Why Is My Child Having So Much Difficulty Eating and How Do I Know When it’s Time for Therapy?!

Oftentimes, when children are experiencing difficulty eating, parents ask one of the following two questions: “What actually caused this?” OR “What can actually be done to determine what is going on?  I wanted to answer these two questions today to help clean up some of the muddy waters surrounding pediatric feeding difficulties!

First, why is my child having trouble eating? 

There are SO many reasons that your child may be struggling with this super important life skill! And, we really can’t just “fix it”. It’s important to determine the root cause and the “why”; trying to treat a child for feeding concerns without looking into what is causing their feeding concerns will never work. Below, you will find a comprehensive, but not exhaustive (that would be impossible!), list of common conditions that lead to a majority of feeding difficulties in children:

• Child temperament (slow to change, does not like new things, easily stimulated, over-stimulated)
• Pain or discomfort with feeding (from things such as reflux or allergy-some allergies are extremely difficult to diagnose such as EoE (Eosinophilic Esophagitis) and take special testing to examine and determine if they are present)
• Negative past experiences with feeding (pain, coughing, vomiting or gagging during feeding)
• Sudden scary choking event
• Negative experiences related to the mouth (history of NG tubes, oral procedures, being on a ventilator, surgeries)
• Time spent in the hospital as a baby, perhaps in the NICU
• Slow emptying of the stomach (gastroparesis)
• Chronic constipation, intermittent constipation (if food is not coming out, food will not go in!)
• Poor oral motor skills (dysphagia)
• Low muscle tone / high muscle tone
• Developmental delays (wide variety)
• Certain developmental disabilities, such as autism spectrum disorder
• Anxiety (anxiety specifically around food is commonly referred to as ARFID)
• ADHD
• Sensory differences (hypersensitivity to taste, smell, or texture)
• Chronic health problems (ear infections, frequent respiratory infections, dental problems, seizures)
• Parent-child conflict, parental anxiety

Next, how do we figure out the underlying cause of the problem before treatment begins?

While we have listed some of the common conditions that lead to a majority of feeding difficulties in children, we know we need to get to the underlying cause of the problem before treatment begins. How do we do that? 

See below to get a better understanding of some of the tests/procedures that may be included with your workup. Many children only participate in one or two of these tests/procedures, while some need more. Your feeding therapist can help guide you through this complex journey.

• Review of medical history, growth pattern, developmental history, and current symptoms
• Assessment of dietary intake (typically a 3-day diet review is very beneficial)-a dietary journal can help because it can be very hard to remember!
• Feeding evaluation to look at intake, setting, response to food presentation
• Evaluation of feeding behaviors 
• Evaluation of oral motor skills, chewing and swallowing
• Special tests to evaluate swallowing, such as a barium swallow or endoscopic assessment. 
• Evaluation by a pediatric gastroenterologist to determine if there are problems of the GI tract (reflux, constipation, or other GI disorders) which may be contributing to feeding problems
• Blood work to evaluate nutrition status or to screen for medical conditions that can contribute to feeding problems. This can often be performed by your pediatrician or your GI doctor if you already have an appointment. 

 
Finally, how do I know when it’s time for therapy?
 
I often hear repeatedly, “Does my child really need therapy?” and “How do I know when it is time for therapy?” And honestly, it is an excellent question! There is SO much advice and information out there and I know that it’s difficult to know the good information from the bad. And let’s face it - many children, as well as adults, are picky eaters.  Developmentally, around the age of 2, children become notoriously “picky” and things they used to love, get thrown on the floor. It’s universally frustrating to parents everywhere! This is a typical stage that almost all toddlers go through and most will outgrow. Some, however, for various reasons, do not. And that is where professional help comes in and can make all the difference in the world. Babies learning to eat and older school aged children may have their own difficulties with food, prompting parents everywhere to ask themselves: “When is it time to step in and seek professional help?” Here are seven signs to look for that can indicate that it’s time to get your child a feeding evaluation: 

1. Your child seems genuinely upset at mealtime. If your toddler is screaming, throwing food, and seems like they may be in actual pain, it’s time to reach out. Anything beyond a “normal” crying fit over wanting mac and cheese instead of broccoli needs to be addressed. Sometimes there are painful conditions associated with eating that we are unable to see and our toddlers are unable to communicate these things to us verbally-their screaming and consistent tantrums around food are their way of telling us something is really wrong. We need to listen and react before the problem gets bigger.
2. Your child is eliminating entire food categories. Sure, liking sweets over veggies is normal, but if your little one eliminates entire textures like “smooth” foods, you may be headed in a direction where you need some intervention.
3. Your child is falling off of the growth chart or your doctor has expressed concerns over his or her weight or development.
4. You cannot go out to dinner as a family. Of course, having kids changes date night! But you should still be able to go out to kid friendly dining establishments and eat out. If not, something deeper than “picky eating” may be going on.
5. Your child is drinking their meals. Yes, milk is good. But not too much! If liquids are a priority for your child and taking the place of meals, this is a red flag that intervention may be needed.
6. You notice gagging or vomiting after meals.  This needs to be addressed by your pediatrician and will need intervention.
7. Anxiety and apprehension around new foods. This often occurs, but not always, with older children or adolescents. Stress and anxiety with eating can be helped with intervention and should be addressed with a professional who is specially trained to help with these types of food avoidance behaviors. Many times, these behaviors can be carried over into adulthood. Adults can also be treated for “picky eating” or anxiety with trying or eating new foods, and can make significant progress with the right intervention.

If you feel your child is having feeding difficulties, there are obviously a huge variety of factors that can contribute.  Feeding challenges go far beyond simple “picky eating” and it is crucial to figure out the cause of the problem and get to the right professional to help fix the issue.  
 
Kelly is an SLP and a feeding specialist. If you have questions, please reach out to Kelly at Picky Eaters Online at kelly@pickyeatersonline.com or check out her website at https://pickyeatersonline.com. 

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