Feeding Problems in Babies and Children

Picky eating vs a feeding disorder

Most toddlers go through a phase of food refusal between about 18 months and 5 years. Their growth slows after the first year, so they need less food than parents expect. That is very different from a feeding disorder.

Doctors now use the term pediatric feeding disorder for eating that is not age-appropriate and lasts at least 2 weeks, linked to medical, nutritional, feeding skill or psychosocial problems. In older children, a pattern of avoiding many foods because of texture, fear of choking or low interest, with weight loss or nutritional deficiency, may be ARFID (avoidant/restrictive food intake disorder).

Common causes of feeding problems

In babies

• Latch and breastfeeding difficulties, including tongue-tie in some babies. See breastfeeding problems.
• Reflux: most spitting up is normal, but reflux disease can make feeding painful, with arching, crying and refusing feeds.
• Cow's milk protein allergy: vomiting, diarrhea, mucus or blood in stools, eczema and fussing during feeds.
• Prematurity: premature babies often have immature suck-swallow-breathe coordination.
• Cleft lip or palate: prevents a seal, so milk comes out of the nose. Special bottles help.
• Heart and lung conditions: babies tire and sweat during feeds and gain weight slowly.
• Illness: colds blocking the nose, mouth ulcers, ear infections and urinary infections.

In toddlers and older children

• Normal developmental pickiness and wanting control
• Constipation, which reduces appetite
• Sensory sensitivities: strong reactions to texture, smell or mixed foods, common in autism spectrum disorder
• Delayed chewing and oral motor skills, often when lumpy foods were introduced late
• Fear after a choking or vomiting episode
• Grazing on milk, juice and snacks, leaving no appetite for meals
• Pressure at mealtimes, which often increases refusal
• Eosinophilic esophagitis: an allergic inflammation of the esophagus causing food sticking, slow eating and vomiting

Swallowing problems

Dysphagia in children is linked to cerebral palsy, genetic syndromes, prematurity and some airway problems. Coughing, choking, a wet or gurgly voice after drinking and repeated chest infections suggest food or drink is going into the airway (aspiration).

How doctors assess a feeding problem

The pediatrician will ask what, how much and how often your child eats and drinks, how long meals take, what happens at mealtimes, about vomiting, stools, breathing and development, and will plot weight, length and head size on growth charts. An observed feed is often the most useful part of the assessment.

Possible next steps:

• Speech-language pathologist: assesses sucking, chewing and swallowing, sometimes with a video X-ray swallow study
• Dietitian: checks calorie, protein, iron and vitamin intake
• Blood tests for anemia, celiac disease or nutritional deficiencies if growth is poor
• Referral to gastroenterology, allergy or developmental specialists
• Feeding team: a multidisciplinary clinic for complex cases

What helps

For everyday picky eating

• Offer 3 meals and 2 to 3 planned snacks at regular times, with only water between them
• Limit milk to about 16 to 20 oz (500 to 600 ml) a day for toddlers, and avoid juice
• Serve small portions, with at least one food your child usually eats
• Offer new foods repeatedly without pressure. It can take 10 to 15 exposures before a child accepts a food
• Eat together and model eating a variety of foods
• Avoid bribes, punishments and long negotiations
• Keep meals to about 20 to 30 minutes, then calmly remove the food

For medical feeding problems

Treatment targets the cause: reflux or allergy management, feeding therapy for oral motor and sensory skills, special bottles or nipples, thickened liquids when advised by a therapist, high-calorie feeding plans, and behavioral therapy for ARFID and food anxiety. A small number of children need tube feeding for a time while they build skills.

Frequently asked questions

What are common feeding problems in babies?

Difficulty latching, reflux, cow's milk protein allergy, slow feeding in premature babies, and feeds disrupted by a blocked nose or illness. Signs that need a doctor are poor weight gain, coughing or choking with feeds, few wet diapers and persistent distress during feeding.

When should I worry that my toddler is not eating?

Worry if your child is losing weight or falling off their growth curve, eats fewer than 15 to 20 foods, gags or vomits with new foods, has very long or distressing meals, or has stopped drinking. A toddler who eats little on some days but grows normally is usually fine.

What is a pediatric feeding disorder?

It is impaired eating that is not appropriate for a child's age and lasts at least 2 weeks, with medical, nutritional, feeding skill or psychosocial problems. It is diagnosed by a pediatrician or feeding team and treated with therapy and support tailored to the cause.

Can a feeding problem be a sign of autism?

Feeding difficulties, especially strong preferences for certain textures, colors or brands and distress with new foods, are common in autistic children. A feeding problem alone does not mean a child is autistic. If you also notice differences in communication, play or social interaction, talk to your pediatrician.