Just picky, or something else?

Most children go through a picky phase. Depending on how it is measured, studies find picky eating in anywhere from about 6 to 50 percent of children, and for most it eases with time and low-pressure exposure (Taylor and Emmett, 2019).

But some children are not just being picky. Eating is hard for them, and they stick with the foods that feel safe. When eating is not age-appropriate and comes with medical, nutrition, feeding skill or emotional challenges, clinicians call it a pediatric feeding disorder (Goday et al., 2019). A national study estimated that more than 1 in 37 children under age 5 in the United States has one each year (Kovacic et al., 2021).

Not sure where your child falls? Start with our shorter guide, Picky eater or something more?, then use this page to explore the possible reasons.

• Reflux (GERD): arching, fussing or coughing during or after meals, spitting up, sour breath, refusing after a few bites.
• Eosinophilic esophagitis (EoE): an allergic condition of the food pipe. Children may chew a long time, drink a lot to wash food down, avoid meats and harder textures, or have food get stuck.
• Constipation: a full, uncomfortable tummy quietly lowers appetite. Hard or painful stools, fewer than three a week or tummy aches are clues.
• Food allergy or intolerance: rashes, vomiting, diarrhea, tummy pain or refusing a specific food group, such as dairy.
• Slow stomach emptying: feeling full quickly, nausea, vomiting hours after eating.
• Celiac disease and other gut conditions: tummy pain, bloating, diarrhea, poor growth.
• A history of vomiting or retching: children remember discomfort and may avoid the foods or textures they connect with it.

• Enlarged tonsils or adenoids: big tonsils take up space in the throat, so chewy or dry foods can feel hard to swallow. Snoring and mouth breathing are clues.
• Nasal congestion and allergies: it is hard to chew with your mouth closed when you cannot breathe through your nose.
• Mouth breathing: changes tongue and lip posture at rest and while eating. See why mouth breathing matters.
• Sleep-disordered breathing: tired children have less energy and appetite for meals.
• Airway conditions in babies: such as a floppy voice box (laryngomalacia), noisy breathing or breathing fast, which make feeding tiring.

• Tethered oral tissues (tongue, lip or cheek ties): a restricted tongue may have trouble moving food to the teeth, clearing the cheeks and forming a ball of food to swallow. See tongue and lip ties 101.
• A high or narrow palate: food can get stuck in the roof of the mouth.
• Cleft lip or palate and other craniofacial differences: affect suction, chewing and nasal flow.
• Dental pain: cavities, teething, sore gums or a bite that does not line up can make chewing hurt.

• Weak or uncoordinated lips, cheeks, tongue or jaw: food falls out, pockets in the cheeks, or is swallowed whole.
• Chewing skill gaps: still munching up and down instead of grinding side to side, so meats, raw veggies and mixed textures feel unsafe.
• Low muscle tone: tires quickly, open mouth at rest, drooling.
• Delayed skills: still mainly eating purees or soft foods well past the first birthday.

• Aspiration: food or liquid going into the airway. Signs include coughing, choking, a wet or gurgly voice, watery eyes or frequent chest infections. Some children aspirate silently, with no cough at all.
• Swallowing weakness: food or liquid left in the throat after swallowing, needing several swallows per bite.
• Discoordination: trouble timing sucking, swallowing and breathing in babies, or chewing, swallowing and breathing in older children.
• A delayed swallow: food sits in the mouth or the swallow starts late, which is often worse with thin liquids.

When swallowing safety is in question, your therapist may recommend an instrumental study, such as a video swallow study (VFSS) or FEES.

• Over-responsive: strong reactions to texture, temperature, smell or mixed textures; gagging at the sight or smell of a food; wanting foods to be the same brand, shape or color.
• Under-responsive: overstuffing, pocketing food without noticing, or not feeling food on the lips and cheeks.
• Body regulation: children who are always on the go or easily overwhelmed may struggle to sit and eat.

• Prematurity and NICU stays: early tubes, oxygen and medical procedures can affect feeding skills and comfort around the mouth.
• Heart and lung conditions: eating takes energy, and children may tire before they are full.
• Neurological conditions: such as cerebral palsy or seizures, which can affect muscle control and swallowing.
• Genetic syndromes: such as Down syndrome, often with low tone and a smaller mouth and airway.
• Autism: sensory differences, a strong need for sameness and anxiety can narrow the food list.
• Developmental delays: feeding skills often follow overall motor development. See feeding milestones.

• Medicine side effects: some medicines lower appetite, cause nausea or constipation, or dry the mouth. Ask your pediatrician or pharmacist if a medicine could be playing a part, and never stop one on your own.
• Low iron and other nutrition gaps: can affect energy and appetite. Your pediatrician can check.
• Too much milk or juice: filling up on drinks leaves little room for food.
• Tube feeds: volumes and timing affect hunger. Changes belong to your medical team and dietitian.

• A scary eating experience: choking, gagging hard or vomiting can lead a child to avoid that food or texture, or many foods.
• Medical procedures around the face and mouth: suctioning, tubes or scopes can make the mouth feel like a place to protect.
• Anxiety and fear of new foods: some fear of new foods is normal, but intense fear that limits eating needs support.
• Avoidant/restrictive food intake disorder (ARFID): a diagnosis for eating that is very limited because of sensory sensitivity, fear of choking or vomiting, or low interest in food, when it affects growth, nutrition or daily life. It is diagnosed by a physician or psychologist.

• Pressure: bribes, "one more bite" and battles usually make eating harder, not easier.
• Grazing: snacks and drinks all day mean children rarely come to the table hungry.
• No routine: meals at different times and places each day.
• Screens and distractions: children may eat without noticing their food or their fullness, or refuse to eat without a screen.
• Seating: dangling feet and slouching make chewing and swallowing harder.
• A stressed feeding relationship: when meals feel like a fight for everyone, a fresh plan helps the whole family.

At NTX, we come to your home and watch a real meal, with your child's usual foods, cups and seating. We look at oral motor skills, chewing, swallowing, breathing, sensory responses and mealtime routines together, and we help you sort out which of these pieces is getting in the way. You leave with clear answers, a written plan and strategies you can start right away, and we coordinate with your pediatrician and specialists.

Learn more about in-home feeding therapy, oral motor therapy, tongue and lip tie therapy and tube feeding support, or book an evaluation.

Summaries above are written in plain language. Here are the sources:

1. Taylor CM, Emmett PM (2019). Picky eating in children: causes and consequences. Proceedings of the Nutrition Society 78(2):161-169. Read more
2. Goday PS, et al. (2019). Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework. J Pediatr Gastroenterol Nutr 68(1):124-129. Read more
3. Kovacic K, et al. (2021). Pediatric Feeding Disorder: A Nationwide Prevalence Study. Journal of Pediatrics 228:126-131. Read more