Does your child need feeding therapy? Is feeding therapy the right next step for an extreme picky eater?

As a pediatric nutritionist dietitian who has worked with picky eaters for 25 years, I’ve watched the feeding therapy industry evolve. Many children have entered my practice for picky eating after trying feeding therapy. Years ago, feeding therapy for toddlers and young children was a nascent niche. Extreme picky eating was more rare. Now that developmental disability in children has skyrocketed, resources for the picky eating or feeding disorders often seen with developmental delay can be had across the US, from hospital systems to sole proprietor occupational therapists who specialize in pediatric feeding disorders. Feeding therapy for children is a commitment that takes several weeks or months, and it can be very costly.

Some parents of picky eaters have expressed frustration to me that feeding therapy was a waste of time and money. Some have even found that this therapy was traumatizing for their children. Knowing if, when, and how to engage it is important. Not at all to diminish the important work and skills of occupational and physical therapists. They work hard at helping kids learn to chew, swallow, touch, and tolerate the act of eating – kids who are tube fed, kids who’ve never mastered chewing by age four or six years, kids who only drink but can’t eat, kids who gag and vomit to different food textures, kids who stop eating at the slightest interruption or sudden sound, kids who are in growth failure because they can’t eat. If your child has had a traumatic brain injury, or has any disability that impedes feeding, help from a knowledgeable occupational therapist is a game changer.

But if all systems are go except for the fact that your child is extremely picky, know this: There are important underlying triggers for picky eating and a strong gag reflex that can be repaired, before you spend thousands on sessions in which you sit behind a two way mirror and watch your child try to touch whipped cream, cheese crackers, and broccoli with peers, before the rigorous home sensory protocols before each meal (trampoline, Nuk massage, Wilbarger protocol), not to mention stringent food routines at the table.

For kids who go from infancy to preschool with a mysterious lack of progression for feeding skills, as a nutritionist, I screen for underlying physiological triggers that keep a child from being able to swallow, chew, and eat normally. Even for kids with physical disabilities and complex conditions who benefit from feeding therapy, footwork on these underlying interlopers can make eating work even better.

Before you go through costly, strenuous therapy that may inch your child slowly forward, but not quite produce the progress your child deserves to grow, thrive, and just plain enjoy food – investigate these problems. Fixing these may not only help you avoid feeding therapy, and can also help your child be healthier, because they will be able to digest and absorb food more comfortably.

Nutrition and digestive problems turn kids into picky eaters

Fix these, and appetites can abruptly improve. You may see changes in as fast three to four weeks, depending on your child’s condition at start, and your compliance with a nutrition and gut health care plan tailored to your child. Here we go:

1 – Fungal Dsybiosis: This is a circumstance where fungal microbes (yeast) are in an overgrowth mode in the large or small intestine. While we all normally harbor some fungal species, an imbalance in their favor is disruptive.. Usual features include bloating, hyperactivity, behavior changes with food, large firm stools, constipation, and cravings for starchy processed food or sweets. Proteins are often refused (meat, fish, chicken) as are fresh vegetables, fruits, or greens.  Processed breads, crackers, noodles, sweets, pizza, or dairy food are fiercely favored over other foods. Solution: Screen for fungal dysbiosis with stool or urine testing; ideally include Candida and Saccharomyces antibody testing too (blood tests). Give a protocol to drop the fungal burden and restore healthy gut bacteria balance.  This may mean using antifungal medications, strong herbal antifungals, probiotics, or prebiotic foods or supplements. This can resolve the intestinal fungal dysbiosis, and allow kids to feel more hungry, poop more regularly, and want new foods, usually in 2-4 weeks. Other nutrition measures may be needed, but this is a foundational piece that can relentlessly stall kids’ appetites.

2 – Bacterial Dysbiosis: Your child may have a bacterial imbalance in the stomach, upper small intestine, or colon. This can make eating very uncomfortable. The small intestine normally harbors little bacteria; when too much is there, kids can have a lot of trouble eating. This will continue until these background dysbiosis  infections are treated. This is called Small Intestine Bacterial Overgrowth (SIBO), and your doctor may need to prescribe antibiotics to treat it. Some herbal treatments work well also;  probiotics can make it worse while some are helpful, so work with a provider who knows how to manage SIBO. Kids with bacterial dysbiosis feel full quickly. They may act hungry but can never manage to eat enough to grow well or feel good. They may gag, or vomit violently, even to the point of shock (they go limp, become pale, you may have even rushed them to the ER where they needed IV fluids – this is FPIES) if they eat the wrong foods. Pressing children to eat with these circumstances is not likely to be successful; you are training them to over-ride legitimate cues for pain or discomfort. Solution: Talk with your GI doctor or pediatrician about possible SIBO. And, do functional stool testing such as GI MAP (one of the tests I use in my practice) to identify what microbes may be interfering. This test can give detail on what your child needs to balance bacteria in the digestive tract, so they can eat and digest food more normally.

3 – Reflux Medications: These drugs, which are not approved for use in children (with one exception), diminish digestion by reducing acid in the stomach. Great for an initial reprieve from what may (or may not) be a painful reflux, but bad longer term. The more stomach acid is reduced, the less your child is able to digest food, and the more food will sit in the stomach and – you guessed it – reflux up to the throat. Many kids in my practice end up on highest allowable doses of these drugs, but still have feeding problems with weak appetites and texture aversions. Reflux medicines also exacerbate fungal infections in the digestive tract, creating even more dysbiosis and difficulty with feeding and eliminating. Solution: Unless your child needs “mercy” dosing of a reflux medicine to ease pain, talk to your doctor about weaning off of it. For more help with that process, check this blog and contact me for more resources if need be.

4 – Weak Iron and Zinc Status: These minerals have a lot to do with what we feel like putting in our mouths. Even adults with poor iron or zinc status will do weird things like hang around, sniff, or even lick gas pumps, chew on paperclips, or refuse to eat vegetables. If your child is mouthing objects beyond early toddlerhood, or insists on eating non food items into school age years, it’s time to straighten this out. It could help normalize eating “behavior”. Solution: Have your pediatrician run labs for ferritin, serum iron, transferrin, iron binding capacity, and serum zinc. These should be solidly in the middle of the lab range – not near either end. If these labs come back looking a little weak, get guidance on supplementing these minerals. Iron and zinc won’t be well absorbed, by the way, if your child takes a reflux medicine – so this is another reason to get off that stuff. It reduces absorption of minerals and B vitamins. Not what your child’s developing brain needs. Measure lead as well: It can displace iron in the body and make children more prone to anemia.

5 – Opiates: Wait, WHAT? Yes, your kid might just be a little high on opiates all day long. Common signs: Do they wake up from 1 to 3 AM all silly or active? Are they constipated? Do they have a crazy voracious appetite and a big head (above 90th percentile)? Are they verbally delayed? Do they bang into stuff and never cry about it? Do they really, really seek proprioceptive input, to the point of endangering themselves? Are they hyper? Do they meltdown fiercely when hungry, or if you don’t hand over that favorite mac and cheese,  yogurt, or noodles and butter? Addictive, opiate-like neuropeptides can form from wheat, dairy, and soy protein in a leaky gut environment. This will make a child relentlessly, extremely, fiercely picky for wheat and dairy food (maybe a little soy too). In this scenario wheat and dairy proteins are weakly digested and absorbed as compounds that mimic opiates. This happens when digestion is weak and the gut is too permissive; that is, the intestinal wall lets bigger-than-it-should molecules across into circulation, something a healthy intestine won’t do. These opiate-like compounds have various names: Dietary peptides, polypeptides, casomorphin, gliadorphin, or exogenous opiates. These will cause a lot of problems, including stunted language development, social delay, even violent or aggressive behavior – and, extreme picky eating. Feeding therapy will go nowhere if your child is swimming in opiate like peptides from milk, yogurt, Pediasure, bread, pudding, crackers – any wheat or dairy food. It’s all your child will want to eat, and anything that looks or feels different will be a non-starter. Solution: Start with my e book on milk addicted kids. Check this blog post for more detail too. Your child may need a strict gluten, casein/dairy and soy free diet (the prime opiate offender foods).

Get your kids clear of these five physiological problems and you may be amazed at how swiftly they can leave feeding therapy behind. Ignore any one of them and it is going to be a longer haul. Check out my quick video recap, click here. Thank you for stopping by.