Picky eating is for real. No, you didn’t cause it by feeding the wrong foods or being a bad parent. It may have snuck up on your child through background noise in the digestive tract that nobody noticed! Good news: Picky eaters can make full turn arounds, and it may be easier than you think.
Picky eaters can get entrenched enough to profoundly affect their health, development, and functioning. Reversing picky eater behavior focuses mostly on that – behavior. Therapists strategize on how to present food, how to desensitize toddlers and kids to new food textures, and of course, on ruling out any mechanical swallowing concerns (important to rule out with your pediatric OT or SPL). It’s a slow, arduous process. There are many dozens of specialist clinics for pediatric feeding disorders in the US (find one here if you like!) that will work with young children with this approach, to teach new habits and less defensiveness around food.
But what I always wondered is this: Why did picky eating even become a thing in the first place? It truly did not used to be. No, we are not all that much smarter at noticing this stuff than we were a generation ago. Kids mostly just… ate. Sure, some of us had our finicky stretches. But this was so not in the pediatric nutrition landscape that my training – graduate, undergraduate, and clinical rotations – made zero mention of the extreme picky eating now so common in kids: Picky eater behavior bad enough to cause growth failure, malnutrition, frequent infections, need for a feeding tube, or clinical intervention.
What happened? This was the question for me, as a dietitian nutritionist working with these kids. Why would a child “choose” to start aversive eating – in infancy? Or even as an older kid, when the diagnosis might become “avoidant restrictive eating disorder” (ARFID). I couldn’t get my head around that part. I figured there has to be a reason why this gets rolling in the first place.
ARFID diagnostic criteria include this statement: “The eating disturbance is not attributable to a concurrent medical condition”.
Is that true? Or maybe the problem is … we need to do a better job of ruling that out.
When things are out of balance in the stomach and digestive tract, or when certain nutrients are depleted, kids become picky. Very picky, and their desire or even tolerance for food can drop out (same with elders, whose stomach acid diminishes in later years, and who are often given medications that stop appetite). Identify and fix these out-of-balance issues, and appetite can be restored. I have supported kids in this very way, many times in my clinical pediatric nutrition practice. And they make brilliant turn arounds. They eat, they poop, they stop throwing up or gagging, and they grow. But best of all, they go out and play again and they stop worrying about food.
In the kids who have come into my practice with ARFID, picky eating, and growth failure from these circumstances, I usually find that there has been no nutrition screening done for them – not even basic lab studies to screen for the most ordinary, but highly impactful, nutrition deficits that can mess with appetite. I’m often the first to look! I will scrutinize causes for things that can cause pain, or make a child feel full all the time, or trigger gagging and texture aversions. And, I find them.
What this means is that picky eater “behavior” is often not so much a behavior as a response to the body trying to cope with something out of balance. Eventually kids will develop behavioral responses that seem counterproductive and exasperating to us adults – as they experience stress from being forced to try to eat things that they can’t digest, or to eat foods that may cause pain they can’t verbalize.
Here are some nutrition and gut features that will trigger or worsen picky eating:
- Reflux medicines, current or past – these diminish stomach acid over time, which eventually leave the stomach sensing that it’s “full”. End of appetite. These also encourage fungal microbes to grow in digestive tract, which can cause gas, more reflux, and picky cravings for starchy food. Finally, they prevent absorption of minerals and B vitamins, which can also affect what you feel like eating.
- Antibiotic use – whether these were given to a child, a child was exposed in utero, during delivery, or through mom’s breast milk, these can alter gut microbe balance enough to disrupt appetite and eliminations – especially when exposures occur in the first weeks or months of life.
- Poor iron status – Anemia and pre-anemia (weak iron status or ferritin with normal hemoglobin level) will cause peculiar cravings (a condition called pica), and at the same time, make appetite overall weaker and more picky.
- Poor zinc status – this tends to worsen oral texture aversions, gagging, and refusal of anything but that one favored texture (usually, crunchy starchy snack food). Mixed foods will cause gagging. These are kids who love biting stuff like erasers, pencils, rubber chew toys, or… other kids!
- Overgrowth of opportunistic bacteria or yeasts in the gut – microbes move in thanks to the ever worsening picky eater diet and/or reflux medicines and/or antibiotics. Helpful microbes are not be able to stick around. The vicious cycle begins. More overgrowth of the wrong microbes –> more reflux –> less digestion –> more pain, nausea, constipation, diarrhea. Appetite drops. These junky microbes are not necessarily pathogens (like Salmonella or Giardia) but I have been the first to find those too on occasion, using more sensitive stool studies than your insurer paid your GI doctor to use.
- Leaky gut has allowed poorly digested proteins from milk and wheat to enter the body in a form that mimics opiates. These are called casomorphin (morphine like molecule from casein, which is cow’s milk protein) and gliadorphin (morphine like molecule from gliadin, which is part of wheat protein). Guess what? These opiate like protein fragments are super addicting. This child will not want any food that is not made of casein or gluten – picky eating, full on. See my Milk Addicted Kids e book for more on this one.
- An existing, unresolved FPIES diagnosis that continues to make eating traumatic.
- Exogenous opiat- like peptides from certain food proteins that are addicting and cause refusal of foods other than dairy, wheat, soy, or pea protein concentrates (Ripple milk, Kate Farms, Orgain Vegan, or most any vegan protein powder, drink, or bar). For more on how that works, check this blog on fierce picky eating.
Endoscopies, celiac blood tests, and basic lab screenings like CBC and chemistry panels will often look normal – but all these other issues can be in play, wrecking your kid’s appetite. These should be ruled out too, before solely relying on cognitive therapy for ARFID or feeding therapy with an OT. Without clearing underlying physiological impediments to a good appetite, behavior based therapies will creep along at a painfully slow pace or fail entirely – which I have seen countless times!
Back to my original question. Why did picky eater behavior ever even become such a thing, to the degree that we have clinics in every city to help change this behavior?
Here’s my 2p: Barring mechanical or structural impediments to normal feeding, picky eating has been caused by overmedication of kids in the last generation or so. Before oral antibiotics were so widely used, before so many early doses of vaccinations were given in the first two years, before reflux medications became so popular for infants and kids, our gut biomes evolved naturally. This allowed normal appetite and digestive skill to progress uninterrupted. But since the late 1980s, we “interrupt” this process with many pharmaceutical interventions, from birth on – even for “healthy” kids.
When digestion is in tact, appetite evolves naturally, and vice versa. Many kids I’ve worked with have spontaneously changed eating habits once they have comfort and ease with digesting food. Screening for nutrition problems that disrupt this process can go far in helping your child enjoy food more readily, and to become a relaxed eater for greater variety.
This does get harder for older kids who have experienced more pain, trauma and frustration with feeding clinics that failed for them. Many of them also go on to fail with psychiatric medications, as they are diagnosed with having a “behavior” problem rather than a physical one. Eating disorders with a psychological component need help on both levels – with counseling and support, and good nutrition screening and strategizing.
Early on, protect your baby’s gut by letting it develop its innate skill for digesting and enjoying food. Use antibiotics only when truly necessary with your doctor’s guidance. Use restorative probiotics and pre-biotic foods. Consider spreading out, delaying, or deferring vaccinations until your baby is older, especially if you are breastfeeding – which gives the protective immunoglobulins and immune defenses that your baby needs. You might be amazed to see the progression of a healthy appetite in action!
For toddlers and older kids who are picky, stay tuned for resources on busting this pattern by following me on facebook here. Repairing gut dysbiosis, replenishing imbalanced minerals, and addressing other underlying problems can turn this around.