Written By: Natalie Drury; SLU Dietetic Intern
Imagine you’re walking into your favorite pizza place just as a hot, cheesy pizza that’s fresh out of the oven wafts by you. You breathe in the delicious aroma and are overcome by the scent of baked dough and melted cheese when your mouth suddenly starts salivating. You sit down at the table and have no choice but to order that pizza and eat it immediately. A few minutes later, your pizza is delivered and you dig in; there’s no time for plates or silverware. You reach out for that first piece, pick up the pizza, and promptly take a big bite out of it with your front teeth. It’s been a long day, so you’re really savoring this pizza and chewing it thoroughly with your molars until it becomes a mushy pizza ball, also called a bolus. Your tongue moves that pizza bolus to the back of your throat then your epiglottis, essentially a flap, flops over the top of your windpipe so that your pizza bolus can slide down your esophagus without making you choke or cough. Now that the pizza bolus is in your esophagus, the muscles in your esophagus squeeze and widen in a coordinated pattern so that the pizza bolus moves effortlessly into your stomach. You lift your hand up to your mouth to take another delicious bite of your pizza, when the pizza bolus hits the lining of your stomach and reminds you of a small detail you forgot when ordering your pizza… you can’t eat dairy. Your stomach starts to cramp and turn and I’ll let your imagination fill in the gaps for what happens next. This is just one example of one problem someone might have when eating, but eating is a complex process that is often taken for granted. Like in the pizza analogy, this complex process of eating begins before food is even in our mouths. It typically starts with our senses (sight, touch, taste, smell) and is followed by the coordination of 13 muscles and 6 cranial nerves that we need to chew and swallow our food (What is Pediatric Feeding Disorder, 2022). If even just one of these processes aren’t functioning properly, it can become very difficult to eat, let alone enjoy eating. If you have a “picky eater” then this is something that’s probably very familiar and it’s a common occurrence for many children; however, sometimes picky eating isn’t just picky eating. In this post we will explore when picky eating is more than just a sticky situation and what we can do about it.
As I mentioned before, picky eating is common in children and while it can cause tension among family members, it’s not a medically diagnosable condition unless it meets the criteria for a feeding disorder such as Pediatric Feeding Disorder (PFD) or Avoidant Restrictive Food Intake Disorder (ARFID), which are the focus of this post. PFD and ARFID are similar in that they’re relatively new diagnoses created to identify feeding disorders, but their origin and diagnostic criteria are quite different. ARFID was established as a mental health diagnosis in 2013 when it was included in the Diagnostic and Statistical Manual of Mental Disorders V, also called the DSM V (Avoidant Restrictive Food Intake Disorder, 2018). Pediatric Feeding Disorder (PFD) was established shortly after ARFID in 2015 by Feeding Matters founder Shannon Goldwater and was officially given an international classification of disease (ICD) in 2020, which means it’s easier for healthcare professionals to monitor and report PFD (The History of PFD, 2021). The table below should paint a better picture of the differences between these two feeding disorders.
Since these diagnoses are closely related, it is generally recommended that children diagnosed with ARFID be further assessed in all 4 domains of PFD (medical, nutritional, feeding skill, and psychosocial) to ensure other factors such as skill or medical dysfunction are not causing their feeding problem (ARFID and PFD 2022). With that in mind, we will focus on PFD moving forward.
Now that you know what feeding disorders are and how they’re diagnosed, you’re probably wondering how in the world that information will help you decide if your “picky eater” needs to be assessed for PFD. First, here are some signs and symptoms to look for that frequently occur in children with pediatric feeding disorder:
If a child or family is experiencing any of these, it’s recommended to schedule a visit with your pediatrician and bring these issues to their attention for evaluation of a PFD. If you prefer something more clear, this Feeding Matters questionnaire is a great tool that will guide you through assessing a child’s eating behaviors and provide you with a method for discussing any concerns with their pediatrician.
Once a pediatrician determines that a child has PFD, they are responsible for referring them to other specialists for further care and the great news is that there is a long list of specialists who are trained to provide treatment for PFDs. Here’s a short list of the specialists they might refer a child with PFD to:
Registered Dietitian Nutritionists (RDN)
These are healthcare professionals that are trained to improve and support a child’s growth and nutritional needs. These healthcare professionals can identify malnutrition, nutritional deficiencies, and assess intake to determine what skills, tools, or nutritional supplements will best support a child with PFD.
Speech Language Pathologists (SLP)
These are healthcare professionals who are trained to treat a variety of communication and swallowing disorders. They can help people to improve their speech sounds, language skills, and feeding and swallowing skills to name a few.
Occupational therapists (OT)
These are healthcare professionals trained to help people improve or gain skills needed for activities of daily living (ADL) such as brushing their teeth, feeding, eating, and swallowing to name a few. These professionals provide therapy that can improve fine motor skills, recover from injuries or illness, and provide adaptations or recommendations specific to each patient to make ADLs easier.
Psychologist
These are typically counselors with a Master’s or PhD in psychology who are trained to diagnose and treat mental disorders that could contribute to PFD.
Gastroenterologist
These are medical doctors that can assess a child with PFD for a medical condition in their digestive system that could contribute to PFD and provide treatment recommendations.
Allergist or immunologist
These are medical doctors that can assess a child with PFD for a food allergy, food intolerance, or respiratory allergy that could contribute to their PFD and provide treatment recommendations.
(Pediatric Feeding Team Specialists)
While this list might seem long already, this is just an abbreviated list of the most commonly used specialists for children with PFD. This PDF provides a more expansive list with descriptions of each profession. If you’re feeling overwhelmed by the amount of options, please know that a child with PFD most likely will not need to see all of the specialists listed and your primary care physician will be responsible for referring you to the right specialist. However, I wanted to share all of this information because knowledge is power. The more you know, the better you can advocate for yourself and the child being treated. If something seems off or you don’t feel things are going the right way, I encourage you to speak up and ask questions! If you’re like me and you like to have clear instructions on what to ask, Feeding Matters also put together this FAQ sheet with example questions to ask each healthcare professional you see.
If you’ve made it to this part of my soap box on feeding disorders, I would assume you’re either very passionate about them or you have a child in your life who you’re worried might have one; either way, I encourage you to remember at least these two things from this post. First, PFD does not have to be a life sentence to unpleasant food experiences; there are people and resources to treat and/or manage PFD. Second, although it’s a relatively new diagnosis, the laundry list of specialists I listed above chose their given career to help people improve their quality of life, which is exactly what they will do for you or the child in your life, and if you feel they aren’t, please remember to be brave and advocate for yourself and/or the child in your life.
