Is Picky Eating a Disorder that Physicians Should Address?

Key Points:

• Picky eating poses consequences for a child’s health.

• The Pediatric Feeding Disorder Consensus Definition and Conceptual Framework published in January 2019 allows the diagnosis of a feeding disorder even among healthy normal children with picky eating.

• The prompt diagnosis of a feeding disorder paves the way for intervention and prevention of the consequences of picky eating among children.

It is not uncommon for us pediatricians to encounter “picky eating” as a chief complaint during a clinic consultation. In fact, all over the world picky eating has been a concern for parents and physicians alike. The prevalence of picky eating in young children has been reported to be as high as 50-58.9% (1,2) which makes it not surprising if 6 out of 10 clinic consultations will include a mother concerned about a picky eating child. The question in mind is does picky eating deserve medical attention by a physician? This article talks about the consequences of picky eating and the definition of feeding disorder that encompasses picky eating among otherwise healthy children.

Physicians and parents alike hope that picky eating will be outgrown in time. For most children, this may be the case. In a prospective study of over 6000 children and their parents, 56% were considered to be picky at 15 months of age, and of these, 83% were no longer picky at 3 years of age if the mother was not worried, or if the mother provided the same meal to the child as the rest of the family, or offered fresh fruits. If the mother was very worried about picky eating, 50% remained picky at age 3 years of age. The study illustrates that picky eating is not necessarily outgrown especially if the mother is worried (3.)

Although it is hoped to be outgrown, picky eating is not totally harmless. Consequences like nutritional deficiency, growth faltering, cognitive dysfunction, and deficits in neuro-development have been reported (4,5). In severe cases of picky eating when tension escalates and the child learns to refuse food despite hunger cues, a longitudinal study reported a long-standing risk of malnutrition and increasing psychopathological symptoms in both, the child and the mother (6). Picky eating impacts not only the child’s nutrition and growth but also negatively affects the nurturing relationship between child and feeder and in turn, influences their psychosocial health.

Given these dire but avoidable consequences, a physician has the task of identifying picky eating as a feeding disorder, and of managing the disorder. However, a feeding disorder is not as confidently diagnosed by most physicians and is more easily brushed off as a phase to be outgrown. In January 2019, a Pediatric Feeding Disorder Consensus Definition and Conceptual Framework was proposed filling the gap in diagnosing feeding disorder in children (7.) Using the World Health Organization’s International Classification of Functioning, Disability, and Health, the authors proposed that we diagnose a pediatric feeding disorder in any child with age-inappropriate impaired oral intake for at least two weeks accompanied by medical dysfunction, or nutritional dysfunction, or feeding skill dysfunction, or psychosocial dysfunction. The article was all-encompassing and included feeding disorders in children with organic pathology like the child with congenital heart disease and intermittency of feeding, or the neurologically-impaired child who cannot swallow well or hold his neck upright (the so-called medical dysfunction.) But the article’s greatest contribution to physicians was that it allowed us to diagnose a feeding disorder in an otherwise healthy child with no medical condition. It validated the chief complaint of the mother who is having an especially difficult time feeding her child or the otherwise healthy child who finds feeding undesirable. Feeding disorder in an otherwise healthy child exists and should be identified and managed by physicians to avoid consequences and to support nutrition and growth as well as cognitive and psychosocial development.

In the proposed diagnostic criteria for feeding disorder, a delay in the child’s expected feeding skill for age, termed feeding skill dysfunction, qualifies the child as having a pediatric feeding disorder if this is accompanied by impaired oral intake lasting at least 2 weeks. A child has feeding skill dysfunction if the feeder finds the need to modify the texture of food, to modify the feeding position, equipment, or feeding strategy. This simple definition allows us to diagnose feeding disorder in a 9-month-old baby who eats only purees and cannot eat textured solids, or a 2-year-old who needs to be chased around the room just to be fed instead of sitting through a mealtime in his high chair. A healthy 6-month-old is developmentally able to swallow pureed, mashed, and semi-solid foods. By 8 months, babies can munch on and swallow “finger foods” like well-cooked vegetables, well-cooked pasta, baby biscuits, or certain sliced fruits. By 12 months of age, a child can consume the same types of foods as the rest of the family although choking hazards need to be avoided. A deviation from these expected feeding skills constitutes a dysfunction that needs to be addressed to allow the child to grow and develop optimally.

Another qualifying criterion is the presence of psychosocial dysfunction which pertains to the feeder or the feeding relationship. Impairment in this area is observed as avoidance of the child when being fed, inappropriate approach by the feeder such as force-feeding or prolonged feeding, or a disruption in the lifestyle or relationship as a result of feeding difficulty. These are observations easily reported by the family of the child which pediatricians can validate as criteria in diagnosing a feeding disorder in the child. The mother may report that the child clamps his mouth closed when fed, or gags at the sight of food. Stories like these are salient features in the diagnosis of a feeding disorder and physicians have a role in treating this to avoid consequences in the child’s health and development. The ideal feeding scenario involves a positive psychosocial interaction between the child and the feeder. The World Health Organization states it elegantly when it promotes responsive feeding of all children from the get-go when complementary feeding is started. The WHO reminds families that “feeding times are periods of learning and love” (8,9.)

Gone are the days when we sit on the fence when a chief complaint of picky eating or feeding difficulty is posed to us by a concerned parent. The Pediatric Feeding Disorder Consensus Definition and Conceptual Framework allow physicians to diagnose a feeding disorder and to confidently redirect the child’s feeding progress by educating the feeder on age-appropriate feeding skills and the responsive feeding of children.

1. Taylor C.M., Wernimont S., Northstone K., Emmett P. Picky/fussy eating in children: A review of definitions and assessment measures, and prevalence in a UK longitudinal cohort. Appetite. 2015;95:349–359.

2. Pavan Kumar K., Srikrishna, S., Pavan I., Chary E. Prevalence of picky eating behavior and its impact on growth in preschool children. International Journal of Contemporary Pediatrics. 2018; Vol 5, No 3.

3. Emmett P.M., Hays N.P., Taylor C.M. Antecedents of picky eating behaviour in young children. Appetite. 2018; 130: 163–173.

4. Kerzner B. Clinical investigation of feeding difficulties in young

children: a practical approach. Clin Pediatr (Phila) 2009;48:960-5.

5. Kerzner B., Milano K, MacLean, W.C., Berall G., Stuart S., Chatoor I. A Practical Approach to Classifying and Managing Feeding Difficulties. Pediatrics 2015, 135 (2) 344-353.

6. Lucarelli L., Sechi C., Cimino S., Chatoor I. Avoidant/Restrictive Food Intake Disorder: A Longitudinal Study of Malnutrition and Psychopathological Risk Factors From 2 to 11 Years of Age. Front Psychol. 2018; 9: 1608.

7. Goday, P.S., Huh, S.Y., Silverman, A, Lukens C.T., Dodrill, P, Cohen S.S., Delaney A.L., Feuling, M.B., Noel R.J., Gisel E, Kenzer A, Kessler D.B., Kraus de Camargo O, Browne J, Phalen J.A. Pediatric Feeding Disorder Consensus Definition and Conceptual Framework. Journal of Pediatric Gastroenterology and Nutrition:2019; 68 (1): 124–129.

8. World Health Organization. Guiding Principles for Complementary Feeding of the Breastfed Child. WHO Press; (2001).

9. World Health Organization. Guiding Principles for Feeding Non-breastfed Children 6 - 24 Months of Age. WHO Press; 2005;