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A certain amount of picky eating is a natural part of development—but in some cases, it can go well beyond what's typical. We asked Katja Rowell MD, and Jenny McGlothlin, MS, SLP, the authors of the new book Helping Your Child With Extreme Picky Eating, what parents need to know.

Q: What are some of the main differences between garden variety and extreme picky eating (EPE)?

A: A typical toddler may throw a tantrum if he wanted plain rice instead of brown rice with peas. But he's consolable and might pick the peas out and try a few bites, or eat other foods. A child with EPE may panic or get overly upset around challenging foods. His attitude is a critical clue. Is he preoccupied with what and how much he has to eat at mealtimes? Would you use words like 'anxious', 'terror', or 'scared' to describe how he feels about eating?

If a child's physical, social, or emotional development is affected by his eating, we call it "extreme". Another reason it would be considered extreme is if there is significant family conflict or worry about a child's eating. For example, a child who doesn't eat enough quantity or variety for growth, a child who becomes anxious about attending parties, camp, or going out to eat, or a child who becomes upset or even gags when at the table with food he doesn't enjoy.

Q: What is your first recommendation for parents of extreme picky eaters?

A: The immediate goal is to support appetite and decrease conflict and anxiety. Our first tip is generally to establish structured meals and snacks. In our book, each of our five STEPs gets its own chapter to walk parents through scary transitions when it feels like children can't be trusted with eating.

Q: What is one common thing that parents do around feeding that can make EPE worse?

A: Anything that triggers resistance or pushback will make it worse— and that will be different for every child. Obviously, holding a child down or otherwise making them eat while they cry or gag is harmful, but far less pressuring tactics can undermine eating: bribes, negotiating, one-bite rules, or using toys or screens as distraction to get a few bites in. Trying to "GET" children to eat tends to slow the process of learning to enjoy eating and tuning in to cues from inside their bodies. In general, if what you are doing increases anxiety, gagging, or conflict, it is not helping.

Q: What would you say to parents who worry that EPE is somehow their fault?

A: There is almost always an underlying reason that starts a family down the path of feeding difficulties: pain with eating (reflux), sensory-motor problems associated with developmental delays, autism spectrum diagnoses, temperament mismatch and others. It's never simply "their fault". Understanding why a child struggles makes letting go of guilt and moving forward possible. Shifting the focus to what parents can do is the answer. We provide tools to support appetite, decrease anxiety and conflict, support oral-motor and sensory development, and improve variety and nutrition. When parents feel understood and listened to, and empowered and confident with specific steps to take— that helps most with the guilt.

Q: Do kids with EPE need help from a feeding therapist?

A: The term "extreme" picky eating includes a variety of diagnoses and labels (feeding disorder, selective eating, avoidant/restrictive food intake disorder, food aversion, etc.) and a spectrum of experiences. A child might benefit from therapy if they have difficulty with transitioning to table food, chewing food well enough to swallow safely, or handling a variety of textures without gagging. Feeding therapy can vary widely, but our approach to therapy targets sensory-motor skills needed for eating, support of the feeding relationship between the parent and child, and empowerment of the family to provide a structured, peaceful mealtime. Our book helps parents decide if they need an evaluation or therapy, describes different approaches and red flags for counterproductive therapy, and offers guidance for finding a therapy partner.

Establishing a supportive and nurturing feeding relationship between parent and child goes much farther than direct intervention can. We want to empower parents to offer gentle facilitation when needed that helps children develop skills at their own pace, and it won't feel like therapy! Families can come together at the table and enjoy mealtimes.

Katja Rowell, MD, and Jenny McGlothlin, MS, SLP, are the authors of Helping Your Child With Extreme Picky Eating. Learn more on their website.

Image: Picky eater via Shutterstock