For a pediatric disorder that affects 1 in 37 children under age 5 –– making it more common than autism –– pediatric feeding disorder (PFD) remains significantly misunderstood and undiagnosed. This is unsurprising in some ways, as the Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework my colleagues and I authored was only released in 2019. PFD only became an International Classification of Diseases (ICD) code in October 2021.

The consensus paper and code aligned pediatric clinicians, allowing for more consistent assessment and diagnosis. Despite these advancements, gaps remain, particularly in primary care and among caregivers, who often lack an understanding of feeding progression and the potential risks for any child to develop feeding difficulties.

Helping more children earlier, whether they have PFD or signs of feeding challenges –– requires a multi-pronged approach to raise awareness, including:

• More translational research that directly helps children and families

• Raising awareness of PFD among primary care providers and pediatric allied health professionals

• Clearly defined feeding milestones for transitioning to solids

• Educating caregivers about feeding

Ensuring clinical research directly supports families

Age 6-12 months, when children transition from milk to solids, is a critical time for feeding development. Unfortunately, it’s also the least researched stage of child development. Infants change quickly in multiple, parallel ways, making research that controls for variables complicated.

One important way to support early diagnosis is to improve feeding guidelines for all children, an area of focus in my Neurodevelopmental Feeding and Swallowing Lab.

Current guidelines from the American Academy of Pediatrics recommend that children begin transitioning from exclusive breast milk or formula to solid foods at 6 months and eat a variety of table foods by the time they turn one. That’s a lot of change in a short window with little direction.

We need more research to answer questions like:

• What are the primary influencers for feeding development?

• What are readiness skills for eating solids?

• When should different foods and textures be safely and positively introduced?

• What are the risk factors for children who struggle?

We have robust nutrition literature on the exact macro and micronutrients and calories children need throughout their first two years of life. However, we are behind on research that focuses on feeding skills and abilities.

To that end, I’m proud to see a new generation of scientists researching all areas of feeding.

Identifying red flags of feeding difficulties early

While research is a long game, children affected by PFD have a short window to best address developmental challenges.

Learning to chew and swallow is among children’s most complex early skills. This makes transitioning from milk to solids in the first two years, particularly from ages 6 to 12 months, the most vulnerable time for children to falter.

Because many children aren’t adequately identified for feeding difficulties until they are older, they miss the optimal window for intervention. In some cases, children most at risk for being overlooked are those considered low-risk, healthy, neurotypical children. Because they aren’t monitored for developmental challenges as closely as a premature baby, for example, early signs of feeding challenges go unnoticed. These children could potentially avoid developing PFD if identified earlier.

For example, a child who starts solids and then gets sick with a virus may have a setback in feeding development. A few times of food refusal while not feeling well can then become a habit. The caregiver often has little knowledge about how to move through solid food textures. The child misses feeding experiences, making it more difficult to introduce new foods and textures later. Early challenges or setbacks like this may not turn into a significant case of PFD, but in some cases, they do.

Following are some red flags parents may notice:

1. Persistent coughing or gagging: Some coughing or gagging is common but frequent occurrences during meals may be signs of a problem.

2. Stressful feeding experiences: Feeding should not be super challenging or miserable. If you dread mealtime, this is an indication of an issue.

3. Sleepy during feedings: Especially in infants, sleepiness can signal feeding difficulties.

4. Transition struggles: Difficulty moving from liquids to solids or new textures.

5. Slow progress: Inability to increase food volume as the child grows.

How clinicians can raise caregivers’ awareness of feeding challenges

As with any disorder, early diagnosis leads to more positive outcomes. For those who present some early signs of PFD, identifying and addressing red flags early can even prevent a child from developing pediatric feeding disorder.

Solid foods are not one thing. A range of foods requires different skills. One way to identify more children earlier is for primary care providers to ask caregivers more direct questions about feeding instead of simply asking if a child is eating solids.

More specific questions about feeding could include the following:

• What types of textures is the child eating?

• What foods does the child eat?

• How much can the child eat?

• Is the amount the child eats steadily increasing?

• How long do meal times last?

• How much refusal occurs?

• Is feeding a struggle?

The Feeding Matters screening questionnaire includes some of these questions to identify children who may have PFD. Asking detailed questions about early feeding habits could prevent some children from developing PFD in the first place.

Raising clinical awareness of PFD

While the past few years have brought significantly more awareness of PFD, it’s still not unusual to encounter pediatric clinicians unaware of the diagnosis.

Widespread advocacy and education are needed within and beyond the healthcare community. Pediatricians, speech-language pathologists, nurses and even early childhood professionals must have the knowledge and tools to recognize and address feeding difficulties early.

What clinicians can do to better support feeding

1. Ask detailed questions: Inquire about specific food types and textures offered.

2. Provide guidance: Offer nuanced advice on feeding progression and when to introduce new textures.

3. Educate caregivers: Share knowledge about developmental milestones and readiness for new foods.

4. Monitor closely: Pay attention to children with feeding struggles instead of encouraging a “wait and see” approach.

5. Encourage early intervention: Identify and address feeding difficulties as early as possible to prevent escalation.

Finally, clinicians must emphasize how important it is for caregivers to trust their guts. When feeding seems like it isn’t going well, it probably isn’t. That warrants discussion and perhaps intervention to adjust the child’s feeding practice.

The more we as researchers and clinicians do to understand feeding and support children and families during the transition from liquids to solids, the more children will have the opportunity for healthy, positive feeding experiences. This could reduce the prevalence of PFD and promote better outcomes for children and families.

Amy Delaney, PhD, CCC-SLP is an assistant professor at Marquette University and director of the Neurodevelopmental Feeding and Swallowing Lab. She is the education pillar chair for Feeding Matters’ PFD Alliance Executive Council. She co-authored the consensus paper creating pediatric feeding disorder (PFD) as a stand-alone diagnosis and the Infant and Child Feeding Questionnaire, an online survey developed by Feeding Matters, to identify red flags for PFD.