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Physical red flags that require further investigation:
  • Frequent ear infections
  • Recurrent pneumonia or reactive airway
  • Low intake or unusually prolonged feeding times
  • Frequent gagging or vomiting
  • Vomiting from the nose
  • Swallowing food whole
Oral-motor, anatomic, structural, or functional anomalies can compromise a child's ability to chew, manipulate, and swallow food comfortably and safely. These red flags indicate the need for further evaluation, including possible referral to an orolaryngologist, gastroenterologist, and/or qualified speech-language pathologist specializing in feeding. A gastroenterology specialist may be an appropriate referral for swallow study and functional considerations.

What increases a child’s risk for feeding challenges?
  • Premature birth
  • Developmental delay
  • A history of surgeries or intubation
  • Sensory processing challenges or autism spectrum diagnosis
  • Gastroesophageal reflux
  • Maternal depression or anxiety
  • Cardiorespiratory problems

Picky Eating: Listening for Clues

From the child's point of view, some clues can help guide a differential diagnosis.
  • "It hurts"—pain may be an indication of a medical or allergy-related problem, such as eosinophilic esophagitis, reflux, or chronic constipation, which can dampen appetite.
  • "I can't"—suggests an oral-motor challenge including anatomic findings (cleft palate or tongue tie). These are associated with developmental delays and cardiorespiratory issues that result in fatigue before the child can eat to fullness (breathing comes before eating).
  • "I don't like that!"—suggests sensory reactions to how a food smells, tastes, or feels; more common in children on the autism spectrum or with sensory challenges. Children who are "supertasters" (roughly 25% of the population) may experience bitter tastes as very unpleasant.
  • "I don't want to"—an often overlooked but common factor is the child's temperament. Some children are fiercely independent and want to do things themselves! A common clinical scenario is to see these temperament traits combined with sensory issues or with sensitivities, perhaps past painful associations or pressured feeding. Understanding temperament is a critical piece to helping parents not make matters worse. These children tend to be exquisitely reactive to any pressure or bribes to eat.
  • "I'm scared"—past negative experiences (eg, a choking episode, witnessing a choking episode, pain, or forced feeding) can increase resistance.
Research suggests that regardless of initial challenges, the clinical picture for many children with extreme picky eating is similar. Many feeding aversions with no apparent anatomic or medical cause are a result of a child's desire to stay comfortable and safe and maintain bodily autonomy. Furthermore, once medical issues or delays are resolved, anxiety and aversions can persist, particularly if there has been coercive feeding.

Parent factors must also be considered. Anything that impairs the parent's ability to be sensitive and responsive can affect feeding. Addiction, poor attachment, depression, anxiety, and active parental eating disorders have been linked with poor feeding and an increased incidence of nonorganic failure to thrive in children.

Slow but steady growth isn't necessarily problematic. A child who appears healthy in all other measures but is smaller than average is simply reflecting his or her own unique growth pattern, parents should avoid counterproductive feeding practices based on physical appearance. Research is increasingly clear: Trying to get children to eat more or different foods, rather than letting them lead the way, tends to backfire.

Source: http://www.medscape.com/viewarticle/856267
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