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:
Help you identify warning signs that should prompt you to seek additional support
Provide ideas about what kind of support might be needed and how to find it
What questions to ask
What to do if the support you find doesn’t seem to be useful
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.
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.
Often unhappy around mealtimes: fighting, yelling, crying, or just generally stressed or anxious at most meals
Refuses to eat what is served, demands preferred foods
Will not taste or explore new foods
Will not eat a certain category of food (i.e., vegetables or proteins) or even certain textures or colors.
Only eats a small number of foods
Insists on eating things in a very specific way (i.e., only specific brands; only if the food is served in the original bag/box; only when food is cut exactly so; only if food is not touching)
Difficulty gaining weight or gaining weight rapidly
Gagging on food occasionally at meals
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.
Complete refusal to eat or drink anything
Dehydration: not producing tears or saliva; concentrated (dark yellow) and infrequent passage of urine
Constipation: passing fewer than two stools per week; passing hard, painful stools; blood in or around stool; significant abdominal pain
Significant weight loss
Choking and/or gagging on solid foods or liquids frequently at meals
Extremely low energy or overly sleepy
Child is feeling extremely overwhelmed or experiencing a significant decrease in quality of life
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.
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:
Struggles to get into or remain seated in the high chair
Tantrums when favorite foods are not offered
Inconsistently refuses vegetables or proteins
Eats a small amount and then says “all done” or leaves the table
Shows preferences for certain foods or food groups
Eats well at some meals and poorly at others
Eats well at daycare/with caregivers and poorly at home or vice-versa
Eats some foods on the plate but will not taste/try everything
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.
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:
Sensory processing deficits that are limiting food exploration and intake.
Oral-motor challenges that limit a child’s ability to chew food safely.
Persistent upper respiratory infections or frequent unexplained fevers paired with coughing/choking with liquid and/or food.
Difficulty gaining weight despite adequate intake.
Reflux or medical issues that limit hunger or interest in eating.
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.
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.
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.
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.
Pediatric feeding therapist (occupational therapist or speech-language pathologist)
Pediatric behavioral therapist
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:
Feeding clinics/in-patient feeding programs
Feeding therapy as part of an outpatient day program
Feeding therapy as part of a sensory clinic or OT/SLP office
In-home or zoom feeding therapy support
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.
Sensory integration or sensory strategy-based services
Oral motor therapy
SOS (Sequential Oral Sensory) approach
ABA (Applied Behavioral Analysis)
Get Permission approach
Orofacial Myofunctional Therapy
Cognitive Behavioral approach
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:
If the child is dealing with sensory-based feeding challenges—i.e., sensitivity to touching/feeling textures—work with a therapist trained in sensory integrative techniques.
If the child has underlying dysphagia (swallowing issues), consider working with a therapist with swallowing experience.
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.
1. Write down your concerns about the child’s eating. Be as specific as possible about your concerns. Possibilities include:
Weight and growth
Tantrums at the table or around certain foods
Picky eating (explain what you mean by this)
Refusing to eat
Preferring one or two types of foods
Hating certain food groups, food textures, flavors, or colors
Eating too much
Not eating enough
Battles/arguments at every meal
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.
Start with a Google search to find your local children’s hospital, regional center, or early intervention services, as well as any private pediatric occupational therapist or speech-language pathologist clinics in your area.
Contact each of these with a brief description of what you need—a feeding therapy evaluation and possibly intervention for your baby or toddler to help with [x, y, z] issue.
Bring the list of concerns about your child’s eating from above.
Bring a list of what you have done to support your child and/or how you have tried to fix the problem.
Bring copies of your child’s growth curve (height and weight). We recommend this, not because growth is a great indicator of whether a child needs feeding therapy, but because it can be helpful to both you and a potential feeding specialist to know how severe the issue is and what to focus on first.
Be prepared to interview each clinic or therapist. Don’t be afraid to ask questions. It is important that you find the right fit for you and your child. You want to make sure you find someone who:
Has pediatric feeding experience
Has advanced practice and training in feeding issues or works closely with a mentor
Uses a variety of approaches in their feeding therapy, not just one approach
Selective eating is common in toddlerhood.
Picky eating behavior ranges from mild to severe—it may only require a few changes at home or intensive therapy and specialty care.
Know the warning signs of picky eating and when to seek professional help.
Come to the clinic prepared. Bring your list of concerns, what you have tried, and questions.
Never doubt yourself. You are your child’s best advocate.
The content offered on SolidStarts.com is for informational purposes only. Solidstarts is not engaged in rendering professional advice, whether medical or otherwise, to individual users or their children or families. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or your medical or health professional, nutritionist, or expert in pediatric feeding and eating. By accessing the content on SolidStarts.com, you acknowledge and agree that you are accepting the responsibility for your child’s health and well-being. In return for providing you with an array of content “baby-led weaning” information, you waive any claims that you or your child may have as a result of utilizing the content on SolidStarts.com.
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