Current Trends in Identification and Management of Feeding Difficulties in Children

This report is based on medical evidence presented at sanctioned medical congress, from peer reviewed literature or opinion provided by a qualified healthcare practitioner. The consumption of the information contained within this report is intended for qualified Canadian healthcare practitioners only.

HEALTH ODYSSEY - Third International Summit on the Identification and Management of Children with Feeding Difficulties

Miami, Florida / April 30-May 1, 2011

Many children with feeding difficulties may actually fall in the normal range of eating behaviours; however, the same presentation may also imply significant medical problems. Causes of feeding difficulties range from picky eating to autism and presentations may be difficult to diagnose.

Prevalence of feeding difficulties is very high worldwide: 50% to 60% of parents report a perceived feeding difficulty in their child (Manikam R, Perman J. J Clin Gastroenterol 2000;30:34-6, Nicholls D, Bryant-Waugh R. Child Adolesc Psychiatric Clin N Am 2008;18:17-30, Satter E. J Pediatr 1990;117:S181-S189).

According to Dr. Benny Kerzner, Professor of Pediatrics, George Washington University, and Children’s National Medical Center, Washington, DC, “Parents worldwide are very concerned about the issue of feeding, but only 50% of parents think pediatricians can resolve the feeding difficulty” ( Jin X. Chin J Child Health Care 2009;17:387-9, 392). He added, “All pediatricians are aware of feeding problems but how to resolve those problems is another story.”

Various strategies for treatment include drug therapy, behaviour modification, parental education and nutritional supplementation. Dr. Kerzner told delegates, “Feeding is a complicated event. Every specialty has a different way of identifying, observing, interpreting and treating patients. Appropriate classification, appropriate diagnosis and appropriate treatment leads to the best resolution of these problems.”

The Role of Pediatricians in Feeding Difficulties

According to pediatric dietitian Kim Milano, Columbia, South Carolina (and formerly at Children’s National Medical Center), “All feeding problems are not the same. When parents have concerns about their child, pediatricians need to address those concerns early. Pediatricians can prevent problems with early guidance for parents and by providing healthy feeding principles.”

Parents have enormous input on feeding and eating behaviours, well into adolescence. Parents model eating behaviour as well as establish techniques—or feeding practices—to feed their children. Parenting style characterizes parent-child interactions across a wide range of situations. That is why pediatricians serve such an essential role in guiding parental behaviours and interactions with their children.

In identifying and treating feeding difficulties, pediatricians must accurately assess nutrition and growth, understand the difference between adequate and optimal nutrition, and ask parents or caregivers critical questions regarding feeding interaction.

Nutritional assessment is vital in determining the quality of food a child consumes. Anchor foods (such as milks containing protein, calcium and vitamin D, and cereal fortified with iron and other nutrients) and food chaining (offering and exposing a child to foods similar to what he/she may be already eating) can be helpful. Other types of supplementation may also be considered when a child does not have adequate types of food intake.

Variety of Feeding Difficulties

The continuum of feeding difficulties ranges from picky eating to autism. Organic disease, infantile anorexia, food allergies, food aversion, food selectivity, food refusal, selective eating, colic, fear of feeding, post-traumatic feeding disorders, and even parental misperception all fall somewhere on this scale. Interestingly, organic disease as a cause is implicated in only 5% of cases (Douglas PS. Med J Aust 2010;193:533-6). Parental strategies to deal with feeding difficulties, though well intended, are often counterproductive.

Untreated, these difficulties can lead to nutritional deficiencies, failure to thrive, impaired parent/child interaction and chronic feeding aversion accompanied by socially stigmatizing mealtime behaviour. Implications can extend beyond growth to emotional and cognitive issues.

Pediatricians are key to resolving these problems, and they commonly address these conditions in the clinical setting. However, pediatricians’ perspectives are often biased by their training, and many may not have been taught basic principles.

A useful identification and diagnostic chart appears below:

Figure 1.

IMFeD: A Helpful Diagnostic and Treatment Tool

The Identification and Management of Feeding Difficulties for Children (IMFeD) Program helps pediatricians identify common feeding difficulties in children. IMFeD helps demonstrate approaches to managing feeding difficulties and aids in parent/ caregiver education. IMFeD now consists of 3 parts: a tear-off questionnaire; a toolkit to facilitate diagnosis and parental education; and brochures available for parents to take home for further reading.

The Program is based on the expertise of thought leaders Dr. Irene Chatoor, Professor of Psychiatry and Pediatrics, The George Washington University and Children’s National Medical Center, and Dr. Kerzner. The IMFeD tool is based on classifications that they developed to categorize feeding difficulties and provide pr
their investigation.


When pediatricians use the IMFed toolkit to assist in diagnosing a child’s feeding difficulty, a parent fills out a tear-off questionnaire in the pediatrician’s waiting room. The questionnaire asks closedended questions in clear, simple language.

Once in the office, the pediatrician slides the parent-reported questionnaire into a diagnostic frame to arrive at an initial diagnosis. The pediatrician works to probe the parent to ensure she/he has reported correct information about the child. Once the diagnosis is established, the pediatrician is able to refer to one of the toolkit’s corresponding tabs (highly selective intake; poor appetite that is a parental misperception; poor appetite in a child who is fundamentally vigorous; fear of feeding; poor appetite due to organic disease; and poor appetite in a child who is apathetic and withdrawn).

The tool is designed to interpret information the parent provides and to assist physicians in making the diagnosis. The pediatrician can also provide parents information in the form of a booklet that includes specific, practical advice about their child’s condition.

According to Ms. Milano, “From a dietitian’s perspective, diagnostic tools such as IMFeD help pediatricians quickly evaluate patients as well as help [the parent] as early as possible so that core feeding problems don’t occur. The IMFeD tool gives pediatricians direction in identifying and treating very complex issues.”

A Simplified Canadian Approach

A colour-coded version of the printed IMFeD toolkit has recently been introduced for pediatricians and parents in Canada. Onepage electrostatic colour-coded reference charts can be put up on treatment room walls in pediatricians’ offices. Parents are asked to complete a questionnaire in the waiting room while waiting for the doctor. By checking the boxes that most appropriately describe their perceptions of their child’s condition, parents are able to quickly provide information for the pediatrician when the office visit begins. The pediatrician compares the questionnaire to the colour-coded reference chart on the treatment room wall.

The pediatrician makes a proper diagnosis based on the appropriate diagnostic criteria and conveys the information to the parent. Again, the pediatrician works to probe the parent to ensure the provided information is accurate. An IMFeD colourcoded form with appropriately checked boxes corresponding to the child’s diagnosis is given to the parent along with a takehome Web key (USB key).

At home, the Web key launches the IMFeD Web site ( for the parent on their home computer. Once the site is launched, the parent selects a language followed by the correct colour-coded diagnostic category. The parent simply follows the colour coding system, which helps to ensure correct information. Relevant information about the child’s condition that would otherwise be found on the hard copy brochures is available.

The system is designed to simplify proper diagnosis and to facilitate patient management by putting information directly into the hands of parents. Also included on the Web site is a wide array of helpful information, including questions and answers, guidelines and tips, and links to videos and additional resources. An added advantage of the simplified Canadian IMFeD system is the use of 1 vs. multiple brochures. (Pediatricians do not have to keep track of, store or locate various brochures in their offices.)

Here at the Summit, Dr. Véronique Pelletier, Assistant Professor of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, described the process of collecting information about patients with feeding difficulties as time-consuming. With the help of a team of professionals (dietitian, psychologist, social worker, nurse and occupational therapist), she developed a screening tool similar to IMFeD that consisted of open- vs. closed-ended questions.

Dr. Pelletier suggested, “The IMFeD toolkit [may] be efficient for gathering and categorizing information as well as useful as a quick assessment tool with the potential for use in teaching.” She explained that with so much information disclosed when the questions asked are open-ended, certain information may be missed. She postulated that when questions are closed-ended, diagnosis may be easier and clearer to identify.

Future Validation Study

According to Dr. Kerzner, there is great interest worldwide in making sure the IMFed tool is achieving its goals and determining whether pediatricians want to use the tool because they find it effective. Consequently, another validation study is on the horizon.

The vision for the study is to select a practice that will evaluate babies during a well baby check. If the parent relates concern about a feeding problem, pediatricians will use the IMFeD tool and its features during the physical exam and history. IMFeD’s diagnostic results will be compared with those of a highly skilled pediatrician and nurse practitioner.

When asked about other ideas for the future, Dr. Kerzner stated, “Our classification system classifies children but not parents. As feeding is a bidirectional activity, different parents’ feeding styles lead to different results. How we incorporate that into a diagnostic mechanism that leads to specific recommendations for specific types of problems is a challenge. Additionally, it would be good to incorporate the red flags for behavioural issues (e.g. force feeding) in the same way we have incorporated red flags for organic issues (e.g. poor growth).”

Feeding Disorder Classifications in the DSM-V

According to Dr. Chatoor, 3 feeding disorder classifications will be represented in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), which is scheduled for publication in 2013. The classifications are infantile anorexia, sensory food aversion, and post-traumatic feeding disorders.

In Dr. Chatoor’s recently published validation study (Chatoor I, Hirsch RP, Wonderlich SA, Crosby RD. Validation of a diagnostic classification of feeding disorders in infants and young children. In: Developing an Evidence-based Classification of Eating Disorders: Scientific Findings for DSM-V. Arlington, VA: American Psychiatric Association; 2011:185-201), 2 psychiatrists and a nurse practitioner diagnosed feeding disorders with high inter-rater reliability. The study demonstrated that different feeding disorders showed different growth patterns. The latest class analysis separated infantile anorexia and sensory food aversions from each other as well as from combined infantile anorexia plus sensory food aversions.

IMFeD Grants Program

This year, participants in the 2011 Third International Summit are eligible to apply for 2 $25,000 IMFeD grants. Final applications should be submitted on-line; the deadline is June 12, 2011. Based on medical, scientific and organizational merit (and likelihood of successful completion), a review committee will assess the applications and award grants. The 3 broad categories for submission are education, program implementation and research. However, there is wide room for manoeuvre in the types of projects deemed acceptable due to the assortment of participating countries as well as cultural contexts of potential eligible projects.


Feeding is a complicated bidirectional activity involving both parent and child. Pediatricians are aware of feeding problems, but identification and treatment are not always straightforward due to the wide variety of feeding disorders. Different specialties have different ways of identifying, observing, interpreting and treating patients. Appropriate classification, diagnosis and treatment can lead to an optimal resolution. The IMFeD Program has been developed to assist pediatricians with this important work. The future includes greater validation of feeding disorder classifications and the IMFeD tool.

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