Help for Picky Eaters and Problem Feeders

Katherine Brier Bode, R.D., is a Saint Francis Children’s Physicians Pediatric Gastroenterology Dietitian with a master’s degree in nutritional sciences. Here, she answers common questions about picky eating habits in children. Learn about the difference between picky eaters and problem feeders, and more.

What is a dietitian?

At the Saint Francis Children’s Physicians Pediatric Gastroenterology clinic, we do a wide variety of things. I can counsel on nutrition interventions for constipation and diarrhea. I can counsel on special diets for things like celiac disease. We manage tube-feeding diets as well as weight management and general healthy diet education. We see lots of kiddos that are having failure to grow.

What is the difference between a registered dietitian and a nutritionist?

A registered dietitian has a national credential and a state license. You need a master’s degree as well as a specific amount of supervised practice in each area of dietetics. Dietitians provide medical nutrition therapy and nutrition counseling and are qualified to treat medical conditions through nutrition interventions.

A nutritionist is not a protected title, so there are no legal requirements, certifications or licenses needed to call yourself a nutritionist. Anyone can call themselves a nutritionist. And they are notably not bound by the ethical codes that medical professionals are, nor are they bound by HIPAA, which is what protects our important healthcare-related information.

Can you definite picky eating habits and tell us how common it is in children?

There is a spectrum to picky eating habits. Some are age-appropriate picky eating habits that happen throughout childhood. Also, there are picky eaters, and then there are problem feeders. It can be difficult to identify each type of picky eater or problem feeder, and it’s not necessarily a simple process.

Picky eaters typically eat at least 30 foods, 80-100 percent of the time.

They also have “food jagging” behaviors when they love a food and want to eat it all the time. They typically burn out on that food, then will take about a two-week break before coming back to that food. They also eat at least one food from each food group: proteins, grains, fruits and vegetables, dairy products. And at least one from each texture group: purees, soft foods that melt in your mouth, wet foods, crunchy foods, chewy foods.

Picky eaters can also tolerate new foods. They might even touch or taste these new foods, even though they complain. They’ll still do it.

They frequently eat different sets of foods than family members, but they will eat at the same times and in the same area as their family members. At well child checks, they are referred to as picky eaters if this happens several times, but less than two years.

What about problem feeders?

Problem feeders eat less than 20 foods, 80-100 percent of the time. There are entire categories of food that they do not eat. For example, they may not eat fruits or vegetables, soft or wet foods. When they burn out on foods that they’re food jagging on, they don’t come back to them, so the list of foods that they eat all the time keeps getting smaller. There will be meltdowns, crying and screaming when new foods are introduced.

Like picky eaters, they don’t eat the same foods as their family members, but they also don’t eat at the same time as family members, sometimes not even in the same area as family members. In primary care appointments, they are referred to as picky eaters persistently and for longer than two years.

You mentioned there are times when children do become picky eaters. Are there developmental ages when that might happen that parents can watch for?

Yes. There are times as we grow up that our brain development changes. Babies, during the sensory motor stage, want to put things in their mouth; they want to touch things.

Toddlers get into magical thinking, so there’s monsters in the closet, there’s unicorns jumping between the clouds.

In the tween stage things are black and it is white. These are the rules, and this is what we do. And then we move into the complex thinking of teenagers.

When we are in those shifts, natural picky eating comes about.

Do we know what causes picky eating?

Eating is really complicated. As far as overall preference of picky eating, it’s difficult to say because our definition of picky eating has changed quite a bit over the years. In the research studies that we have, oftentimes there are different definitions for picky eaters, and they can be very broad. As far as prevalence right now in the literature, there is a seven-to-57 percent chance of having picky eaters, which is a wide, wide range.

What are some common myths surrounding picky eating?

There are 10 big, well-known myths surrounding picky eating. I’ll just go through a couple. The biggest myth is that eating is the body’s number-one priority. That is not true. Breathing is actually the body’s number-one priority. If we’re not breathing well, we’re probably not going to eat well, either. And what do we not do when we’re swallowing food? We’re not breathing, right? So, if we’re having breathing difficulty, we’re probably not going to be crazy about doing something that’s going to stop us from breathing.

You might think that eating is probably the second priority of the body, right? It is not! Making sure we don’t fall on our face is the second priority of the body. Postural stability is the second priority. Eating is the third priority of the body.

If my child has some of these behaviors you’ve mentioned, when should I talk to my doctor?

If your child is exhibiting picky eating or problem feeding behaviors, talk to your primary care physician to get a referral to either a dietitian or to a feeding therapist.

What if I want my child to try new foods, how do I go about doing that?

The key is that we want to convince our children to want to try new foods. We want internal motivation to try these foods, versus an external motivator. An external motivator would be saying, “If you eat your vegetables, I will take you to the park. If you eat these vegetables, I will give you three cookies after dinner.” The problem is, once we take away that external motivator, this child is not going to eat their vegetables. Like most medical answers, it’s not simple, especially if you have a picky eater or problem feeder. If you do feel like you have a problem feeder, don’t change anything about their feeding behavior until you can talk to a primary care physician about a referral to other medical professionals.

For the average child that just has a little bit of picky eating every now and then, increasing their engagement and interest in their feeding environment can go a long way in increasing their willingness to try new foods. That can happen before we ever get to the table. Have kids help with food planning. Maybe get out grandma’s recipe book and see if there’s a recipe that sounds tasty to them to try. Maybe make it together. Try foods when they’re raw (as long as it’s safe), and maybe re-try them after they’re cooked. Once you’re at the table, have a conversation about that food. What do you think of it? What is the texture like? What is the taste like? So on and so forth.

Parents worry so much about their children eating. There are many brands of nutrition supplements on the market. Is a nutrition supplement a solution for picky eating?

It’s not a solution for picky eating. It doesn’t replace learning how to eat. I have lots of parents that come to the nutrition clinic that are worried about their children not growing well. They’re concerned about the nutritional quality of their child’s diet, and that’s oftentimes why they add that nutrition supplement. In specific situations, nutrition supplements are very appropriate and can be helpful in providing adequate nutrition to children with feeding difficulty. But we don’t necessarily want to add a supplement.

If you have a regularly eating child, they don’t need a supplement. Just increase the volume of what they eat right now, and that’s going to help them grow.

If your child can’t eat adequately because you feel like they don’t have a good appetite, or you feel like they get full very quickly, that’s another sign to talk to your primary care doctor and get those referrals.

What is the SOS Approach to Feeding?

The SOS Approach to Feeding stands for Sequential, Oral, Sensory Approach, which was developed over 30 years ago by Dr. Kay Toomey, a child psychologist. It’s a specific approach to feeding therapy designed to assess and address all factors involved in feeding difficulty in a variety of settings and populations. This whole child approach is family centered and child directed.

I attended a conference on the SOS Approach to Feeding, and now I’m able to work in tandem with feeding therapists in the area.

So, again, talking to your healthcare professional, starting with you pediatrician, maybe getting referrals…It sounds like you work as a team to assess the child.

Yes. This is a multi-disciplinary approach. That means we have parents involved, we have physicians involved, occupational therapists who are certified as feeding therapists, speech therapists, dietitians and mental health professionals, if it’s appropriate.

What other resources are available to parents with picky eaters or problem feeders?

Your child’s medical care team can connect you with resources and other medical professionals. The dietitians at the Saint Francis Children’s Physicians Gastroenterology clinic are taking new patients right now, so we’re happy to see you.

Other resources are the SOS Approach to Feeding website, sosapproachtofeeding.com. They have a free, two-hour parent and caregiver workshop, blogs, podcasts and educational resources.

The SOS Approach to Feeding does a lot of research as well, and they have found that picky eaters and kids with feeding difficulty can cause significant parental stress, so they created Feeding Matters, feedingmatters.org. It is a parent-peer support resource for parents of picky eaters or problem feeders. Their feeding questionnaires are really helpful. If you’re feeling like your child is a picky eater or problem feeder, go to their website, fill out that questionnaire, and bring it to a primary care appointment. The site also has an SOS-trained provider directory.

Thank you for the parent resources. I can imagine parents feel guilty, helpless and frustrated.

There have been numerous studies looking at parental causation of picky eating habits, and we have found that neither household chaos or maternal sensitivity, structuring, attending responses, encouragement, emotion or problem-focused responses were correlated to children’s food fussiness, fullness responses, slowness to eating or food enjoyment.