Problem feeders – beyond fussy to something more serious

What is the best approach to problem feeding in kids?

There is a difference between a fussy eater and a problem eater. Both fussy and problem feeding are stressful for parents to deal with, and make us question whether our children are getting the nutrition they need to grow and develop properly. While the management of fussy feeding is mostly behavioural, as we discussed in a previous blog, specific strategies and interventions by a team of health professionals may be required in cases of persistent problem feeding.

So, what exactly is problem feeding?

Problem feeding is where a child has a chronic difficulty with feeding. There is very restricted dietary variety and the child’s nutritional requirements are usually not being met, both of which are often associated with behavioural difficulties at mealtimes and significant parental stress. Specific difficulties with swallowing, chewing, choking, gagging, vomiting or aspiration of food or fluid into the child’s lungs may be occurring. Up to 25 per cent of typically developing children can have problems with feeding, whereas in children with developmental disabilities, the number is drastically higher – up to 85 per cent. Problem feeding can be short term, but will become even more problematic if it persists.

Problem feeding is commonly associated with the following conditions:

  • Structural abnormalities of the nose, mouth or jaw (such as those found in children with a cleft palate); of the airways or feeding tube (such as Trache-Oesophageal Fistula, or TOF, where there is a connection between the main breathing tube [trachea] and feeding tube [oesophagus]).
  • Neurodevelopmental problems such as cerebral palsy, where the control of movements responsible for ingesting food or drink may not be coordinated.
  • Sensory and behavioural difficulties that can affect a child’s willingness to eat.
  • Following illness, or after a period of necessary tube feeding, where a child may have had negative experiences associated with food.
  • Gastro-intestinal discomfort including reflux or dietary intolerances that also cause negative associations with early feeding experiences.
  • Forceful feeding in early infancy.

At any stage of development, interruptions or changes to a child’s eating and drinking skills can occur, and affect how problem feeding presents.

The Eating, Drinking and Swallowing Clinic

This clinic at RCH is comprised of a team that deals with problem feeding, and I’d like to share their wholistic approach to this difficult issue with you.

The first step is to recognise when there is a problem with a child’s feeding, which is often quite clear. The more difficult step is for parents to understand how they are reacting to their child as a result of the feeding problems, to understand the range of factors that might be affecting their child’s ability and desire to eat and drink, and knowing what to do about it.

Many professionals can be a part of a child’s ‘feeding team’, including a lactation consultant, Maternal and Child Health Nurse (M&CHN), paediatrician or medical professional, occupational therapist (OT), speech pathologist, dietitian, physiotherapist and infant mental health clinician. These professionals may see you individually, with communication between team members being vital for success.

The feeding team will always assess a child’s:

  • Physical development, including their motor and sensory skills, and nutrition.
  • Developmental stage and milestones, as well as their communication around food, e.g. their ability to request and refuse food, their ability to get their hands to their mouth to self-feed.
  • Social and emotional development, especially the child’s relationship with their main carer(s).
  • Mealtime experience i.e. the home environment and family routines around mealtimes.

It’s a problem when a child is distressed during a mealtime. Kids need to enjoy and feel included in mealtimes, as well as have some control over what they eat and drink. It’s important for a child’s future wellbeing that they build a positive relationship with food. The RCH team supports parents to recognise and follow their child’s hunger and feeding cues, to STOP feeding despite the burning need to ‘make sure the child eats’, and to allow their child to regain some control over mealtimes.

I will describe strategies for specific difficulties such as choking or gagging on foods or difficulties with certain food textures, in more detail in a future blog.

When should you seek help?

In cases where your child’s growth and nutrition are compromised, stress at mealtimes is impacting on family mental health, or your child is unable to comfortably manage to eat a range of foods as expected, it is important to consult your GP or M&CHN. A local speech pathologist, dietitian or OT with experience in paediatric feeding may be a good starting point. These professionals can be accessed either through a community health service or in private practice, however, choose a service that offers a team management approach to problem feeding in children. A speech pathology referral for the Eating, Drinking and Swallowing Clinic at RCH may be indicated. Your treating medical professional or M&CHN can make this referral if needed.

It can take a significant period of time and lots of small steps to change chronic problem feeding for the better. A consistent approach, tackling challenges when they present, and having a team of professionals alongside to assist you with goal setting, will help you to support your child to overcome their feeding difficulties and to start enjoying mealtimes.

Some further reading:

Please note: Dr Margie is no longer monitoring this blog. If you are concerned about your child, please contact your child health nurse or GP for further advice.

12 comments for “Problem feeders – beyond fussy to something more serious”

  1. penny

    My son has a oral aversion. He does not drink at all and does not eat anything. Sometimes he will put food in the mouth only to spit it out. He was seeing a hospital speech pathologist and OT monthly but last month the speech pathologist said she is been transferred to aged care 3 days a week and wont see my son until next year. Due to my son been born with health problems relating to CDH he has multiple specialists who have said this is ridiculous they think he should be having weekly therapy not monthly and certainly not happy with no service for the rest of the year. What would you recommend? He is 21 months old.

    Reply
    • Dr Margie

      Hi Penny, thanks for your question. I agree you son needs ongoing assistance and would recommend that you get a referral from your GP to the RCH speech pathology led feeding clinic, or to another service closer to you. It sounds as though your son does need the input of a speech pathologist, OT and ongoing good communication with the rest of his team. – Dr Margie

      Reply
  2. Cate

    I have an almost 12 year old son who hates food. He has always hated food. From a very young age he has consistently refused food. He eats maybe half a dozen things. No meat at all. He has been remarkably healthy all of his life…for a kid that doesnt eat. We saw a poo specialist when he was younger who told us that the worst thing we could do was force him to eat. He will eat when he is ready. We had him at a psychologist a few years back but that didn’t help at all. We dont know what to do or where to go. People say serve him up dinner and make him go hungry if he won’t eat it….he would prefer to go hungry. He is a really sensitive kid and a real pleaser…would do anything to please…..he tries to eat food but he can not physically bring himself to put it in his mouth. When his father gets angry with him and tells him we will have to get some kind of help, he gets totally distraught.
    I don’t know what to do or where to go. We live 3 hours from a capital city in a small country town with very few resources.
    Can you give me any ideas?

    Reply
    • walshh

      Hi Cate, This has certainly been a very longstanding problem for you. I would suggest that your son needs to be seen by a paediatrician now to evaluate him for any nutritional deficiency if he only eats six foods and to see if there are any other issues or underlying causes related to his eating that need to be addressed. It may be that he does need to see a psychologist again as part of a team approach to assist with his eating. I would suggest speaking with your GP regarding a referral to paediatrician close to you. If this is not possible, you could get a referral to general paediatrics at RCH or your nearest hospital. – Dr Margie

      Reply
  3. Ricky

    Hi Dr Margie, i have a 5 month old who was born 4 weeks prem. From the beginning there was a lot of emphasis towards his weight gain and he had a ngt in for 3 weeks whilst he was in the special care nursery. My son had also been diagnosed with a severe hip dysplasia at birth, unfortunately having the orthokids hip braces has not helped and he is due for surgery next month. Due to this the emphasis of weight gain has continued the past few months to get him to the ideal weight for anesthetic administration. Throughout the past 4 months we have had a lot of difficulty feeding him as he has had severe reflux. We have seen our paediatrician, GP and maternal child health nurse countless times regarding our difficulties however they seem to be getting worse. We have also seen a lactation consultant who unfortunately was not able to provide us with any new strategies. On a whim we tried using a reflux based formula over a month ago with some success with his reflux, however the past few days have been extremely difficult to feed him as he screams and turns away from the bottle, he even starts to cry when we get him in position for a feed. Im worried our son has now developed a feeding aversion. We have been overwhelmed, stressed and exhaused the past few months, my wife has been burnt out and i have been taking an extensive amount of time off work to try support them. We dont know what to do anymore, is there any advice you could possibly suggest to help us?

    Reply
    • walshh

      Dear Ricky,
      Your son’s feeding seems to have escalated to a point where you need more intensive help having already accessed a paediatrician, MCHCN and GP. Your wife’s exhaustion is also concerning. Could I suggest that you please speak with your GP regarding an admission to a mother baby unit or attend your nearest hospital for assessment for a possible short admission. I think that a re-assessment of your sons feeding by a paediatrician, maternal and child health nurse and a speech pathologist may be helpful at this point given the difficulties you have had for 5 months and your son’s impending surgery. Oral aversion in babies can be very challenging and sometimes needs a team approach to turn things around. Best wishes, – Dr Margie

      Reply
  4. Fleur

    My daughter’s situation is not extreme but ongoing. A few years ago she gagged on melted cheese on top of a pizza. From then on, she will only chew tiny pieces of food near the front of her mouth – for fear, I suppose, that she may choke again. She dreads mealtimes – esp. dinner – as she knows she may have meat to chew etc which scares her. Her weight is low (5-10 percentile) but other than that, she is pretty healthy and active. She eats small amounts across the day. I wonder if a psychologist could help her – given it seems more anxiety-related than a physical constriction? (Although the latter may have developed over time?) i would be interested in your thoughts. Thanks.

    Reply
    • wattsc

      Dear Fleur, it is hard to be sure your daughter doesn’t have a physical problem from the history you give – I would suggest speaking with your GP first to ensure the food is not getting stuck or that she is not having trouble swallowing and to understand the bigger picture better. It may also be helpful to get a speech assessment. If this is all OK then I agree a psychologist would be very helpful to work through her fear of chewing and/or swallowing. I hope you and your daughter can get some more answers soon. – Dr Margie

      Reply
  5. Tracey-Lee

    Hi Dr Marie.

    My son has recently stopped eating solid foods. Looking back at his eating habits before he stopped, I can see how we slowly got to this point. I thought that he was just being fussy and then getting sick of having the same things all the time, that he stopped wanting certain foods, but now we are this point, so a slow decline.
    He is currently living on chocolate or plain milk, yoghurts, custard and soup (only wants chicken cup a soup, and I have to strain it). He drinks water and cordial as well. At first he wouldn’t eat his proteins, then his fruits. Before he stopped, he was eating chocolate, but because he said that melts in his mouth. He now wont even eat that.
    He was putting food in his mouth and chewing, but then has to spit it out. He now wont even do that as I was hoping he could get some nutrients from at least sucking it but nope.
    When asked why he wont he says he is scared it will get stuck in his throat. That he will choke.
    I have been to our GP and he is being treated for reflux, but I do not think this is the reason.

    He has started prep this year and is back at school and I worry even more now about snack and lunch time, as I am not with him and can only pack so much!? (His got soup in to school today with some yoghurt and a mandarin which Ive asked his at least sucks the juices from, but I doubt he will ).

    What would you advise us to do? Would greatly appreciate any feedback.

    Reply
    • Dr Margie

      Hi Tracey-Lee, your son needs to be reviewed by a paediatrician and needs a multi-disciplinary assessment, which may include a psychologist, speech pathologist and dietitian. With a totally liquid diet that is mostly milk and sugar based he is not getting enough nutrients and his difficulty chewing and swallowing needs to be reviewed. You can ask your GP for a referral to a paediatrician as a fist step. Good luck! – Dr Margie

      Reply
  6. Kelly

    Thanks for the article. My son is 21 months and is continuely going down hill with eating. He eats bread, cheese, almost any fruit, and biscuits. (He will bite into apples and chew) until recently his nutritional needs were met by two baby food pouches he would eat daily but now he is refusing them. So zero vegetables or meat is being consumed with minimal protein at all. He often has severe tantrums when offered new food (eggs/pasta/vegetables/chicken/ham) or when he isn’t given the food he wants. When he is in a tantrum he won’t eat the food he normally eats. He is probably a little behind with speech at about 15 words. We tried seeing at OT trained in SOS however we weren’t overally confident in the actual therapist. Our stress levels at eating time is probably a big contributor to the problem. We are seeing a peadatrician next week to find out where we should try next and I’m wondering if he/we would be suitable for the RCH clinic?

    Reply
    • Dr Margie

      Hi Kelly, it sounds as though you do need to see a paediatrician to have your child’s growth and development reviewed. A multi-disciplinary team approach is best with a dietician, speech pathologist and paediatrician to start – you can set this up yourself or attend a clinic such as what is offered at RCH. I would be guided by the paediatrician. Good luck! – Dr Margie

      Reply

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