Picky (Selective) vs. Problem Eating in Children/Youth: Information for Primary Care
You are seeing 8-yo Caleb in your primary care practice. He is brought to you by his parents due to problems with his eating. “Every mealtime is a struggle. All he wants to eat is chicken nuggets! You have to do something!”
On one hand, it is good to be picky enough about the foods we eat. It would not be good to be indiscriminate and eat anything and everything.
In picky eaters however, their limited food choices are sufficient to cause stress with parents. Studies on picky eaters show the following themes:
Reduced intake of
- Vegetables and fruits
- Whole-grain products, fish and seafood, meat, and unsweetened cereals
Increased intake of
- Junk food, sweet cereals and French fries
- Processed foods
- Dairy products
When a child has a very restricted range of foods they will eat, then it becomes ‘problem eating’, which can cause issues such as
- Growth problems,
- Nutritional deficiencies,
- Dental decay,
Prevalence: About 25-40% of parents report feeding problems in their infants and toddlers (Reauy, 1996.)
There are various issues that can contribute such as
Autism spectrum disorder (ASD)
Global developmental delay (GDD),
A negative ‘cycle of feeding conflict’ can become set up where 1) the concerned parent pressuring the child to eat, which leads to 2) the child resisting, which leads to less intake, which leading back to 1).
Pain or discomfort from an underlying medical condition,
Immature swallowing skills,
Sensory processing problems, cognitive delays
|Autism spectrum disorder (ASD)||
Are there signs of problems with reciprocal social interactions?
|Global developmental delay (GDD)||
Is the child delayed across many domains of development?
Are there problems with sensory sensitivities, e.g. sound, light, touch?
Does the parent feel they have to pressure the child to eat?
Does the child resist?
How is your child’s oral hygiene? Any dental problems?
Is child seeing a dentist every 6-12 months?
Any pain in child's mouth?
Does child have stools that are usually hard, dry, small in size, difficult to eliminate?.
Gagging or Vomiting?
Food Refusal (especially in the morning)
Grazing throughout the day
Excessive milk intake
Wakes frequently at night
Chronic Bad Breath
Complaining of stomach pain
Arching the back during or after
Hiccough, burp, multiple swallows
at meal times
Saliva bubbles around the mouth
|Pain or discomfort from an underlying medical condition||
Are there other medical issues? Any pain or discomfort?
|Oral motor difficulties, e.g. immature swallowing skills||
Are there troubles swallowing? Choking on food?
Does the child tend to not chew?
Does the child cough or choke with food/drink?
Problems transitioning from liquids to purees
Take excessively long time to drink or eat?
|Sensory processing problems||
Any sensitivities to sound or loud noises?
Any sensitivities to being touched?
|Cognitive delays||Any troubles with learning compared to his/her peers?|
Any signs of low folate, B12, iron, zinc or other nutritional deficiencies such as:
● Fatigue, weakness,
● Lack of appetite,
● Delay in growth or developmental delays,
● Irritability or mood issues
● Brittle or dry hair or nails
● Mouth ulcers or sores at corners of the mouth
|Food or environmental allergies||
Family history of allergies?
Try removing certain foods to see if it the child improves
Differential Diagnosis of Picky vs. Problem Eating
|Picky Eating||Problem Eating|
Eat fewer than 30 foods
Eat at least one food from almost all textures
Eat the same food everyday (food jag)
Eat fewer than 20 different foods
Restricted range or variety of foods and textures
|Foods lost to food jags are re-acquired||
Foods lost to food jags are NOT re-acquired
Tolerate new foods on their plate
Willing to touch or taste new foods
Willing to eat new foods after repeated exposure 15-25 times
Cries and “falls apart” when presented with new foods
Not willing to touch or taste new foods
Adds new foods in more than 25 times
- CBC, Hemoglobin,
- Serum ferritin, iron
- Vitamin A
- Vitamin D (25- OH) Note that although Vitamin D is recommended by certain guidelines, testing is may be discouraged by certain provincial Ministries of Health.
- Vitamin B12.
- Calcium, zinc
- Thyroid function
- Celiac testing
Nutritional supplements and vitamins
Studies confirm that picky eaters generally still get enough macronutrients (e.g. protein, carbohydrates, fats), but that they may struggle to get enough micronutrients (e.g. vitamin, zinc, calcium) (Taylor, 2016).
- Pediatric nutritional supplements
- Infant cereal (for increased iron intake)
- Stage 2 formulas (6-18 months)
- Fer-N-Sol (if low iron levels and prescribed by doctor)
- Children’s complete multivitamin (with iron and without)
- Boost Juice
- Aim for a children’s complete multivitamin with iron, calcium, vitamin D
Address underlying developmental, medical and/or behavioural contributors
In general, underlying issues need to be managed before a child can be expected to change their eating behaviour and accept new foods and beverages.
Address underlying developmental, medical and/or behavioural contributors
Autism spectrum disorder
|Refer to developmental services|
|Global developmental delay (GDD)||Refer to developmental services|
● Food play
● Sequential Oral Sensory (SOS) approach, commonly used by OTs.
Consider referral to developmental services; occupational therapy (OT)
|Medical issues||Manage and refer as necessary|
|Behavioural issues||Provide parent education (see below)|
- Try to make changes gradually
- Try to make only 1 change at a time.
- Do have consistent mealtime routines
Ensure family meals
- Eat meals at a table as a family, in the kitchen or dining room if possible.
- Limit distractions to encourage your child to use all of his/her senses to experiment with new food. I.e. no watching TV, no electronics at the table.
- Thank your child for good mealtime behaviours, e.g. trying new foods, etc.
- Be a good role model for your child by eating the same healthy foods. Human beings are wired to imitate each other.
- Ensure appropriate food portions for children, i.e. portion size for children is ¼ to ½ of an adult portion.
- Remove unfinished food within 20 to 30 minutes of serving
Encourage fluid intake.
- Age 2 years: 2% milk
- Ideally 2 cups of milk at meals; (less than) ½ cup of juice (may be diluted with water); 2 to 3 cups of water per day. If milk is not a favorite beverage, consider adding it to fruit or yogurt smoothies.
Place a non-preferred food next to the child’s preferred food to change the appearance of their meal. Having a favorite food on her plate will help attract his/her attention to her plate. Remember it can take up to 20 positive exposures to a food before a child accepts to eat it.
For more information (http://www.cheo.on.ca/en/Foodchaining)
Limit meal and snack times. Offer 3 meals and 2 snacks per day. There should be two hours between each meal and snack with nothing in between (except water) to ensure that your child is hungry.
Food play. Allow your child to explore new foods, such as ‘food play activities’. Give your child a chance to see, touch and smell a variety of foods. There should be no expectation of eating during the times set aside for food play. It can take up to 15 or more positive food experiences for a child to accept a new food.
- Do try to stimulate the various senses:
- Help unpack vegetables/fruits and place them in a bowl or sort them by color, etc
- Bring your child grocery shopping and encourage them to feel the fresh produce
- Have your child help serve the food; build a rainbow of colours on the dinner plates
- Find books and games with pictures of food and introduce them to your child
- Describe the color, taste and shape of a food
- Encourage your child to participate in meal preparation, children love to stir!
- Have your child help arrange cut vegetables or fruits on a plate
- Have your child wash fruits and vegetables in the sink
- Ask your child to add fruit to a fruit smoothie
- Use raw or cooked foods during craft activities:
- Spaghetti can become a road for cars, or hair for a happy face
- Cucumber slices can become wheels for a car or eyes for a happy face
- Bread or carrot sticks can be used to make a fence
- An orange slice can become a sun
- Finger paint with pudding or pureed food, and make Jell-O gigglers
- Use peas, cherry tomatoes, orange slices, crackers or other food for a counting or stacking activities
- A potato or other firm fruit can be used to make a stencil
- Dried fruits can be used to make a walking path
- A cucumber can be used as a rolling pin
- Rub foods on hands, arms and progress to cheeks and mouth area. As child builds acceptance to touch, you can rub tastes along the lips and encourage your child to lick the food.
- Expose your child to a variety of scents (vanilla, lemon, spices) and discuss whether they like/do not like that smell. Make a graph with pictures of “Nice Smells” vs. “Not-so-Nice Smells”.
- Game: What noise does this food make?
- Exaggerate the sounds of biting, chewing, and swallowing.
- Don’t reward eating foods, e.g. don’t reward with screen time, don’t reward with dessert, etc. You might say that “After we finish eating, then it will be time for ____”. As opposed to saying, “If you eat ___, then you will get ___.”
- Don’t allow other food unless it’s a planned mealtime or snacktime, i.e. don’t graze constantly throughout the day.
- I will plan and prepare meals.
- I will include a food or two at each meal that you generally eat. This way, you can decide whether and how much you will eat of the foods I have included in the meal.
- I will expect you to show up for dinner on time and hungry. Comments? Criticisms?”
- Cruciferous vegetables (cauliflower, cabbage, garden cress, bok choy, broccoli, Brussels sprouts)
- Spicy cuisine
- Fermented foods (e.g. kimchi)
- At 4-6-months, when starting to introduce solid foods to the baby, include pureed vegetables, iron-fortified cereals and meats first and then offer fruits.
- At age 8-mos. to 10-mos., most babies can handle small portions of finely chopped finger foods, such as soft fruits, vegetables, pasta, cheese, well-cooked meat, baby crackers and dry cereal. Include foods that are bitter, spiced or have interesting flavors; eventually, introduce different texturess
- Difficulty swallowing/chewing
- Pouching food in their cheeks
- Strong aversions to textures/tastes
- Being touched in the head/face area.
- Oral motor and/or sensory integration difficultie
If YES to the above then → Occupational therapy (OT) and/or Speech language therapy (SLP)
- Picky/problem eating at any time
If YES then → Dietitian.
The Canadian Association of Occupational Therapists (CAOT) has a directory of OTs across Canada
Dietitians of Canada has a directory of dieticians across Canada
For Parents with Babies
Food Chaining Handout from CHEO
Eat Right Ontario
Canada’s Food Guide:
- Food Chaining: The Proven 6-Step Plan to Stop Picky Eating, Solve Feeding Problems, and Expand Your Child’s Diet. Fraker, C., Fishbein, M., Cox, S., Walbert, L. (2007). Da CapoPress
- Just Take a Bite: Easy, Effective Answers to Feeding, Ernsperger, L., Stegen-Hanson, T. (2004).USA: Future Horizons.
- Feeding With Love and Good Sense: 12 Through 18-years, by Ellyn Satter
Date of Last Revision: Jan 18, 2019