Picky Eating or a Misdiagnosis? What You Need to Know About Picky Eating and all Pediatric Feeding Disorders

By Jaclyn Pederson, MHI

As CEO of Feeding Matters, I hear stories regularly about picky eating, disordered eating and what we now know to call pediatric feeding disorder (PFD). Recently, the lived experience is happening even closer to home. After the birth of my second son on October 29th, 2022 we too, like so many families I’ve met over my ten years with the organization are now navigating a PFD journey.

In the two years since PFD became an official diagnostic code, I’ve seen hundreds of families in the U.S. and around the globe become more informed and able to access better care for their children.

Naming the issue that has many symptoms and requires a multidisciplinary approach has given families tremendous relief and support.

Maybe you have never heard of PFD. You are not alone. Maybe you, like so many, innocently presume that a toddler’s loathsome attitude toward certain foods is an act of defiance or that they are simply a “picky eater.”

Even if you are not a medical expert you’ve likely heard the terms: “picky eater,” “picky eating,” and perhaps a widely circulating, newer, diagnosis called “ARFID.”  But there is so much more to this story.

Through this Q&A we hope to inform and demystify a few popular constructs:

Question: What is Pediatric Feeding Disorder?

Answer: A Pediatric Feeding Disorder, or PFD, is when a child is not eating appropriate for their age and often involves a dysfunction in one or several domains which impacts their feeding, including:

  1. Medical
  2. Nutrition
  3. Feeding skill
  4. Psychosocial

Q: What does a classic case of PFD look like?

Answer: While there is not necessarily a “classic case” of PFD because there can be so many reasons PFD exists, but typically a child with undiagnosed PFD will have a history of feeding issues. These can include any combination of issues, including: allergies, reflux, challenges with bottle feeding and trouble transitioning to solids. The most classic scenario is that a parent or caregiver knows that there is an issue with feeding and has tried to share that something is wrong with anyone who will listen but often is told by well meaning professionals and families to “wait and see” or that “it’s a phase and they’ll grow out of it”.

Question: What is ARFID?

Answer: Avoidant/restrictive food intake disorder, otherwise known as ARFID is an eating and feeding disorder often described as extreme picky eating. It is a mental health diagnosis for children who have the following:

  1. Significant weight loss (or failure to achieve expected weight gain or faltering growth)
  2. Marked interference with psychosocial functioning
  3. Nutritional risk or deficiency
  4. No coincident body image problems
  5. Disturbance is not due to a medical condition (such as allergies, GI conditions)

Q: What does a classic case of ARFID look like?

Answer: A classic case of ARFID might look like a child with no feeding skills issues but could be described as having odd eating habits and one who had no history of challenges with feeding before its onset. is someone with no history of feeding.

Q: How can I tell if it is just picky eating vs. something more serious?

Answer: This is a question that we all struggle with.  For me, having been with Feeding Matters for six years already on the birth of my first son, I realized it’s hard to even know what is age appropriate in feeding development. As parents, we’re faced with many conflicting messages. We get one set of guidelines from our pediatrician, then we see social media and get a whole different perspective on how to teach our children how to eat. We have a 6-question screening tool that can help identify if we need to look further into causes but often, there are two things I like to focus on when trying to figure out if it’s picky eating or more serious: 1. Feeding Development history, what is the history of feeding? Have problems always been present and now feel exacerbated? 2. Parents relationship with their children.  Have mealtimes always felt stressful? Is the parent or caregiver at their wits-end?  Is the family dreading every meal? These questions lead you to think about feeding development in a different way. If there has been a history or if stress is present, it is worth exploring if this may be more serious.

Q: Explain the difference between a PFD and an eating disorder. They sound the same. Why are they not?

Answer: Feeding disorders and eating disorders are distinct and often have differences in diagnostic criteria, cause, and treatment.  While research is continuing to move forward for both fields, most often, eating disorders are mental health conditions and feeding disorders involve the medical and behavioral health fields.  It is important to note though, that there can be overlap where some disorders co-occur or one, often PFD (feeding disorder), can lead to another, such as ARFID (eating disorder).

Q: What happens when a Pediatric Feeding Disorder is mistaken for an eating disorder?

  • The biggest worry that I have for this is that a child’s picky eating is then described as a mental health condition. This can then allow us to miss critical reasons why a child may be having trouble with feeding. They may have undiagnosed allergies that make it painful to eat. Maybe they don’t have the anatomy that allows them to chew and swallow certain foods.  Often children with severe picky eating aren’t not getting the comprehensive look that we need to be doing with children.  Children that are having tantrums at meals are trying to communicate something with us and it’s not all in their head.  And unfortunately, if we go straight into treating it from a mental health perspective without assessing from a medical perspective, we cause long term damage and can make the psychological impact even worse.
  • Children are being misdiagnosed as having a psychiatric condition.
  • The actual cause of a child’s picky eating is sometimes overlooked.
  • The longer feeding challenges go untreated, the greater the psycho-social impact
  • As children get older, the difficulties from having trouble feeding can go from being a developmental one to a mental health condition.

Q: What do I do if I think my kid is more than a picky eater?

The first thing to do is to share your concerns with your provider.  You know your child best and if mealtimes feel stressful or feeding has always felt like it was off, pay attention to that feeling.  As you express your concerns, in order to get the right diagnosis, we need to make certain that we are looking at this from four domains: medical, feeding skill, nutrition, psychosocial.  If your provider assumes its ARFID or that it’s all in their head, it is worth advocating to get a full assessment to ensure it isn’t also PFD.  As a parent it can be helpful to know that PFD can sometimes be misdiagnosed as ARFID .

Unfortunately, clinical providers have limited expertise in feeding and nutrition and are navigating an ever-changing field.  While Feeding Matters is working to ensure providers are aware of all types of feeding disorders, including PFD, we are still facing an uphill battle to ensure families get the care they need.

The sooner a family can identify the actual challenge at hand, the more quickly they will be on the best corrective path for their child’s individual issue. Early intervention equates to better health outcomes in every case.

Are you looking for more information? Visit Feeding Matters’ resource page: PFD and ARFID as well as their Family Support Page. Or, take the quick and easy Feeding Matters Infant and Child Feeding Questionnaire© for a simple support tool to take to your next pediatrician appointment.