By Dr. Jamie Chaves, OTD, OTR/L, SWC
Food is such an integral part of our society and a necessary component to our health. A well-balanced diet, including a variety of foods from each of the food groups (grains, dairy, fruits, vegetables, proteins), gives energy, boosts the immune system, helps with growth, and protects from certain diseases. But eating is more than just food. Mealtimes often dictate gatherings with family, friends, and colleagues. Gathering around a table facilitates conversations, laughter, and shared memories.
For a child who is a picky eater (defined as eating less than 20 foods), mealtimes are often a struggle for a variety of reasons: they must be distracted in order to eat, they must have their food prepared in a very specific way, restaurants do not offer the kind of food they like, the possibility of gagging or vomiting with any slight change of texture, sitting for a meal seems impossible, the entire process takes 45+ minutes, to name a few. Caregivers may hear phrases such as, “it’s not the kind I like”, “it looks funny”, “why does it smell so bad?”, “I’m not hungry”. Rather than turning the dinner table into a battlefield at the cost of precious calories, it is much easier to present the same 6 foods the child likes on a rotating basis while crossing fingers that each food stays in the rotation.
So why is it that some kids are such terribly picky eaters? Quite simply, it is more of a matter of “cannot”, not “will not”. Medical issues aside (e.g., reflux, hypertonia, hypotonia, food allergies/intolerances, pneumonia), sensory processing challenges oftentimes negatively impact the entire mealtime experience. People usually think about how food tastes and smells when eating, but the reality is that there are many more senses at play. If any one of the senses is not processing information about the food appropriately it can wreak havoc—the more often this happens the more the negative response is reinforced and the more the child will refuse to try anything new.
Understanding how a child’s sensory challenges are impacting eating is the first step in the journey to expanding a child’s diet. Once these sensory challenges are identified, then effective interventions, such as occupational therapy, can be initiated. It’s essential to realize that these eating problems won’t just magically disappear—early recognition of the need for therapeutic intervention is important. Here’s a breakdown of each sensory system and how it impacts the process of eating in order to help you identify possible sensory-related challenges in your picky eater.
The Vestibular System: [provides information about our balance, coordination, and relationship to gravity]
Most cultures sit to eat—whether in a chair, on the floor, or atop a stool. This alone is critical at mealtime in order to maintain a safe position and open airway. Our vestibular system helps to promote an upright seated posture with our head in a neutral position. Some children lack the postural stability to maintain a position in a chair or on the floor, while others lack the small postural adjustments not to fall out of the chair or off the stool. Some children crave movement so much they just cannot calm their body long enough to fully partake in a meal. This may result in “drive-by” eating, eating quickly, or leaning on someone nearby—none of which are very functional.
In addition, the process of eating takes a lot of oral coordination. Our jaw moves in a rotary motion in order to transfer food from one side of our mouth to the other. Our tongue facilitates the movement of food in conjunction with the jaw movement, and then coordinates with the cheeks in order to produce a swallow. Children who have a difficult time with motor planning and coordination, as a result of decreased vestibular processing (and decreased proprioceptive processing), may present with immature chewing patterns that negatively impact the types of food that are safe for them to eat. Soft, pureed, or meltable foods are preferred because they dissolve easily with saliva without needing a mature chewing pattern. They might push their tongue out of their mouth to move food to the back of the mouth because coordinating tongue elevation with cheek compression is too challenging. Limiting their diet to certain foods is not a choice, it’s a necessity.
The Proprioceptive System: [provides information about our body position and muscle engagement]
Each bite we take requires us to evaluate how much pressure to exert from our jaw muscles—biting a carrot will take considerable more force than biting a banana. As we progress in our chewing and the food breaks down, we need less and less force from our jaws. If we want to hold a piece of food between our teeth, we must do so at exactly the right force so as not to drop it or crush it. These are all the proprioceptive system at work. Ever have that feeling that you put too much food in your mouth? Again, the proprioceptive system at work. We also need to avoid biting our tongue and cheeks when chewing, which means we need to know where they are at in relationship to our teeth. Some children overstuff their mouths because they enjoy the sensation they get from it; others may repeatedly bite their tongue during a meal. Biting a carrot might seem impossible for a child who is not consistently exerting enough force. All are signs that their proprioceptive system is not receiving or interpreting the input accurately.
The Tactile (Touch) System:
Our lips and tongues are loaded with touch receptors. They provide important information to the brain about the where our food is in our mouth, about the size of food, about the temperature of the food, and about the texture of the food. When we eat a messy ice cream cone, our lips detect that we need to lick the remains or wipe them with a napkin. As we chew, our tongue detects where the food is in our mouth. And when our tongue detects that a piece of food is small enough, then we can swallow it. We all have food temperatures and textures that are more favorable than others. However, in general, people have a wide range of hot, cold, warm, crunchy, chewy, smooth, mushy, chunky, meltable foods they eat. Some children become overwhelmed by the feeling of cold or hot food, so they wait until food is room temperature. Some children crave the calming sensation of munching on popcorn or chewing on granola bars. And some other children get completely overstimulated (at times to the point of gagging or vomiting) with mushy foods like mashed potatoes or cottage cheese, or foods that “pop” in their mouth like grapes or blueberries.
When we eat a mixed-texture food, such as yogurt with granola, our tongue must differentiate between the hard granola that must be chewed and the smooth yogurt that must be swallowed. The tongue moves the granola in between the teeth to breakdown the granola into pieces that can be swallowed along with the yogurt. While this discrimination happens all the time subconsciously, there are some children who lack these discrimination skills for safe eating. Most of the time these children limit their diets to foods they can trust (including particular brands), investigate their food carefully before consuming, and/or only eat single-textured foods. They cannot trust their tongue’s tactile discrimination abilities so they employ their own safety mechanisms.
The Gustatory (Taste) System:
Food taste can be categorized as sweet, sour, bitter, salty, or umami (i.e. savory). Saliva helps to not only breakdown our food in order to be swallowed, but also increases the temperature of our food in order to release flavors from the chemicals in food. In general, the more taste buds one has, the more intense their taste experiences. Our taste buds continue to mature until the age of 16 years—so don’t be surprised if as an adult you now like tomatoes that you hated as a child. Bitter foods, like many vegetables, generally take more time to accept because of our biological design to avoid ingesting harmful substances. It is recommended that infants start with vegetable purees before fruit purees for that reason. Some children are understimulated by food, and seem bored or inattentive when eating, until flavors like curry, chili, lemon, vinegar, or saffron are added to their food. While other children respond to these flavors like someone washing out their mouth with soap; one blackberry in their smoothie can make it seem like they’re drinking lemon juice. Bland foods are safe and predictable. As a note, children who have a history of repeated ear infections may prefer more savory, fatty, creamy foods because a branch of a cranial nerve runs from the middle ear to the anterior and middle tongue thus impacting what tastes they experience.
The Olfactory (Smell) System:
Smells of certain foods evoke such strong memories that we can almost taste the food without even taking a bite: grandma’s fresh apple pie, dad’s homemade biscuits, Aunt Carron’s savory lasagna. That’s because about 80-90% of the taste of food can be attributed to its smell. Everyone knows the trick of plugging your nose when eating something off-putting in order to diminish the taste. This works because it blocks “retronasal olfaction” – a fancy name for the passage of air from the back of the oral cavity into the nasal passage—that enhances the smell of food when eating. Our brain identifies this smell as coming from our mouth (which it does) and therefore associates it to taste rather than smell. For some children it is the smell of food that elicits a gag reflex or avoidance of many flavorful foods; odorless foods are preferred because overstimulation does not occur. Other children crave smell and repeatedly bring their food to their nose in order to enhance its taste.
NOTE: Children and adults who have anosmia (i.e. loss of smell) lack the cues from the olfactory system about the taste, and to a degree the texture, of food and may therefore activate their gag reflexes more quickly with unfamiliar foods.
The Visual System:
Presentation of food can make or break your mealtime experience. It sets up expectations for whether or not the food is fresh, and whether or not the food is cooked thoroughly (but not too thoroughly!). Eating with your eyes closed can dramatically change a meal because our visual system gives us a lot of information about our food before it even enters our mouth. We can see if there are croutons in our tomato bisque or whipped cream on top of our pancakes. How often do children decline trying a new food before they’ve tried it—just because of the way it looks? Some children cannot get past the visual cues from their food so they want it to look the same each time, they want to see the box or package it came from, they want to inspect each French fry to make sure it has no crispy parts, and/or they want to watch their food being prepared. The look of unfamiliar or undesired food triggers a part of the brain to become too overstimulated with the thought of how it might taste or feel in the mouth. That’s why repeated exposure of food (10-15 presentations!) is so important with children—familiarity is half the battle.
The Auditory (Sound) System:
Of the sensory systems with which we’re most familiar, this is often the least considered when it comes to eating. We generally do not attend to the sound of our food when we’re eating—probably because we’re busy attending to the conversation around the table. Some children cannot tolerate the sound of crunchy food as it’s being chewed because they have such extreme auditory sensitivity. This sensitivity may cause such dysregulation that the thought of eating evokes anxiety.
NOTE: Misophonia is a specific diagnosis associated with an extreme sensitivity to the sound of people chewing or smacking their lips, along with certain other sounds.
For those of you who weren’t counting, that’s seven senses that combine to make eating possible—3 to 5 times per day! Parents want their children to thrive in all areas, including participating in mealtime and eating a well-balanced diet. For children who are picky eaters, eating can be overstimulating, dysregulating, or disengaging. They may miss out or opt out of social opportunities around eating. Helping to address associated sensory processing challenges can open the doors to new mealtime experiences for the child and decrease the level of anxiety/stress/frustration at mealtime for the caregivers. If you have or know a child who is a picky eater (not due to medical issues), a comprehensive sensory evaluation by an occupational therapist certified in swallowing and feeding is recommended.