The term feeding challenges is a broad term used to describe a variety of feeding or mealtime behaviors perceived as problematic for a child or family. This article will address a range of feeding challenges to include feeding disorders, feeding developmental delays, feeding difficulties, and feeding issues requiring more serious intervention. Whatever we call these challenges, they show up in our classrooms and we are often met with questions and concerns from parents/caregivers and advice from everyone—including Dr. Google. As a board certified behavior analyst, I am called in to face many challenges. I am lucky to work with a dedicated and neurodivergent-affirming Speech Language Pathologist, Chloe Calenzo, who specializes in feeding therapy. I had the pleasure of interviewing Chloe for this article.

Me: I have read a lot on feeding challenges, and, as a professional in early childhood education, I feel that I am seeing more challenges over the past few years.

Chloe: As a feeding therapist, I would say yes there has been a slight increase in feeding challenges over the last five years. I would attribute this to more awareness due to social media platforms. Nowadays, we have access to lots of advice around feeding—good and bad advice. In my professional experience, it feels like more people are seeking professional advice due to experiences shared on social media.

Me: What are the most common feeding challenges you see?

Chloe: There are SO many reasons that children face feeding challenges in early childhood. I often hear, “My child is picky!” Developmentally, around the age of 2, children become notoriously “picky” and things they used to love, get thrown on the floor or spit out. Some might like broccoli one day and the next day refuse it. It is very frustrating to parents everywhere! This is a typical stage that almost all toddlers go through, and most will outgrow. However, for various reasons, some children do not.

If you feel a 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 the right professional to help fix the issue. As a feeding therapist, it is common for individuals to experience feeding challenges due to sensory, behavioral, anxiety, phobias, medical, etc.

Below, is a comprehensive 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, overstimulated)
• Chronic constipation, intermittent constipation (if food is not coming out, food will not go in!)
• Sensory differences (hypersensitivity to taste, smell, or texture)
• 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)
• 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)
• Parent-child conflict, parental anxiety

Me: I know that one of the first steps to treating a feeding challenge is parental involvement. The parent or caregiver should report any signs of a feeding challenge to a pediatrician. Evaluation of a potential disorder will include a review of medical history, growth patterns, developmental history or disorders, and current eating habits. When parents get to you in the intervention process, what are the most common solutions you offer when faced with a feeding challenge?

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Chloe: A feeding therapist can help identify the cause of the child’s feeding needs and work with caregivers to develop a treatment plan. It is important that the therapist determines which variables contribute to the child’s feeding struggles. If a child has overall anxiety, it can be helpful that they receive intervention from a psychologist, especially if there is trauma (e.g. sudden scary choking event or witness someone choking) causing fear of eating.

I encourage caregivers to involve their children in the process of grocery shopping, putting away groceries, helping prepare foods, cooking, washing dishes, and even packing the lunchbox. Exposure in all forms is great! Exposure can decrease anxiety around “less familiar” foods.

It is not always feasible, but it is highly encouraged that all meals and most snacks are offered when other family members or others (such as classmates) are eating, and preferably eating the same food(s) whenever possible. With this in mind, it is critical to always ensure a child’s “safe” or familiar foods are presented. It can be helpful to place unfamiliar food on a napkin or a separate bowl next to the plate. Reducing pressure to try foods is highly beneficial. With consistent exposure, a child is more likely to try a new food. In therapy, I strive to help my patients build positive relationships around food. As adults, we don’t like all foods that we try, and that is ok! The same goes for kids.

Me: What advice would you give parents when faced with a new diagnosis?

Chloe: Feeding struggles can make some parents feel like they are failing. I remind parents that they are not bad parents if their child does not eat well. It is important to keep in mind that picky eating can stem from a variety of reasons. These can include medical concerns (e.g. constipation, gastroparesis, or Eosinophilic esophagitis), sensory concerns, oral motor delays, and/or anxiety. It is important for parents to have resources and help their child foster a positive relationship with food.

Me: So, I have some specific questions I have heard from parents/caregivers. Ready?

Chloe: Ready!

• Q: Is it ever too late to get help for my picky eater? My child is 10 and still only eats like five foods. Is therapy only for little ones?
  • A: No! Many feeding therapists often see children who are older and can make significant gains. Often, older children with a food selectivity may have undiagnosed conditions that make eating so challenging they struggle with it their entire lives.
• Q: My child has a diagnosis of Autism. Is it typical for him to also have eating difficulties with this type of diagnosis?
  • A: It is extremely common for children on the Autism spectrum to have some type of feeding challenge. Their feeding challenges may be sensory in nature, behavior, oral motor functioning, or a combination. Children with ASD often face feeding challenges that may require therapy to overcome.
    • You might hear the following:
      • My son will eat fries but ONLY from Burger King™.
      • My daughter can eat this food, but it has to be a specific shape or brand.
      • My child only likes smooth foods.
• Q: My daughter is 1.5 years old and only eats purees! Is this normal?
  • A: For children not progressing to table foods, therapy often is recommended to determine the “why.” Some children have a medical component, such as tongue or lip ties or enlarged adenoids/tonsils contributing to their difficulties progressing to table foods. It is important to rule out these variables.

Feeding challenges are among the most common childhood developmental delays. Research has shown that up to 25 percent of children may demonstrate signs of a feeding disorder. In addition, as many as eight out of 10 children with a disability can have an accompanying feeding disorder. Chloe taught me that are as many reasons for the challenges as there are interventions. The ongoing process may involve multiple steps, including dietary intake assessment from a registered dietician, observation from a physician or nurse practitioner who specializes in feeding disorders, assessment from a clinical or child behavior psychologist, and evaluation of oral motor skills from a speech-language pathologist.

Many of these challenges will pass with time. They are considered typical feeding development. However, sometimes the behavior is prolonged. It is the severity and duration of behaviors that signifies a problem. As a BCBA, I am always looking for patterns. I encourage teachers and caregivers to do the same. The more documentation and pattern-finding you have, the easier it will be for a qualified healthcare professional to point you in the right direction, toward the right intervention.