Pediatric Feeding Disorders

What is a Pediatric Feeding Disorder?

A pediatric feeding disorder is a condition in which a child will not orally consume adequate nutritional, hydration or caloric intake in amounts needed in order to thrive. Behavior deficits or excesses that inhibit such intake may result in a child, toddler or infant to be characterized as failure to thrive (FTT). Failure to thrive is characterized by being under the third percentile for weight.

Other pediatric feeding disorders can be characterized by the consumption of a limited number of foods (e.g. only eats goldfish crackers, only eats foods that are yellow, only eats particular food groups such as starches or only eats certain textures, such as purees). Additional pediatric feeding problems include failure to self-feed, vomiting, packing solids or pooling liquids, eating non-edible items, or general food refusal.

Food Refusal in Children: an Overview of a Growing Epidemic

Recent statistics (source) reveal that one in four children have some sort of feeding disorder. Food refusal can take the form of food selectivity, G-Tube (Gastrostomy Feeding Tube) or NG-Tube (Nasogastric Feeding Tube) dependency, bottle dependency, texture selectivity or poor oral intake in general.

Nutritionists, dieticians, pediatricians, pediatric gastroenterologists, speech and language pathologists (SLP), occupational therapists (OT), and behavioral therapists all work in different ways to solve this growing epidemic in children. Behavioral feeding therapists structure the environment and consequences during mealtime to facilitate healthy eating habits.

Behavioral Approach to Feeding

Of all the approaches, behavioral management strategies have been proven to be the most effective and efficient. A significant amount of progress can be made within a 4-6 week period. Unfortunately, most behavioral clinics, such as the Kennedy Krieger Institute (Baltimore), Marcus Institute or Marcus Autism Center (Atlanta), Children’s Hospital of Philadelphia (Pennsylvania), and St. Joseph's (New Jersey), Penn State Hershey Feeding Program (Pennsylvania) are located on the East Coast.

Food Refusal

Food refusal refers to behaviors that interfere with proper nutritional, caloric and/or hydrational needs. These behaviors include (but are not limited to) throwing food or utensils, holding food in the mouth, hitting the spoon when fed, spitting out food, kicking at mealtimes, crying and vomiting. (Some children without reflux or prior medical history can use a finger or other means to gag and vomit food.)

Causes of Food Refusal

Most times it is difficult to pinpoint the cause of a particular case of food refusal.

Medical Conditions

Food refusal may be caused by a prior medical condition that has in the past or in the present caused discomfort during eating. This makes the act of eating uncomfortable to a child or the experience of discomfort in the past has been paired with eating in general.

Tube Dependence

Tube dependence can be a major cause of food refusal. For various reasons, some children are unsafe to eat orally, while at other times children are at an unsafe weight when a feeding tube is placed.

Attention Maintained

Sometimes children are easily reinforced by attention to their eating behaviors. If a child is being coddled subsequent to the child shaking a head after food is presented, it will be more likely that during the next meal that the presentation of food will result in head shaking.

Food Refusal Treatment

The goal of using behavior analysis is to identify problematic behaviors during mealtimes and then to teach an appropriate set of behaviors that will yield a proper mealtime experience.

Types of Food Refusal Related Conditions

  1. Texture - Child accepts only certain textures
  2. Complete Food Refusal - Child will not accept any food
  3. Food Selectivity - Child only accepts a limited number of foods
  4. Low Volume Acceptance - Child refuses to eat after a certain volume of food is consumed


Mealtime Behaviors

Every child exhibits a different set of behaviors during treatment.

Pediatric Feeding Disorders 2

The extent to which behaviors are engrained and exhibited also differ from child to child. This makes the number of distributions nearly infinite. The probability of two children (even identical twins) exhibiting the same distribution of behaviors is miniscule.

Children also respond differently to the various forms of treatments used for each individual behavior, which adds another degree to the complexity of dealing with food refusal.


Studies have shown that 25% of the pediatric population exhibits moderate to severe food refusal.

Pediatric Feeding Disorders

Not every child in the 25th percentile that exhibit "moderate" food refusal needs to seek treatment. Other may only need a few treatment sessions.

The criteria used for determining whether to proceed with treatment is to what degree the food refusal is causing a child's health to be affected.

Medical Implications and Testing

While most pediatric feeding disorders are simple to treat, there may be medical complications which interfere with treatment possibilities. Before starting treatment, a child with a feeding disorder should be carefully evaluated by a physician to determine whether he or she is physically safe to eat. These evaluations are done both to ensure the safety of your child or baby and also to optimize the treatment effects.

The most common medical conditions, which interfere with treatment of pediatric feeding disorders, are reflux, allergies, aspiration, and motility problems (explained below). These conditions are typically solved with medications, surgery, or special treatments.

In the case of reflux, medications are usually prescribed. In the most severe cases a surgery is performed called a Nissen Fundoplication. This involves a repositioning of the stomach which results in a smaller opening into the organ. This allows for a greater probability of food going in without reflux or vomiting.

Allergy testing is essential because if a child ingests a food to which he or she is allergic, lesions or irritations can form in the GI tract, which can make eating a very painful ordeal. There are several ways to test for allergies. Talk to your pediatrician for advice on the best test to administer to your child.

Aspiration occurs when liquids enter the lungs. This occurs when a ligament over the passage to the lungs, which usually closes during oral intake, remains open. This can be dangerous because the liquid in the lungs can cause pneumonia. A speech pathologist or an occupational therapist can help determine if aspiration is occurring and which consistency of food is likely to lower the probability of aspiration occurring.

Lastly, with motility issues, food does not pass through the GI tract at a normal rate. This can cause food to stay in the stomach too long, overfilling it, and causing vomiting, pain, and constipation. This can be treated with medications such as Reglan and Erythromycin.

Common tests to do before seeking treatment to increase your child’s food/drink intake orally:

  1. Allergy testing - blood tests (RAST) or skin tests (prick tests or patch tests)
  2. Upper GI - liquid with barium is consumed to check for structural abnormalities in the esophagus, stomach and small intestine
  3. Swallow study - liquid with barium is consumed (starting with very thin liquid and getting thicker) to determine if aspiration is occurring and if there is a safe thickness for the child to eat without aspirating
  4. PH probe - a thin tube is placed in the esophagus near the opening of the stomach to measure acid levels for several hours, may be used to confirm reflux
  5. Gastric emptying study - radioactive material is added to food that the child ingests, the stomach is monitored to see how long the radioactive material (and therefore food) remains in the stomach, can be used to check for slow gastric emptying
  6. Endoscopy - the child is anesthetized and a small tube with a camera is passed into the esophagus, stomach and small intestine to check for damage due to reflux or gastiritis or for physical abnormalities.


Los Altos Feeding Clinic
2235 Grant Rd. Ste 2
Los Altos, CA 94024


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