Until I gave birth to my daughter last fall, I couldn’t have imagined just how complex, nuanced, and challenging it could be to feed a small child. Whether feeding by breast or bottle, I was amazed (and, frankly, overwhelmed) to learn how subtle a child’s hunger cues can be and how many strategies exist to ensure a baby receives the nourishment required to thrive.

According to the nonprofit organization, Feeding Matters, there are 26 muscles and six cranial nerves involved in perfectly executing one single swallow. And when one or more of those necessary parts are missing or malfunctioning, eating and drinking can become extremely difficult if not impossible for a young child. When this happens, it results in a serious issue called pediatric feeding disorder, or PFD.

While pediatric feeding disorder may not be a condition that many people are familiar with, it affects more than one in 37 children under the age of five in the United States each year. Infants and children with pediatric feeding disorder may experience pain, fear, or anxiety about eating, leading to compromised nutrition, growth, and general well-being.

Pediatric feeding disorder is a feeding disorder, not an eating disorder, but it has many overlaps with eating disorders and can have similarly serious consequences. It’s important that parents are aware of the risks of pediatric feeding disorder, how it could potentially lead to an eating disorder, and what to do if you’re concerned about your child. Read on to learn more about pediatric feeding disorder, symptoms to look out for, treatment options, how to get help, and more.

What is pediatric feeding disorder?

While there’s not a universally accepted definition for pediatric feeding disorder, researchers have proposed defining it as “impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction.”

“Pediatric feeding disorder is a condition that reflects problems with the age-appropriate skills or processes needed to eat,” explains Equip’s Vice President of Program Development, Jessie Menzel, PhD. “Pediatric feeding disorder has always been around, although not necessarily captured by a single, unifying diagnostic classification system. In the past, different professional fields have referred to the feeding challenges captured by PFD using their own terminology.”

According to Menzel, pediatric feeding disorder is associated with impairment in one of the following categories:

• Medical: this can include allergies, gastrointestinal conditions, or genetic disorders
• Nutritional: many children with PFD have a restricted quality, quantity, and/or variety of foods, increasing the risk of malnutrition, micronutrient deficiency, dehydration, and more
• Skills-based: when a child lacks the oral or motor skills needed to consume food
• Psychosocial: this can include developmental factors, mental and behavioral health problems, social influences, environmental factors, and more

Menzel shares some specific examples of what those impairments could look like:

• An infant who experienced early medical trauma and developed an aversion to feeding
• A toddler who has never eaten foods with chewy or challenging textures and has a strong emotional response to being asked to try new foods at meal times
• A young child who lacks the fine motor skill coordination to feed themselves using utensils and requires assistance to eat.

“Basically, PFD can be present any time feeding or eating is hard, scary, or painful for a child,” Menzel says.

Pediatric feeding disorder, along with avoidant/restrictive food intake disorder (ARFID), is one of several feeding disorders, which are defined as “a range of eating activities and behaviors that may or may not include problems with swallowing.” There’s not one hard and fast line between feeding and eating disorders, but the latter tends to affect older children, teens, and adults, and involves a significant mental health component, whereas the former tends to affect young children and generally has a physiological root. ARFID is unique in that it can be considered both an eating disorder and a feeding disorder, whereas pediatric feeding disorder is strictly a feeding disorder.

Symptoms of pediatric feeding disorder

Because pediatric feeding disorder can be linked to difficulties in one of four domains, the signs and symptoms can vary widely and can affect kids at various developmental stages, from birth to school age and beyond. “There are a number of different symptoms that may indicate the presence of pediatric feeding disorder, and they vary based on whether PFD is associated with medical, skills-based, nutritional, or psychosocial impairments,” Menzel explains.

Some potential symptoms of pediatric feeding disorder include:

• Vomiting
• Physical discomfort when eating or drinking
• Crying, gagging, coughing, grimacing while eating
• Weight loss or lack of growth
• Dependence on supplements
• Dependence on tube feeding
• Lack of dietary variety
• Avoidance of specific food textures
• Need for special equipment to eat or feed
• Failure to advance textures of foods
• Difficulty chewing
• Excessively long or short mealtimes
• Mealtime anxiety
• Inability to eat outside the home or with others
• Tantrums at meals
• Refusal to eat

Note that while several of these symptoms overlap with the symptoms of ARFID, they are distinct conditions and require different treatment.

Health risks of pediatric feeding disorder

“Pediatric feeding disorder can have devastating consequences for a young child and their family,” Menzel says. “Because PFD can present so early in a child’s life, sometimes at infancy, there are significant and dangerous risks to a child’s ability to grow and develop.”

In addition to failure to thrive (when a child’s weight or rate of weight gain is significantly below that of other similarly aged children of the same sex), PFD is associated with malnutrition, aspiration (when food accidentally enters the airways), dehydration, and allergic reactions.

Beyond the immediate physical risks, Menzel adds that pediatric feeding disorder can have a profound impact on the family system. “Often, PFD causes significant stress in the relationship between child and caregiver,” she says. “Children may develop significant anxiety or aversion to food and mealtimes. PFD can also result in financial strain, as children with PFD may need to see multiple specialists and require in-home therapy or special equipment to feed.”

Pediatric feeding disorder vs. ARFID

Menzel notes that the delineation between pediatric feeding disorder and ARFID is currently a major topic of discussion in each respective field. “Generally, experts in these fields agree that there is a significant overlap between PFD and ARFID, particularly when PFD is associated with impairment in the nutritional and psychosocial domains,” she says. In fact, Menzel and several other experts in both ARFID and PFD recently published a consensus paper on the overlap between the two conditions, which underscored the need to both improve diagnostic criteria and educate more clinicians on how to identify and distinguish between PFD and ARFID.

Both PFD and ARFID can result in the following symptoms:

• Mealtime anxiety
• Tantrums
• Food avoidance and restriction
• Weight loss or failure to grow
• Poor appetite or lack of interest in food
• Limited dietary variety

Despite these similarities, Menzel says a key differentiator between pediatric feeding disorder and ARFID is the extent to which the eating or feeding problems are related to a child’s development of age-appropriate feeding skills. “The primary developmental window for acquiring feeding skills is between birth and five years of age, after which feeding skills continue to progress and be refined,” she says. “Any feeding or eating challenges that present before a child has met all of their developmental feeding milestones should be strongly considered for pediatric feeding disorder.”

According to Menzel, experts in both fields agree that feeding or eating problems primarily associated with medical or skills-based impairments reflect pediatric feeding disorder and not ARFID— although these impairments have the potential to lead to ARFID over time. “In general, in young children, any feeding or eating challenges should be thoroughly assessed for PFD,” she says.

How is pediatric feeding disorder treated?

Because eating is such a complex process—especially during early development—Menzel explains that treatment of pediatric feeding disorder largely depends on which domain(s) a child is experiencing impairment in:

• Medical impairment: For those with medical conditions that contribute to feeding or eating problems, healthcare providers such as gastroenterologists, developmental pediatricians, cardiologists, or allergists may need to be involved in treatment.
• Nutritional impairment: Those who need help expanding dietary variety, resolving malnutrition, or addressing specialized dietary needs or challenges may benefit most from working with a dietitian.
• Skills-based impairment: “Speech language pathologists or occupational therapists can address any skills-related deficits that make eating challenging,” Menzel says.
• Psychosocial impairment: “Psychologists use behavioral and psychotherapeutic approaches to address difficult mealtime behaviors, anxiety or fear, and improve child-caregiver interactions,” Menzel says.

What to do if you’re concerned your child has PFD

Trying to discern whether your child has any type of feeding difficulty can be scary, but it’s important to stay calm and consult a medical expert. “Pediatricians are commonly the first point of contact for identifying PFD,” Menzel says. “They will be able to facilitate the appropriate referrals to the right specialist who will be able to evaluate your child further, depending on the domain where you are seeing problems.”

Another great place to start is Feeding Matters. Originally known as Parent Organized Partnerships Supporting Infants and Children Learning to Eat (P.O.P.S.I.C.L.E.), Feeding Matters was founded in 2006 by Shannon and Bob Goldwater when their newborn triplets struggled to eat. Today, the organization continues to advocate for families affected by pediatric feeding disorder, as well as educating the public about the condition and researching treatment and support options.

And as with all things parenting-related, it’s important to listen to your own intuition and trust your gut. If you suspect something is wrong or causing your child pain, fear, or anxiety around food, seek professional help immediately. “Parents shouldn’t hesitate to raise concerns about a child’s eating, growth, or development,” Menzel says.