Sarah Remmer: The Non-Diet Dietitian


The Extreme Picky Eater: When Should You Worry?

How to differentiate between 'typical' and 'extreme' picky eating

link between anxiety and refusing to eat

There’s picky eating and then there’s picky eating.

When picky eating tendencies cross the borders of what’s considered “typical” and start affecting your child’s growth, weight, mood, and family mealtimes in a drastic way, it’s likely time to seek help. Dealing with extreme - or even moderate - forms of picky eating can feel hopeless and isolating. It also causes worry, stress, and sometimes panic for parents, as well as anxiety, fear, and social isolation for the child. In fact, a recent study in the September 2015 issue of Pediatrics showed that (after screening caregivers of over 900 children aged 2-5), children with severe forms of selective eating were much more likely to experience elevated symptoms of social anxiety, anxiety. and depression.

It was also found that moderate forms of selective eating were associated with symptoms of separation anxiety and ADHD. Although these findings likely aren't terribly surprising - especially to parents of extreme picky eaters - they will hopefully create more awareness and perhaps pave the way for more appropriate screening tools and intervention strategies for those kids who struggle with selective eating. 

It's important to realize that most toddlers and young children go through a "picky eating" phase (or several) and that it is, for the most part, typical. Even though “normal” picky eating isn’t cause for concern (and doesn’t typically affect growth or nutritional status) it can easily be made worse (and enter the realm of “extreme” picky eating) if healthy feeding practices aren’t followed. 

If well-meaning parents intervene in an unhealthy way (perhaps bribing, forcing, hovering at mealtimes etc.), typical picky eating can easily escalate into more extreme forms of picky eating and psychological issues may ensue. Here are some blog posts that may be helpful for parents of typical picky eaters: 

47 Resources for Parents of Picky Eaters

Picky Eating: 3 Strategies that WORK

6 Ways To Deal With Your Picky Eater

6 Game-Changing Questions to Ask Your Picky Eater at Mealtimes

Extreme Picky Eating

Katja Rowell, MD and Jenny McGlothlin, MS, SLP wrote a very helpful book Helping Your Child with Extreme Picky Eating which guides parents on how to deal with more severe forms of picky eating. In it, they define extreme picky eating as “not eating enough quantity or variety to support healthy emotional, physical, or social development; or eating patterns that are a significant source of conflict or worry”.  Sound familiar? 

Picky eating isn't a one size fits all.Your child may have been labeled a "problem feeder" or "selective eater" and you may not know exactly what that means or whether it's accurate. In their book, Rowell and McGlothlin outline the various types of extreme picky eating. Unfortunately, there isn’t an official classification system for extreme feeding difficulties in kids, but these labels help parents to better understand their child. 

What the Labels Mean*

Problem Feeder: A child who eats fewer than twenty foods, drops food without adding others, eats different foods than the rest of the family, avoids entire food groups (like meat and vegetables), or becomes upset around new foods is often labeled a problem feeder.

Selective Eating Disorder: Similar definition to problem feeder. Not officially a diagnosis in adults or children; increasingly used to describe a limited range of accepted foods and refusal of unfamiliar foods.

Food aversion: May emerge after an unpleasant experience including illness, trauma, choking; also generalized fear or anxiety around food. Often occurs with selective eating disorder or among problem feeders.

Neophobia: Fear of new things. Toddlers typically experience a phase of suspicion with new and even familiar foods, but extreme negative reaction to new foods may be labeled neophobia.

ARFID: Avoidant/restrictive food intake disorder, previously called infantile anorexia. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines it as starting before six, lasting longer than one month, and characterized by an inability to take in enough nutrition orally for optimal growth, with a negative impact on weight and or psychological functioning. There are three ARFID subgroups: sensory, little to no appetite, and aversion.

Failure to thrive: Inadequate physical growth. Often defined as weight below the fifth percentile; however, clinicians have used cutoffs at the tenth, fifth, or first percentile, or when growth slows significantly.

Feeding Disorder: According to the American Speech Language-Hearing Association, describes problems gathering food in the mouth and sucking, chewing, or swallowing for appropriate intake.

* Above from “Helping Your Child With Extreme Picky Eating” by: Katja Rowell, MD and Jenny McGlothlin, MS, SLP

Parents —Picky Eating is NOT Your Fault

It’s important for you to know that you're not alone, and more importantly, it’s not your fault.  Although there are many factors that can contribute to extreme picky eating — sensory processing disorders, oral-motor delays, being on the autism spectrum, a child being a “super-taster,” or even a “non-taster” etc. - the most important piece of the puzzle is the interaction between you and your child at mealtimes. Of course, feeding therapists, dietitians, or other feeding specialists play active roles in the management of extreme picky eating, but the dynamic between parent and child is by far the most important. As the parent, it’s important to arm yourself with the proper tools to help your child, and avoid advice and strategies that will make matters worse (I’m sure many of you have received advice that you regret following).

Typical or Extreme?

Toddlers, preschoolers and even school-aged kids can have erratic and unpredictable appetites and eating tendencies. Every child isn’t cut from the same cloth — even when it comes to siblings. Some kids will be pickier than others and learn to enjoy foods at different times than others. Here are some typical issues that may come up with your healthy child around eating and food: 

Typical eating may include:

  • Eating a large amount at one meal and nothing at the next
  • All of a sudden rejecting a food that was previously loved
  • Going through a “food jag”: only asking for one or two foods for days or even weeks at a time
  • One day eating a lot and the next day hardly eating anything
  • Preferring carbohydrate-rich foods above all others
  • Only eating one or two foods at a meal and then eating everything at the next meal

Typical growth:

When it comes to your child's growth patters, growth charts aren’t the be all and end all, despite what some health professionals may tell you—they shouldn’t be used as a judgment tool, rather as a tool to observe your child’s growth patterns over time. Percentiles tell us how big or small your child is compared to a sample of children around the same age—not whether this is normal or not. We all come in different shapes and sizes, so it’s important to know that there is no “normal”. If you’re told by your family doctor or another health professional that your child is “failing to thrive”, make sure to get a second opinion, because this term can be inconsistently thrown around. The important thing is that your child is healthy, happy, active, sleeping well and over the period of a week, eating a balance of nutrients.

How Extreme Picky Eating Affects Your Child

Children who experience extreme forms of picky eating are affected not only physically, but emotionally and socially as well. Emotionally, a child may become upset, or cry at the sight of food, feel bad or self-conscious about his eating habits and feel inadequate or that something is “wrong” with him as compared to his peers or siblings. He may feel socially isolated and not want to participate in play-dates, go to friends’ houses or avoid sleep-overs. He may be ridiculed by peers or friends, and often over-observed and hovered over by well-meaning adults (parents, teachers etc.)

Extreme picky eaters aren’t trying to be "bad" or misbehave—they genuinely cannot eat in a typical way, for one reason or another—sometimes this reason will never surface, and that’s ok. You can still help your child without a clear diagnosis as to why she struggles with extreme picky eating.

How your child experiences extreme picky eating:

The following is a summary from Rowell and McGlothlin’s book of common reasons--from the child’s standpoint--of why eating is hard and why qualified help may be needed.

“Ouch!” Eating hurts:

If your child has trouble eating because of an underlying medical concern, it may actually hurt to eat. These concerns may include food, allergies, gastro-esophageal reflux, eosinophilic esophagitis (painful erosions in the esophagus), or severe constipation. Conditions that affect breathing or muscle movements such as congenital heart defects, chronic lung disease or muscular dystrophy can also impact a child’s ability to eat comfortably.

“I just can’t do it”

Because proper oral-motor control and jaw formation and function are necessary for eating, physical conditions such as cleft palate, malformations of the trachea or esophagus, dental issues, enlarged adenoids and tonsils, or even a tongue-tie can play a role in extreme forms of picky eating. Even subtle deficits such as moving the tongue in and out only, instead of up and down, restricts children to only eating soft mashed foods and not being able to progress to more solid textures. Rowell and McGlothlin suggest that parents seek professional help from a qualified speech language pathologist if they’re finding that their child cannot chew with gums and early molars by about fifteen months. 

“This food makes me feel uncomfortable”

Children with sensory integration challenges may be more sensitive to tastes and textures (they just feel more intense), or simply can’t feel food in their mouth (this is where food pocketing may come in). Some children only feel comfortable eating foods with a uniform texture (only crunchy or only smooth), but this is also a fairly typical picky eating tendency for a developmentally-typical toddler. The sight or smell of certain foods can also turn a child off, likely due to a negative past experience. 

“No! I want to do it my way!"

Temperament and mood can also affect the eating of extreme picky eaters. In their book, Rowell and McGlothlin describe that many of their clients feel and express intense emotions, and exhibit similar behaviours such as being highly verbal and intelligent; becoming easily upset and frustrated; and having a strong desire to figure things out in their own time and in their own way. They mention that many neurologically-typical children with extreme picky eating are often very independent, strong-willed and determined, are very attuned to the pressure that their parents put on them and may experience anxiety because of this. Food refusal can be seen in kids who are shy, emotional, and irritable, among other traits.

“This is scary. I don’t want ___ to happen again”:

Children who experience trauma while eating — even kids with no history of picky eating — may become aversive to food. This can happen after a choking episode (a child is so fearful of choking again that he won’t eat at all), or if a child has experienced coercive or forceful feeding (eg. a well-meaning and desperate parent forcing food into a child’s mouth). Vomiting, aspirating (food moves into airway or lungs) or severe nausea can also render a child scared to eat.

Rowell and McGlothlin mention that parents should be aware of a syndrome called Pediatric Acute Neuropsychiatric Syndrome (PANS), which is a “rapid-onset brain-based illness occasionally triggered by infection” if their child all of a sudden stops eating, becomes fearful of food, or starts experiencing obsessive compulsive thinking around food. They stress that it’s important to rule out PANS, as well as any underlying medical condition, eating disorder or aversive food experience.

What You Can Do for Your Child's Extreme Picky Eating

If you think your child’s picky eating is extreme, and has started to affect her growth and consistently disrupt family meals, we suggest consulting with a pediatrician to request a referral to qualified speech therapist who specializes in feeding issues as well as a Registered Dietitian who has specialty training in pediatric feeding, feeding disorders and picky eating. The book “Helping Your Child with Extreme Picky Eating” written by Katja Rowell, MD and Jenny McGlothlin, MS, SLP is a fantastic resource. Rowell and McGlothlin also have a facebook page where they post helpful articles and resources for parents of extreme picky eaters. 

For childhood feeding and picky eating advice (and easy family recipes), also check out my Facebook page