When to Seek Help for Picky Eating

Picky eating has a wide range of severity. Some picky eating cases are relatively harmless and bothersome and resolve with time, while others are severe and persistent with significant negative health and wellness repercussions. This article will:

It should be noted that our professional team has a low threshold for advocating for additional support and feeding therapy services. If mealtimes are stressful for your child and/or your family, even if your child is gaining weight appropriately without any nutritional concerns, please alert your child’s primary medical provider. They should be able to help you problem-solve and decide if feeding therapy or any other referral may be helpful.

What is picky eating?

Picky eating means many different things to different people, and there isn’t a single globally accepted definition of picky eating. It could mean a child that doesn’t eat a wide variety of foods, a child who refuses to taste all new foods, a toddler who refuses to eat family foods, or a kid that refuses to eat what is served and only will eat what they request.

A child’s growth curve does not define a picky eater—some picky eaters struggle with gaining weight, others demonstrate too rapid weight gain, while others continue to track appropriately. For toddlers, refusing food, saying no, and having tantrums at the table, are, unfortunately, usually developmentally normal.

There’s a developmental shift in how children interact with food in toddlerhood. Around 12-18 months old, most children move from a phase of intense interest to try new foods into a new phase that experts call “food neophobia,” or fear of new foods. Toddlers in the phase of food neophobia are significantly more skeptical of food and particularly hesitant to try anything new and unfamiliar, even when parents demonstrate or tell them it’s safe.

Some anthropologists believe food neophobia was baked into our toddler DNA through evolution. They suggest that neophobia would have been a wise protective response since a healthy dose of food neophobia would make a child less likely to put a poisonous item into their mouth if they wandered away from a caregiver. Even though today’s toddler is less likely to wander away from us into the wild, food neophobia is still strong for most toddlers.

At this stage, toddlers are also pushing boundaries, learning rules, and figuring out how to communicate with caregivers. These behaviors can show up during meals primarily because a child has some control over whether they eat, and children learn quickly that their choices at meals can get a big response from a tired and worried parent. This behavior is typical toddler selectivity, or selective eating, not picky eating. Strong yet empathetic family rules and boundaries can successfully move a child through most selective eating phases without progressing to picky eating.

For a subset of children who struggle to eat at most meals, have a very narrow diet, have difficulty gaining adequate weight, and/or experience a decline in their quality of life /family life, additional intervention by a professional may be helpful.

Signs that a child may be struggling with picky eating:

With the above signs, there is usually no need to seek professional help immediately. Many of these challenges can be addressed with extra support from parents and caregivers at home. (See our Picky Eating Bundle for guidance.) Expect significant progress after a few weeks to several months; however, you should see *signs* of improvement within a month.

*If you see zero progress or worsening behavior after strategy implementation, strongly consider contacting your child’s primary healthcare provider. Following a detailed history and physical exam, individualized support from a feeding specialist and/or referrals to other specialists may be warranted.

Warning signs that specialized care is needed urgently:

If your child is experiencing any of the above signs, seek care urgently. This may be an urgent care visit with your child’s primary care provider, another provider, or a trip to the emergency department.

Beyond typical toddler selective eating

As noted above, toddler selective eating is a common phase that many toddlers go through, starting around 12-18 months old. During this phase, toddlers tend to test boundaries and become more resistant and less adventurous at the table. Many children will show one or more of these normal and common toddler mealtime behaviors:

These behaviors, while frustrating, are usually quite responsive to loving boundaries. Often these behaviors will pass in time with consistent limits from the parent.

Picky eating takes toddler selectivity to a new level. Picky eating is often related to underlying issues like anxiety or fear around food and/or meals, sensory processing, or developmental delay. Approximately 20-50% of typically developing children and 70-89% of children with special needs are reported to demonstrate some degree of feeding and/or swallowing challenges. These feeding problems are varied and may include oral-motor, sensory, swallowing, or behavioral challenges at mealtime. Picky eating is just one eating challenge common in typically developing children and kids with special needs, and can range from mild to severe.

Pediatric Feeding Disorder (PFD)

As of 2020, Pediatric Feeding Disorder (PFD) is a documented medical diagnosis. PFD is “impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction.” This classification is further broken down into acute and chronic PFD, depending on how long the problem has existed—between two weeks to less than three months is acute, while anything longer than three months is considered chronic.

PFD is a step beyond typical, developmentally appropriate levels of selective eating. A few examples:

With this diagnostic code, it is much easier for children across the United States to receive skilled feeding support from a clinician specializing in pediatric feeding. If you suspect your child’s picky eating might be severe enough to warrant a diagnosis, speak to your child’s medical provider for further evaluation.

Avoidant Restrictive Food Intake Disorder (ARFID)

Another severe pediatric feeding issue is Avoidant Restrictive Food Intake Disorder. ARFID is a serious condition similar to anorexia. ARFID involves severe limitations in the amount and/or type of food eaten but does not present with the same issues around body image and appearance common with other eating disorders like anorexia. ARFID can be diagnosed at any age.

Picky Eating vs. ARFID or PFD

Unlike picky eating, children with ARFID and PFD do not eat enough calories to grow or develop properly, limiting increases in height, impacting concentration and learning, energy levels, and ability to participate in everyday activities. The primary difference between ARFID and PFD is whether there is an underlying medical or developmental cause of food refusal. If there is a medical condition—such as Eosinophilic Esophagitis—or a developmental delay—such as oral motor concerns—the diagnosis would likely be PFD; if there is no medical or developmental issue and the cause is likely anxiety or related to psychosocial issues, the diagnosis would likely be ARFID. Either diagnosis requires a comprehensive evaluation and team approach to treat these concerns.

There is effective treatment available for ARFID, including both medical interventions, talk therapy (cognitive-behavioral therapy), and feeding/dysphagia therapy if necessary. Many of these programs are inpatient and intensive, with weeks of outpatient follow-up after discharge.

If you are concerned that your child is experiencing symptoms or concerns for ARFID, speak to your child’s medical provider immediately.

Where to turn for help for typical and more severe picky eating?

For non-urgent cases, most caregivers will discuss their concerns with the child’s primary care provider at an upcoming well-child visit, send a secure message to their child’s healthcare team, or contact an advice nurse. In most cases, a clinic visit is scheduled, where the healthcare team will collect a thorough history, review vital signs and growth trends, and perform a physical exam. The primary care provider may order lab work, studies, weight checkups, and/or refer to other specialists to diagnose and address any underlying problems contributing to picky eating behavior. Remember: Picky eating is a spectrum and ranges from mild and self-resolving to severe and debilitating.

Need help finding someone near you? Our Solid Starts Professionals Directory offers a list of professionals who are familiar with our evidence-based approach to feeding.

Types of specialists that may be involved in the care of a child who struggles with picky eating:

If my child needs feeding therapy, what does that look like?

Feeding therapy can occur in conjunction with other treatments or by itself. Actual delivery of feeding therapy is quite varied and can range from the following:

What are the different feeding therapy approaches?

There are a few different tools, certifications, theories, and approaches that feeding therapists may be trained in. This list is not comprehensive; if a therapist suggests a different approach or tool from those listed here, ask them to tell you more about it.

Feeding, eating, and swallowing are highly complex activities and engage multiple body systems, muscle groups, and parts of the brain, as well as engage social-emotional skills. Each child's feeding challenges can be met with various approaches, but ideally, there is a good fit between the child and therapist/approach. Some examples:

As a caregiver, it’s not expected for you to know what type of therapy approach best suits the child's needs, but we hope you can use this information to discuss your child's unique feeding needs with therapists to determine if it's a good fit.

Ideally, you want to find a therapist who understands and is trained in various approaches. Feeding, eating, swallowing, and mealtimes are highly complex activities and engage multiple systems, muscle groups, and relational elements. Remember, you can always change therapists or approaches if things don't seem to work for you and your child. Ask questions, join sessions, and ask the therapist to show you what they mean if something does not make sense.

How can I prepare for a visit with my child’s primary care provider?

1. Write down your concerns about the child’s eating. Be as specific as possible about your concerns. Possibilities include:

2. Write down what you’ve done to support your child or remedy the problem. Be as specific as possible.

3a. If your child’s primary care provider does not seem concerned and/or does not offer you a referral to a feeding therapist, ask for one! You have every right to tell your child’s physician that you want and need more help with this. Make it clear that you’d like a referral for a feeding therapy evaluation from a licensed pediatric occupational therapist or a speech therapist.

3b. If your child’s primary care provider thinks feeding therapy is warranted, ask for therapist recommendations or where to go. Often the primary care provider will have a few local resources that he or she uses, which can be an excellent starting point.

3c. If your child’s primary care provider feels feeding therapy is warranted but has no recommendations, or if you start at the recommended resources but would like other options, you can do your own research to find local support.

How can I prepare for a visit with my child’s feeding therapist?

Final thoughts