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 - Pediatric Nutrition

May 2010

Worldwide, between 30% and 60% of parents believe their children are not eating appropriately. The spectrum of feeding difficulties is broad, ranging from picky eating to autism. Organic disease, infantile anorexia, food allergies, food aversion, food refusal, selective eating, colic, fear of feeding, and even parental misperception all fall somewhere along this continuum. Parental strategies to address feeding difficulties—e.g. force feeding, distracting or inducing the child to eat various foods—often fail, and in fact may be counterproductive.

Consequences of feeding difficulties, if untreated, can include nutritional deficiencies, failure to thrive, impaired parent/ child interaction, or chronic aversion accompanied by socially stigmatizing mealtime behaviour. Implications can extend beyond growth to emotional and cognitive limitations.

Most feeding difficulties arise in the second year of life, during the transition to self-feeding, according to Dr. Irene Chatoor, Professor of Psychiatry and Pediatrics, The George Washington University, and Children’s National Medical Center, Washington, DC. Here at the Miami Summit, when asked about the prevalence of feeding difficulties in North America in comparison to obesity, Dr. Chatoor commented, “Feeding difficulties are more prevalent than obesity, especially in children in the first three years of life.” A new program, IMFeD (Identification and Management of Feeding Difficulties for children), has been designed to facilitate identification of common feeding difficulties in children. The program also helps delineate tailored approaches to the management of feeding difficulties and to contribute to parent/ caregiver education about how to manage a child’s feeding difficulties. The IMFeD program consists of two parts, a tear-off questionnaire for parents and a toolkit for physicians to facilitate diagnosis and parental education.

Dr. Chatoor’s and Dr. Kerzner’s categorizations of feeding difficulties include:

1. Infants with poor appetite because of organic causes

2. Those with poor appetite due to parental misperception

3. Those with poor appetite who are otherwise vigorous

4. Poor appetite in an apathetic or withdrawn child

5. Children who display highly selective food behaviours

6. Infants with colic that interferes with feeding

7. Infants or children who fear feeding

The IMFeD tool is based on classifications (see table) recently developed by Dr. Chatoor and her colleague Dr. Benny Kerzner, Professor of Pediatrics, The George Washington University and Children’s National Medical Center. The classifications categorize feeding difficulties and provide a practical approach to their investigation. According to Dr. Kerzner, a vast number of mothers identify at least one of their children as having feeding difficulties. Commenting on the importance of the IMFeD program, Dr. Kerzner told delegates, “We have created a classification system that spans the whole spectrum of feeding disorders and helps pediatricians identify and treat particular problems. We’ve now added a tool to enable physicians to arrive quickly at a desired diagnosis and to educate parents about the problem.”


The first part of the IMFeD program involves parents completing a tear-off questionnaire in the physician’s waiting room before an office visit. The reported information helps physicians identify parents who perceive a feeding difficulty in their child.

The questionnaire’s front page consists of symptoms and statements that describe a child’s feeding behaviour. Addressed first are issues of underlying organic disease—“red flag” feeding behaviours—that allow physicians to rule out organic pathology. If red flag indicators have been marked, the physician can investigate for organic pathology and treat appropriately.

Following organic issues are brief descriptions of characteristics to identify other types of feeding difficulties. However, the purpose of IMFeD is not to restrict a physician to a certain diagnosis but to alert physicians to parents’ concern and to where the child’s feeding difficulty may lie. In addition to organic pathology, a child may have a feeding difficulty: dual diagnosis is not at all uncommon. The questionnaire is meant to begin a discussion between parents and physicians and to provide insight for parents about their child’s feeding behaviour.

The back page of the questionnaire elicits basic information about both parents’ height, the child’s gestational age at birth, the parents’ own history of delayed puberty or slow growth, and information about the child’s diet. The back page also provides for the physician to record basic information about the child’s height and weight; weight-for-age; height-for-age; weight-for-height (or body mass index) percentiles; projected height at age 20 years; and mid-parental height calculations. Provided information may help the physician with confirmation of the diagnosis regarding genetic predisposition, adequacy of the child’s diet, and whether the child is meeting growth expectations.


The second part of the program, the IMFeD toolkit, entails diagnostic frames into which physicians insert the completed parent questionnaires. The frames allow the physician to match the parent-reported symptoms with corresponding potential diagnoses, making the pertinent preliminary diagnosis apparent. The IMFeD toolkit also provides individualized preliminary guidelines with valuable information relevant to the following four diagnoses: highly selective intake; poor appetite that is a parental misperception; poor appetite in a child who is fundamentally vigorous; and fear of feeding.

In some instances, parents may misperceive a child’s feeding behaviour. In these cases, the above–mentioned tool allows a physician to evaluate the child’s feeding behaviour and to reassure the parent that the child is growing well. Additionally, the physician may provide guidance about future parent-child interaction. As presented by Dr. Chatoor, the transactional model for feeding disorders indicates that infantile anorexia develops in the presence of conflict between parent and child, where a parent’s anxiety drives them to pressure a child to eat and the child resists feeding. A vicious cycle ensues. Changing the behaviour of the parent will change the behaviour of the child, thereby alleviating the confiict.

One concern about the use of the IMFeD program is adequate time during an office visit for its implementation. According to Dr. Russell Merritt, Clinical Professor of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, the IMFeD program helped his practice in that he acquired an approach for structuring his thinking, a valuable component of the program. Dr. Merritt told delegates, “Responsible discussion of feeding difficulties includes the fact that some children may need additional nutritional support. These determinations should be made on a case-by-case basis.”

A healthful diet provides for realization of full genetic potential by supporting growth, development, reproduction and health longevity and by providing protection from environmental stresses (such as infection, stress and diathesis toward disease). When age-appropriate nutrition is not being provided in children for healthy growth and development, complete and balanced nutritional supplementation may be considered to improve nutritional status and intake. Various strategies for the treatment of feeding disorders include behaviour modification, parental education, drug therapy or nutritional supplementation.


The IMFeD program represents a systematic approach for investigation of feeding difficulties in children, helping physicians to acknowledge parents’ reports of feeding difficulties as well as concerns about feeding. The program manages each patient using a tailored approach that addresses differences in needs according to type of feeding difficulty. Outcomes data evaluation is planned for the future.

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