a practical approach to classifying and managing...

A Practical Approach to Classifying andManaging Feeding DifficultiesBenny Kerzner, BSc, MBBCh, FCPa, Kim Milano, MS, RDb, William C. MacLean, Jr, MD, CMc, Glenn Berall, MD, FRCPC, MBAd,Sheela Stuart, BA, MS, PhDa, Irene Chatoor, MDe

abstractMany young children are thought by their parents to eat poorly. Although themajority of these children are mildly affected, a small percentage havea serious feeding disorder. Nevertheless, even mildly affected childrenwhose anxious parents adopt inappropriate feeding practices may experienceconsequences. Therefore, pediatricians must take all parental concernsseriously and offer appropriate guidance. This requires a workableclassification of feeding problems and a systematic approach. Theclassification and approach we describe incorporate more recentconsiderations by specialists, both medical and psychological. In our model,children are categorized under the 3 principal eating behaviors that concernparents: limited appetite, selective intake, and fear of feeding. Each categoryincludes a range from normal (misperceived) to severe (behavioral andorganic). The feeding styles of caregivers (responsive, controlling, indulgent,and neglectful) are also incorporated. The objective is to allow the physician toefficiently sort out the wide variety of conditions, categorize them for therapy,and where necessary refer to specialists in the field.

Parents of young children worldwideare concerned about feeding difficulties.When asked, more than 50% of mothersclaim that at least 1 of their childreneats poorly; this implicates ∼20% to30% of children.1–4 These perceivedfeeding problems encompass a broadrange, from mild (so-called pickyeating) to severe (as seen in autism).The pediatrician seeking to resolvethese concerns needs a comprehensiveapproach, one that extends beyondthe guidelines more suited forsubspecialists and multidisciplinaryteams, who are confronted by the moresevere end of the spectrum: theso-called “feeding disorders” (Fig 1).

Feeding disorders are recognized in thepsychiatric Diagnostic and StatisticalManual of Mental Disorders, FifthEdition (DSM-V) and medicalInternational Statistical Classification ofDiseases and Related Health Problemscoding systems.5–7 Classifications ofthese disorders dating back to the

1980s tend to reflect the discipline ofthe authors and often lack an agreed-upon nomenclature.8–11 Those fromthe pediatric medical communitygenerally focus on well-defined organicconditions, but do not emphasizea systematic approach to behavioralissues.8,9 Classifications from thepsychiatric field12 focus more onbehavioral problems, whose diagnosticlabels are necessarily “constructs,”(ie, models devised on the basis ofclinical observation, subject to variability,but nonetheless affording opportunityto institute appropriate therapy).

Bryant-Waugh et al,6 as well as Kreipeand Palomaki,13 in excellent reviewsexplaining the most recent DSM-Vclassification, concluded that earlychildhood feeding disorders should begrouped under the umbrella term“avoidant/restrictive food intakedisorder.” They recognize 3fundamental, aberrant feedingbehaviors: children eating too little,

Departments of aPediatric Gastroenterology, Hepatology,and Nutrition, and ePsychiatry, Children’s National MedicalCenter, The George Washington School of Medicineand Health Sciences, Washington, District of Columbia;bPediatric Nutritional Consultant, Geneva, Illinois; cFAAPGastroenterology, Hepatology, and Nutrition, NationwideChildren’s Hospital, College of Medicine, The Ohio StateUniversity, Columbus, Ohio; and dDepartment of Paediatrics,North York General Hospital, Department of Paediatrics andNutritional Sciences, University of Toronto, Toronto, Ontario,Canada

Dr Kerzner developed the original concept for thecurrent classification and after discussions with allauthors refined it. He wrote the first draft andsubsequent revisions; Ms Milano and Dr MacLeanparticipated in discussions and refinement of theoriginal concept, and shared in the writing of thefirst draft and subsequent revisions; Drs Berall,Chatoor, and Stewart participated in discussion andrefinement of the original concept and commentedon early drafts; and all authors approved the finalmanuscript.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-1630

DOI: 10.1542/peds.2014-1630

Accepted for publication Oct 15, 2014

Address correspondence to Benny Kerzner, BSc,MBBCh, FCP, Department of PediatricGastroenterology, Hepatology, and Nutrition,Children’s National Medical Center, 111 Michigan AveNW, Washington, DC 20010. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,1098-4275).

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mailto:[email protected]

mailto:[email protected]

eating a restricted number offoods, or displaying a fear of eating.With rare exception,14 recentclassifications have not identifiedparental misperception as a distinctsubcategory of feeding difficulty, butit clearly is a clinical problem needingresolution. We concur with Davieset al15 that feeding difficulties mustbe conceptualized as a relationaldisorder between the feeder and thechild and that the caregivers’ feedingstyles must therefore be incorporatedinto the management of theseproblems.

The primary care provider needs anapproach that (1) is straight forwardand easy to use in the office setting,(2) integrates both organic andbehavioral perspectives, (3) accountsfor the wide spectrum of severity thatboth the child and feeder display,and (4) incorporates the impact ofparenting and feeding styles. Thisarticle describes a comprehensiveclassification that recognizes theabove issues and details a systematicscreening and management sequencethat allows the pediatrician todistinguish the key characteristicsof each feeding difficulty and thenprovide appropriate management.Although our focus is on thosechildren who resist oral feeding, thepractitioner should keep in mind thatwell-nourished, and even obesechildren, can have feeding difficulties.Pediatricians should be aware thatfeeding difficulties often emergeduring a child’s feeding transitions

(moving from breast to bottle or cup,when complementary foods areintroduced, or when self-feedingbegins)16–18 and guidance duringthese developmental phases isparticularly helpful.

NOMENCLATURE

An agreed-upon nomenclature isfundamental for any classification.The terms below, frequently used inthe literature without uniformity, areused in this article as follows:

Neophobia: Defined as “the rejectionof foods that are novel or unknownto the child.” Such rejection is seenin all omnivores and resolves withrepeated exposures.19

Picky eating8,19,20: A moniker that hasinconsistent definitions and mean-ings in different countries. Variouscriteria for picky eating are used bydifferent authors and in some cul-tures include “fussy” children withpoor appetite.2,21 Others view it asa mild form of more overt sensorydisturbances.12 It generally con-notes a mild or transient problem.Although it is not considereda “medical condition,” it requiresthe attention of the primary careprovider.

Feeding disorder8,20,22: A term con-noting a severe problem thatresults in substantial organic, nu-tritional, or emotional con-sequences. It equates to avoidant/restrictive food intake disorder di-agnoses in the DSM-V and the

International Statistical Classifica-tion of Diseases and Related HealthProblems, 10th Revision.

Feeding difficulty4: A useful umbrellaterm that simply suggests there isa feeding problem of some sort. Inessence, if the mother says there’sa problem, there is a problem.

IDENTIFICATION OF FEEDINGDIFFICULTIES

Our approach to identifying andmanaging feeding difficulties isillustrated by the algorithm shown inFig 2. If a parent voices concern abouta child’s feeding, that is sufficient torequire constructive resolution of theissue by the pediatrician. Additionalfeatures that may indicatea dysfunctional feeding interactionare listed in Table 1. When it isapparent that a potential feedingdifficulty exists, a complete historyand physical examination, includingcarefully done anthropometrics anda brief dietary assessment, arenecessary with special attention toserious red flags, defined as medicaland behavioral symptoms and signsthat require prompt attention and inmany instances referral for in-depthinvestigation/specialized treatment.

Organic Red Flags

Probably the most critical areindications of dysphagia andaspiration (Table 1). In the nonverbalchild, dysphagia and odynophagiamay present with food refusal.Features that suggest incoordinateswallowing may be overt(eg, coughing or choking). Aspirationcan be “silent” or more subtle(eg, wheezing). Evaluation of dysphagiarequires identifying which phase ofdeglutition (oral, pharyngeal, oresophageal) is disorganized23 and isbest handled by oral motorspecialists. Although generally lessurgent, growth failure, diarrhea, andvomiting also need resolution. Theynecessitate consideration of the fullrange of causes, which might requirehelp from a pediatricgastroenterologist. Be aware that

FIGURE 1Pyramidal representation of young children’s feeding behaviors.

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failure to thrive is in many societiesmore often a feature of behavioralproblems than of organic disease.Virtually every child suspected oforganic disease might benefit froma basic laboratory evaluation(eg, a complete blood count, metabolicpanel, sedimentation rate, orC-reactive protein and urine analysis).Screening for infections andconditions such as celiac disease hasdiffering regional imperatives.24

Behavioral Red Flags

Whether or not organic issues areidentified, behavioral red flags shouldbe sought because they may coexist.The behavioral red flags help selectthose children who will need moreintensive and prompt support andare most likely to benefit fromintervention by experts in behaviormodification (Table 1).25 They alsoaddressed the parents’ feeding style,

noting that when it is forceful ormechanistic (independent of thechild’s positive or negative feedback)feeding difficulties are likely. Complexproblems with both organic andbehavioral red flags will benefit fromearly referral to centers that havemultidisciplinary feeding teams,when available. Milder cases improvewith the services of a pediatricnutritionist.

CLASSIFICATION AND MANAGEMENT OFTHE CHILD’S FEEDING DIFFICULTY

Our conceptualization of feedingdifficulties is represented bya pyramid (Fig 1). Of the ∼25% ofchildren identified by parents to havefeeding difficulties, only an estimated1% to 5% at the apex meet criteriafor a feeding disorder.26,27 The other∼20% of children are representedfurther down the pyramid.28 In this

latter group, differentiating “normal”children with concerned parents fromchildren with mild, but recognizableand treatable conditions ischallenging, but necessary.

Our criteria for a practical, systematicclassification of feeding difficultiesare shown in Table 2. We classifychildren based on the parents’expressed concerns about theirchild’s feeding/eating behavior, whichfall into 3 principal categories: thosenot eating enough (limited appetite);those eating an inadequate varietyof foods (selective intake); and thoseafraid to eat (fear of feeding). Eachcategory has subcategories toacknowledge that such concerns maybe a misperception on the part of theparents or primarily behavioral ororganic, both with a spectrum rangingfrom mild to severe (Fig 2). Becausefeeding is a transaction influencedby both the child’s behavior and theparents’ feeding technique, we alsoinclude the 4 fundamental feeding

FIGURE 2An approach to identifying and managing feeding difficulties.

TABLE 1 Presenting Features of FeedingDifficulties

Suggestive Symptoms/Signsa,b,c

Prolonged mealtimesFood refusal lasting ,1 moDisruptive and stressful mealtimesLack of appropriate independent feedingNocturnal eating in toddlerDistraction to increase intakeProlonged breast or bottle-feedingFailure to advance textures

Organic Red Flagsa

DysphagiaAspirationApparent pain with feedingVomiting and diarrheaDevelopmental delayChronic cardio-respiratory symptomsGrowth failure (failure to thrive)

Behavioral Red Flagsc

Food fixation (selective, extreme dietarylimitations)

Noxious (forceful and/or persecutory) feedingAbrupt cessation of feeding after a trigger eventAnticipatory gaggingFailure to thrive

Red flags: signs/symptoms that require prompt attentionand in many instances referral for in depth investigationor specialized treatment.a Adapted from Kerzner.14b Adapted from Arvedson.23c Adapted from Levine et al.25

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styles that have the potential topositively or negatively affect everyfeeding problem.

THE CHILD’S FEEDING DIFFICULTY

The following section describes the3 fundamental feeding difficulties ina way that facilitates categorizationand assessment of severity so as toselect appropriate intervention.Implicit in the discussion is the ideathat children may exhibit more than1 feeding problem and the necessaryinterventions will then need to beprioritized.

Children With Limited Appetite

These children range from those whoare eating appropriately, but appearto eat too little (misperception), tothose with overt organic disease.

Misperceived

The most important characteristic ofmisperceived poor appetite isexcessive parental concern despitenormal growth. Parents commonlyperceive genetically small childrenwith correspondingly “small”appetites as poor eaters. Saarilehtoet al4 drew attention to thispossibility in a study of over 400children in which 30% weredescribed as poor eaters by theirparents. The children were somewhatsmaller than children in the controlgroup. However, intake relative tobody size was equivalent to normaleaters and appropriate to meet

nutrient needs. Parents fail toappreciate that growth rate slowstoward the end of the first year andinto the second with a concomitantdecrease in appetite. Misperceptioncan be the basis of a feeding difficultyif anxious parents adoptinappropriate feeding practices.

The Energetic, Active Child With LimitedAppetite

These children are repeatedly alludedto as nonorganic failure to thrive29,30

and nutritional growthretardation.31,32 Chatoor et al12,33

characterized them in detail and referto them as having “infantile anorexia.”These problems develop during thetransition to self-feeding;characteristically, these children areactive, energetic, curious, and far moreinterested in playing and talking thaneating. They refuse to remain seatedduring meals, eat small amounts, andfrequently fail to gain weight. There isno underlying organic explanation.A hallmark is conflict between parentand child, which if unresolved mayhinder the child’s ability to reach hisor her optimal cognitive potential.34

This reflects conflict in the homeenvironment, rather than low nutrientintake.35

The Apathetic, Withdrawn Child

These children are inactive,disinterested both in eating and theirenvironment, and communicatepoorly with their caregivers.36 Theymay appear undemanding37 andoften fail to make eye contact, babble,or talk. They and their caregiversappear depressed and often interactpoorly. Malnutrition is evident inthese children. Malnutrition itselfmay be a cause of depression andanorexia, creating a vicious cycle inwhich anorexia and poor nutritionexacerbate each other.

Organic Disease

In our approach to identifying thesechildren, we employ Burklow et al’s38

modification of Rudolph and Link’s9

classification to prompt consideration

of the more relevant conditions:structural, gastrointestinal,cardiorespiratory, neural, andmetabolic. A history and physicalexamination identify a significantpercentage of these children, buta high degree of suspicion forconditions with subtle presentationsis important (eg, food allergy and, insome regions, celiac disease).Conditions causing pain in responseto feeding (eg, esophagitis, gastritis,more subtle motility disorders, andeven constipation) are relevant.Gastroesophageal reflux isa consideration, but is infrequentlythe root of the problem,39 whereaseosinophilic esophagitis is emergingas a more prominent cause.40

Management of Limited Appetite

Treatment generally focuses onemphasizing the contrast betweenhunger and satiety. In the case ofmisperception, parents must beencouraged to accept the child’s owninterpretation of hunger and satiety.This requires persuading them thatthe child is growing normally bydemonstrating a normal growthpattern, explaining growth potential(using midparental heightcalculations41) and reviewing basicfeeding guidelines (Table 3).

The energetic child with limitedappetite needs help to recognize andrespond appropriately to hunger andsatiety. A feeding schedule thatencourages hunger is essential:a maximum of 5 meals (including

TABLE 2 Criteria for an “Ideal” Classificationof Feeding Difficulties

Systematically categorizes• behavioral issues• organic conditions• caregiver feeding styles

Separates misperceived, mild, and severeconditions

Conditions are• readily recognized• identified by familiar and accurateterminology

• logically related to each other• manageable in number

Specific treatment options are available for eachcondition

TABLE 3 Feeding Guidelines for All Children

Avoid distractions during mealtimes (television,cell phones, etc)

Maintain a pleasant neutral attitude throughoutmeal

Feed to encourage appetite• limit meal duration (20–30 min)• 4–6 meals/snacks a day with only water inbetween

Serve age-appropriate foodsSystematically introduce new foods (up to 8–15times)

Encourage self-feedingTolerate age appropriate mess

Adapted from Kerzner.14


snacks) per day with nothing butwater in between. Parents mustmodel healthy eating, adhere to thefeeding schedule, and set limits formealtime behavior, includingappropriate discipline. A mealtime“time-out” is often effective; parentsoffer the child attention in responseto positive eating behavior, butwithdraw attention by turning awaywhen the behavior is unacceptable.42

Growth failure associated with poorappetite often necessitates enrichingthe diet calorically including theaddition of nutritional supplements.

Providing adequate nutrition andsupportive interaction with anexperienced feeder is sufficient toimprove the apathetic child withlimited appetite. This may beachieved through early childhoodintervention programs or childprotection services; sometimes thisnecessitates hospitalization.

With organic disease, the medicalcondition influencing appetite must beaddressed and, if possible, resolved.Management is often complexrequiring alternate feeding routes(eg, enteral tube or intravenous feeding,which further suppress appetite).43,44

Children With Selectivity

Children who are considered to beselective range from those who areeating appropriately for their stage ofdevelopment (misperception) tosensory-related aversions to organicdisease.

Misperception

Neophobia is frequently misperceivedby parents as inappropriateselectivity. However, it is a normalbehavior that begins at the end of thefirst year of life, peaks between 18 to24 months and eventually resolves.Most children accept new foods,especially bitter vegetables, only afterrepeated exposures.19,45

Mild Selectivity

Mild selectivity includes a largeamorphous group of children, often

referred to as “picky eaters.” Thesechildren consume fewer foods thanaverage. Wright et al3 found that astoddlers they tried the same numberof foods as “nonproblem” eaters, butliked far fewer of them. Dovey et al19

noted that unlike neophobia, repeatedexposure to rejected foods tends notto result in acceptance by pickyeaters. These children typically growand develop normally and haveadequate energy and nutrientintakes.1,2

The major concern for them is nottheir nutrition,1,3,46 but familydiscord centered around coercivefeeding and subsequent behavioralconsequences. Chatoor et al34

reported that conflict around feedingresulted in a lower Bayley MentalDevelopmental Index independent ofthe child’s nutritional status. Ina study of children defined by theirparents as picky, Jacobi et al2 showeda higher incidence of subsequentbehavioral problems, includinganxiety, depression, aggression, anddelinquency. The problem may wellbe bidirectional: poor behaviorprompting coercive and indulgentfeeding practices, which in turnaggravate the behavior and mayresult in long-term problems.

Highly Selective

Here the consequences are severeenough to consider it a feedingdisorder. These children limit theirdiet to ,10 to 15 foods.47 Chatoor12

refers to these children as having“sensory food aversions”: a refusal toeat whole categories of foods relatedto their taste, texture, smell,temperature, and/or appearance. Thisproblem can interrupt developmentof normal oral motor skills. Some ofthese children may have additionalsensory manifestations, includingadverse responses to loud noises,bright lights, and textures on skin.Autism is an extreme example. Up to90% of autistic children have feedingproblems, the vast majority of whomare selective.48 In our experience,feeding difficulties have been the

presenting issue in some autisticchildren and should be consideredwhen there are questionable socialinteractions.

Organic

Selective eating may be theconsequence of medical conditionsand is often seen in children withdevelopmental delay due to anoxia,chromosomal, mitochondrial, andinexplicable causes of neurologicdamage.49,50 Selectivity may berelated to hypersensitive orhyposensitive responses to thesensory properties of food and/ordelayed development of oral motorskills.51,52 Children with organicselectivity due to motor disorderstend to accept objects placed in theirmouths, but have difficulty with alltextures, both liquid and solid; thehighly selective child due to sensoryprocessing deficits gags inanticipation of objects touching theirmouth and then rejects only certaintextures, mainly solid foods.49

Management of Selectivity

With misperception, educatingparents to have reasonableexpectations and counseling them toconsistently and repeatedly exposechildren to new foods is needed.Foods must often be offered 8 to15 times without pressure to achieveacceptance.1 In the mildly selectivechild, other simple techniques may beneeded, such as “hiding” pureedvegetables in sauces, using “dips” toenhance flavor, modeling eating,giving foods appealing names,involving children in foodpreparation, and presenting it inattractive designs.53–56 In contrast,the highly selective child frequentlyrequires a more intense andsystematic approach to increasingvariety. Behavioral therapists havedocumented the effectiveness ofa number of these methods(eg, offering a desired food contingenton the progressive acceptance of lessdesired foods). Often, “food chaining,”the replacement of 1 food with


a similar one, is effective.47 In moresevere cases, “fading” and “shaping”(gradually altering the taste, color,texture, and exposure to the food)are coupled with positivereinforcement.57–60 In children withdelayed oral motor development, theoral motor therapist may also havea critical role.

Children with organic disease andthose with autism are frequentlyresistant to treatment. They may benutritionally vulnerable with moreextreme eating behaviors.48,50,61,62

Treatment therefore is best managedby specialists and includes hungerinducement coupled with nutritionalsupplementation and sensoryintegration approaches (eg, tactileexposure on skin, and then oral motordesensitization, and shaping andfading).42,63 In cases ofhyposensitivity, strongly flavoredfoods and beverages may be betteraccepted and worth trying. Providingheightened oral sensation with spicyfoods may improve incoordinateswallowing in some.64,65

Children With Fear of Feeding

Any severely aversive feeding-relatedexperience may cause fear of feeding.Such experience might be ongoing orconditioned by past events, justifyingChatoor’s12 term “post traumatic.”Three distinct patterns arediscernible: fear of feeding aftera single event, notably choking; fearof feeding in the young child who hasbeen subjected to painful orunpleasant oral procedures; and fearof feeding in children who are tube-fed or have missed feedingmilestones, lack experience, and/orfeel threatened when food isintroduced orally.

Misperception

Some infants with excessive cryingbehavior are misperceived to behungry and fearful of feeding as theyresist the bottle or breast. Most ofthem are crying for other reasons,possibly an inability to calmthemselves, so called disordered state

regulation or colic. In almost all cases,they are receiving adequate amountsof food.66

Fear of Feeding in the Infant

Painful feeding is surmised in anapparently hungry infant who eagerlystarts feeding and then after a fewswallows, rears off the nipple inapparent pain, but will eatcontentedly when sleepy. In time,overt fear of feeding emerges andmerely presenting the breast orbottle, approaching the feedingenvironment or high chair inducesresistance and crying in thesechildren.

Fear of Feeding in the Older Child

This is seen in the child who chokes,gags, or vomits on food and thenceases to eat, most often solids. Thishas been termed functionaldysphagia, choking phobia, orphagophobia.12,67,68 Sometimes it isthe result of a parent forcefullyfeeding the child,12 and frequently itcan be severe enough to result inweight loss.

Organic

Any organic condition resulting insignificant pain with feeding has thepotential to cause a fear of feeding.Tube-feeding dependent children area prominent example, as isodynophagia due to esophagitis. Moresubtle causes like gastroparesis anddisordered small bowel motility arenow associated with feedingproblems.69,70

Management of Fear of Feeding

The main goal is to reduce anxietyassociated with feeding/eating. Withmisperception of the crying infant,the principal treatment isreassurance, a systematic appraisaland treatment of the causes ofdiscomfort in the child as well as thealleviation of the feeder’s anxiety.When there is actual fear of feeding inan infant, pediatricians must identifyand resolve the cause of pain anddecondition the infant’s fear. Feeding

can initially be done when the infantis starting to fall asleep, allowingestablishment of a sleep-feedingschedule to provide adequatenutrition.12 The feeding environmentand equipment may need to be alteredto improve acceptance of foods. Insome children, earlier transition to thecup or solid foods is helpful.

Reassurance is the key to recoverywith fear of feeding in the older child.If initial counseling fails, then the useof anxiolytic medication,71 positivereinforcement with rewards,cognitive behavioral therapy, orpsychiatric referral may berequired.67,68 In addition, liquid oralsupplements are often necessary tosupport the child nutritionally astextures are gradually advanced. Inselected cases, contrast studies orendoscopy are warranted to excludeunderlying pathology.

With organic disease, resolution mayrequire the cause to be identified andtreated. Often the original insult mayhave resolved and visceralhyperalgesia and/or anticipatoryanxiety may persist. In enterally fedchildren, severe appetite suppressioncomplicates the issue.44 Theseproblems require more complextreatment, such as hungerinducement,42 oral motordesensitization, and a gradualnonthreatening exposure to food,58

and in almost all instances should bereferred to specialists competent inthese approaches. Specializedtechniques proven to be effective bybehavioral therapists includedistraction to avoid gagging,49 use ofa chaser to overcome “pocketing”(food retained in the cheeks),72

following the mouth of the child withthe spoon, or guiding the childphysically to accept food.73 Recently,medications to suppress visceralhyperalgesia have helped establishnormal feeding in tube-fed children.74

THE CAREGIVER’S FEEDING STYLE

Parents’ actions alter a child’s eatingbehavior.75,76 Incorporating the


influence of caregiver feeding stylesis therefore an essential part ofmanagement. Parental feedingpractices are based on 4 well-described parenting and feedingstyles.77,78 These styles areinfluenced by cultural norms,parental concern, and childcharacteristics.79–81 We refer to thepreferred style as responsive. Theremaining 3 (controlling, indulgent,and neglectful) generally havenegative consequences.

Responsive feeders follow theconcept of a division of responsibility;the parent determines where, when,and what the child is fed; the childdetermines how much to eat.82

Responsive feeders guide the child’seating instead of controlling it.They set limits, model appropriateeating, talk positively about food,and respond to the child’s feedingsignals.76 A responsive feederarranges the schedule to induceappetite or by rewarding theachievement of goals, but does notresort to unpleasant coercivetechniques. This feeding style hasbeen reported to result in childreneating more fruits, vegetables, anddairy products and less “junk food,”resulting in a lower risk of becomingoverweight.76,83–85

Controlling feeders are common;approximately half of all mothers anda greater proportion of fathersemploy these methods.86 Thesecaregivers ignore the child’s hungersignals and may use force,punishment, or inappropriaterewards to coerce the child to eat.78

These practices initially appeareffective, but becomecounterproductive, resulting in pooradjustment of energy intake,consumption of fewer fruits andvegetables, and a greater risk ofunder- or overweight.76,83–85

Indulgent feeders cater to the child.They tend to feed the child wheneverand whatever the child demands,often preparing special or multiplefoods. This feeder feels it is

imperative to meet the child’s everyneed, but by doing so ignores thatchild’s hunger signals and sets nolimits.78 Consequences of thesefeeding practices include lowerconsumption of appropriate foods(eg, milk) that contain importantnutrients and a disproportionateconsumption of items high in fat,increasing the risk of becomingoverweight.76,83–85

Neglectful feeders abandon theresponsibility of feeding the child andmay fail to offer food or set limits.When feeding their infants, they mayavoid eye contact and appeardetached. Older toddlers are often leftto fend for themselves. Neglectfulparents ignore both the child’shunger signals and other emotionaland physical needs. They may haveemotional issues, developmentaldisabilities, depression, or otherconditions that make it difficult forthem to feed their childeffectively.78,87 Neglect may be severeenough to result in failure to thrive. Inat least 1 study of older children,a greater risk of obesity wasassociated with these feedingpractices.88

Pediatricians can readily differentiatefeeding styles by asking 3 questions:How anxious are you about yourchild’s eating? How would youdescribe what happens duringmealtime? What do you do when yourchild won’t eat? Responses fromneglectful parents will be vague;controlling parents will describepressuring/forcing their child to eat.Indulgent parents will describepleading, begging, and preparingspecial foods. Another way to assessmealtime interactions is to have theparents videotape part of it,something easily accomplished withsmart phones.

General feeding guidelines (Table 3),which help caregivers become moreresponsive feeders and preventcounterproductive feeding practices,should be part of anticipatoryguidance for all children.

Pediatricians should adjust theirinstructions based on the parent’sfeeding style. Controlling parentsshould be guided to offer foods ina noncoercive way, rather than on thespecific amounts or types of foods tobe given. Advice to indulgent orneglectful parents should be morestructured and precise.

Time is at a premium during clinicvisits; we have providedSupplemental Material of resources:books, articles, and Web sites thatprovide guidelines for anticipatoryguidance, appropriate meal timeinteractions, nutrition ideas, andother tools.

DISCUSSION

Parents deserve guidelines to preventand/or resolve feeding difficulties,whether mild or severe. Health careprofessionals, therefore, needa systematic approach to assessingand managing feeding difficulties inthe primary care setting, whereparents first seek help. The currentclassification reduces the diagnosticgroups to 3, determined by parents’presenting concerns, integrates bothorganic and behavioral subcategoriesin each group, and incorporatesfeeding styles into the evaluation. Itshould allow the practitioner to tailortherapy specifically to the problem,addressing both the child’s behaviorand the parents’ feeding practices.Mild conditions should be resolvedwithin the confines of the office.Severe feeding difficulties or feedingdisorders may require specialists toresolve the problem. Properclassification facilitates more targetedreferrals to the appropriate individualspecialists or multidisciplinary teams.

Although the proposed classificationmakes treatment more manageablefor pediatricians, some limitationsremain. The 3 categories of feedingdifficulties are supported by theliterature. However, the subgroupswithin each category, although helpfulin illuminating subtle differencesimportant in management, fall on


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a continuum without well-defineddivisions. Also, children may havemore than 1 feeding difficulty, andmore than 1 medical condition, all ofwhich complicate management.

The caregiver leaving thepediatrician’s office should have anunderstanding of whether the feedingproblem is one of limited appetite,

selectivity, fear of feeding, ora combination of them. Specific

guidelines for mealtimes, feeding

practices, and limit setting should be

clear and based on the parent’s

feeding style. Caregivers should alsohave the confidence to carry out theappropriate intervention, understandthe risks of coercive feeding, and have

reasonable expectations of goals andoutcomes.

ACKNOWLEDGMENTS

We thank Drs Paul E. Hyman andRobert L. McDowell, Jr for helpfulcomments on an earlier draft of thearticle.

FINANCIAL DISCLOSURE: All authors have received honoraria from Abbott Laboratories for speaking at conferences on the diagnosis and management of feeding

disorders in young children. Drs Kerzner, MacLean, and Chatoor are currently carrying out a clinical study funded by Abbott Laboratories to assess the ability of

pediatricians to correctly classify young children with feeding problems in the office setting. Dr MacLean retired from Abbott Laboratories 11 years ago; he owns no

stock in Abbott Laboratories. Employees of Abbott Laboratories had no input into the ideas expressed in this article, nor the writing of the article.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: All authors have received honoraria from Abbott Laboratories for speaking at conferences on the diagnosis and management of

feeding disorders in young children. Drs Kerzner, MacLean, and Chatoor are currently carrying out a clinical study funded by Abbott Laboratories to assess the

ability of pediatricians to correctly classify young children with feeding problems in the office setting. Dr MacLean retired from Abbott Laboratories 11 years ago; he

owns no stock in Abbott Laboratories.

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