children may have additional requires a more intense and
24 months and eventually resolves. sensory manifestations, including systematic approach to increasing
Most children accept new foods, adverse responses to loud noises, variety. Behavioral therapists have
especially bitter vegetables, only after bright lights, and textures on skin. documented the effectiveness of
repeated exposures.19,45 Autism is an extreme example. Up to a number of these methods
90% of autistic children have feeding (eg, offering a desired food contingent
Mild Selectivity problems, the vast majority of whom on the progressive acceptance of less
Mild selectivity includes a large are selective.48 In our experience, desired foods). Often, “food chaining,”
amorphous group of children, often feeding difficulties have been the the replacement of 1 food with
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influence of caregiver feeding styles imperative to meet the child’s every Pediatricians should adjust their
is therefore an essential part of need, but by doing so ignores that instructions based on the parent’s
management. Parental feeding child’s hunger signals and sets no feeding style. Controlling parents
practices are based on 4 well- limits.78 Consequences of these should be guided to offer foods in
described parenting and feeding feeding practices include lower a noncoercive way, rather than on the
styles.77,78 These styles are consumption of appropriate foods specific amounts or types of foods to
influenced by cultural norms, (eg, milk) that contain important be given. Advice to indulgent or
parental concern, and child nutrients and a disproportionate neglectful parents should be more
characteristics.79–81 We refer to the consumption of items high in fat, structured and precise.
preferred style as responsive. The increasing the risk of becoming Time is at a premium during clinic
remaining 3 (controlling, indulgent, overweight.76,83–85 visits; we have provided
and neglectful) generally have Supplemental Material of resources:
Neglectful feeders abandon the
negative consequences. books, articles, and Web sites that
responsibility of feeding the child and
Responsive feeders follow the may fail to offer food or set limits. provide guidelines for anticipatory
concept of a division of responsibility; When feeding their infants, they may guidance, appropriate meal time
the parent determines where, when, avoid eye contact and appear interactions, nutrition ideas, and
and what the child is fed; the child detached. Older toddlers are often left other tools.
determines how much to eat.82 to fend for themselves. Neglectful
Responsive feeders guide the child’s parents ignore both the child’s DISCUSSION
eating instead of controlling it. hunger signals and other emotional
Parents deserve guidelines to prevent
They set limits, model appropriate and physical needs. They may have
and/or resolve feeding difficulties,
eating, talk positively about food, emotional issues, developmental
whether mild or severe. Health care
and respond to the child’s feeding disabilities, depression, or other
professionals, therefore, need
signals.76 A responsive feeder conditions that make it difficult for
a systematic approach to assessing
arranges the schedule to induce them to feed their child
and managing feeding difficulties in
appetite or by rewarding the effectively.78,87 Neglect may be severe
the primary care setting, where
achievement of goals, but does not enough to result in failure to thrive. In
parents first seek help. The current
resort to unpleasant coercive at least 1 study of older children,
classification reduces the diagnostic
techniques. This feeding style has a greater risk of obesity was
groups to 3, determined by parents’
been reported to result in children associated with these feeding
presenting concerns, integrates both
eating more fruits, vegetables, and practices.88
organic and behavioral subcategories
dairy products and less “junk food,”
Pediatricians can readily differentiate in each group, and incorporates
resulting in a lower risk of becoming
feeding styles by asking 3 questions: feeding styles into the evaluation. It
overweight.76,83–85
How anxious are you about your should allow the practitioner to tailor
Controlling feeders are common; child’s eating? How would you therapy specifically to the problem,
approximately half of all mothers and describe what happens during addressing both the child’s behavior
a greater proportion of fathers mealtime? What do you do when your and the parents’ feeding practices.
employ these methods.86 These child won’t eat? Responses from Mild conditions should be resolved
caregivers ignore the child’s hunger neglectful parents will be vague; within the confines of the office.
signals and may use force, controlling parents will describe Severe feeding difficulties or feeding
punishment, or inappropriate pressuring/forcing their child to eat. disorders may require specialists to
rewards to coerce the child to eat.78 Indulgent parents will describe resolve the problem. Proper
These practices initially appear pleading, begging, and preparing classification facilitates more targeted
effective, but become special foods. Another way to assess referrals to the appropriate individual
counterproductive, resulting in poor mealtime interactions is to have the specialists or multidisciplinary teams.
adjustment of energy intake, parents videotape part of it,
Although the proposed classification
consumption of fewer fruits and something easily accomplished with
makes treatment more manageable
vegetables, and a greater risk of smart phones.
for pediatricians, some limitations
under- or overweight.76,83–85
General feeding guidelines (Table 3), remain. The 3 categories of feeding
Indulgent feeders cater to the child. which help caregivers become more difficulties are supported by the
They tend to feed the child whenever responsive feeders and prevent literature. However, the subgroups
and whatever the child demands, counterproductive feeding practices, within each category, although helpful
often preparing special or multiple should be part of anticipatory in illuminating subtle differences
foods. This feeder feels it is guidance for all children. important in management, fall on
FINANCIAL DISCLOSURE: All authors have received honoraria from Abbott Laboratories for speaking at conferences on the diagnosis and management of feeding
disorders in young children. Drs Kerzner, MacLean, and Chatoor are currently carrying out a clinical study funded by Abbott Laboratories to assess the ability of
pediatricians to correctly classify young children with feeding problems in the office setting. Dr MacLean retired from Abbott Laboratories 11 years ago; he owns no
stock in Abbott Laboratories. Employees of Abbott Laboratories had no input into the ideas expressed in this article, nor the writing of the article.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: All authors have received honoraria from Abbott Laboratories for speaking at conferences on the diagnosis and management of
feeding disorders in young children. Drs Kerzner, MacLean, and Chatoor are currently carrying out a clinical study funded by Abbott Laboratories to assess the
ability of pediatricians to correctly classify young children with feeding problems in the office setting. Dr MacLean retired from Abbott Laboratories 11 years ago; he
owns no stock in Abbott Laboratories.
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A Practical Approach to Classifying and Managing Feeding Difficulties
Benny Kerzner, Kim Milano, William C. MacLean Jr, Glenn Berall, Sheela Stuart and
Irene Chatoor
Pediatrics 2015;135;344
DOI: 10.1542/peds.2014-1630 originally published online January 5, 2015;
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/135/2/344
Supplementary Material Supplementary material can be found at:
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014-1630.DCSupplemental
References This article cites 82 articles, 11 of which you can access for free at:
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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print
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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: .