Pediatr Gastroenterol Hepatol Nutr. 2015 Mar;18(1):1-9. English.
Published online Mar 30, 2015.
Copyright © 2015 by The Korean Society of Pediatric Gastroenterology, Hepatology and Nutrition
Review

How to Improve Eating Behaviour during Early Childhood

Robin John Green, Gamal Samy,* Mohamad Saleh Miqdady, Mohamed Salah, Rola Sleiman,§ Hatim Mohamed Ahmed Abdelrahman, Fatima Al Haddad, Mona M. Reda,** Humphrey Lewis, Emmanuel E. Ekanem,†† and Yvan Vandenplas‡‡
    • Department of Paediatrics and Child Health, University of Pretoria, Pretoria, South Africa.
    • *Department of Child Health and Nutrition, Institute of Postgraduate Childhood Studies, Ain Shams University, Cairo, Egypt.
    • Division of Hepatology and Nutrition, Department of Pediatric Gastroenterology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates.
    • Wyeth Nutrition, Dubai, United Arab Emirates.
    • §Doctor Soliman Fakeeh Hospital, Jeddah, Kingdom of Saudi Arabia.
    • Cornell Medical College and Hamad Medical Corporation, Doha, Qatar.
    • Salmaniya Medical Complex, Manama, Kingdom of Bahrain.
    • **Institute of Psychiatry, Ain Shams University, Cairo, Egypt.
    • ††Department of Pediatrics, University of Calabar and University of Calabar Teaching Hospital, Calabar, Nigeria.
    • ‡‡Department of Pediatrics, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
Received January 21, 2015; Accepted January 30, 2015.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Eating behaviour disorder during early childhood is a common pediatric problem. Many terminologies have been used interchangeably to describe this condition, hindering implementation of therapy and confusing a common problem. The definition suggests an eating behaviour which has consequences for family harmony and growth. The recent Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition does not cover the entire spectrum seen by pediatricians. Publications are substantive but level of evidence is most of the time low. This purpose of this review is to clarify terminology of eating behaviour problems during early childhood; including benign picky eating, limited diets, sensory food aversion, selective eating, food avoidance emotional disorder, pervasive refusal syndrome, tactile defensiveness, functional dysphagia, neophobia and toddler anorexia. This tool is proposed only to ease the clinical management for child care providers. Diagnostic criteria are set and management tools are suggested. The role of dietary counselling and, where necessary, behavioural therapy is clarified. It is hoped that the condition will make its way into mainstream pediatrics to allow these children, and their families, to receive the help they deserve.

Keywords
Eating behaviour disorders; Eating disorders; Picky eater; Early childhood; Meals

INTRODUCTION

The eating process is of importance for survival and health. Eating disorders have been adequately addressed and discussed in adults and adolescents with many randomized controlled trials and system atic reviews. They have been classified in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) [1]. By contrast, eating behaviour of early childhood, a common problem for pediatric practitioners, is a topic without clarity. Moreover, in DSM5 [1] both "Other Specified Feeding or Eating Disorder, 307.59" and "Unspecified Feeding or Eating Disorder 307.50" cannot adequately explain many of the problems observed during early childhood. The chapter on eating disorders of infants and early childhood was replaced in DSM5 by "Avoidant/Restrictive Food Intake Disorder: 307.59" but it was not analysed in sufficient detail to help plan a therapeutic approach. The picky eater category was not included, considering it a non-mental problem. This confusion can be attributed to lack of agreement on the terminology used, little available original research and possible psycho-behavioural and organic, multifactorial nature of this problem. The aim of this review is to evaluate the publications and opinions in the context of the disorder and in light of the available levels of clinical evidence.

The terminology "eating behaviour disorder of early childhood" which we introduce includes conditions such as picky eating [2], limited diets, sensory food aversion [3], selective eating [4], food avoidance emotional disorder [5], pervasive refusal syndrome [6], tactile defensiveness [7], neophobia [8] and toddler anorexia [9]. This tool is proposed to ease the clinical management for child care providers. The DSM5 classification of "Avoidant/Restrictive Food Intake Disorder: 307.59" will overlap with eating behaviour of early childhood as the former includes all age groups and the latter will include other disorders excluded in the former group.

METHODOLOGY

An exhaustive search of Pubmed for the last 20 years was conducted. Keywords used included "childhood feeding" and "childhood eating (problems, disorders or difficulties)". All works were retrieved and their level of evidence and quality was determined (Table 1) [10]. The most valid and recent literature was used in this review.

Table 1
Evidence Level and Quality

DEFINITION

The proposed definition of eating behaviour disorders of early childhood states "a condition that imposes a short-term eating behaviour of the child with possible risk of long-term health consequences" (Table 2) [11]. These effects are important for both child and family. Wherever possible, the definition builds on the definitions used in the many conditions described above [1, 2, 3, 4, 5, 6, 7, 8, 9].

Table 2
Definition of Eating Behaviour Disorder of Early Childhood

PREVALENCE

Based on the previous definition, eating behaviour disorders of early childhood are a common chronic condition and prevalence rates vary from 13% to 22% or 13% to 50%, depending on age and various definitions [12, 13].

RISK FACTORS

Many risk factors that predispose to eating behaviour disorders of early childhood (Table 3) [14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24]. Risk identification may provide a clue to early intervention.

Table 3
Risk Factors for Eating Behaviour Disorder Early Childhood

DIAGNOSIS

A high index of suspicion for the diagnosis of eating behaviour disorders of early childhood should be raised if one or more of the following factors are present:

  1. Parents are concerned about an abnormal established eating behavior that is related to diet or meal time regarding [12, 25, 26] (level of evidence: B): content (avoidance/preference), quality, texture/color, duration (slow/incomplete), unpleasant, messy, behavioral abnormalities

  2. Health care worker identified consequences where objective history and examination of the child reveal [14, 27, 28]: growth faltering (B), micro-nutrient deficiency (C), obesity (B), behavioral disorders (B), chronic illness (C), sleep disturbance (B), anemia (C), constipation (C), family disharmony (B)

  3. Occurs at any age (usually after the age of 2 years) in which a child independently begins to eat and is usually present for more than one month [14]

  4. Not related to food availability due to poverty or food insecurity

  5. Thorough clinical evaluation excluded a significant underlying organic disease that may, on its own, produce micro- or macro-nutrient deficiencies

Questionnaires to identify eating behaviour disorders of early childhood have been developed [15]. In making an assessment of a child with an eating behaviour disorders of early childhood it is important to assess food quality and quantity (consumption) and behavior during meals and to perform a thorough examination of the child. Some important elements of assessment are listed in Table 4.

Table 4
Assessment Form for a Child with a Suspected Eating Behaviour Disorder Early Childhood

CONSEQUENCES AND PROGNOSIS OF EATING BEHAVIOUR DISORDERS OF EARLY CHILDHOOD

The condition is, in some cases, not benign and if left untreated may result in a number of consequences such as anorexia, growth disturbance, conduct disorders, food preferences into adulthood and, importantly, macro- and micro-nutrient deficiencies [13, 14].

DIFFERENTIAL DIAGNOSIS

Although eating behaviour disorders of early childhood is proposed as a specific entity in this context, it should be remembered that many conditions may cause disordered eating such as cow's milk protein allergy and medication side effects [29].

Co-morbidities may include other behavioral problems especially around meal times, including messiness, poor manners, foul language and lack of attention.

Specific neurological or psychological disorders that form their own syndrome may overlap with eating behaviour disorders of early childhood but are not a natural extension of this specific syndrome. These may include pervasive developmental disorder, attention deficit disorder, conduct disorders and sensory integration disorder [30]. However, some chronic illnesses do not affect appetite but may disturb family or eating behaviors that set the scene for eating behaviour disorders of early childhood.

STAGING-SEVERITY ASSESSMENT

As the proposed definition of eating behaviour disorders of early childhood encompasses a heterogeneous group of disorders, a severity score is mandatory to plan a protocol of management and follow up. This will avoid managing all children with eating behaviour disorders of early childhood in the same way.

Important features to assess severity include:

  • Parental perception of severity (words such as "always", "severe", "worried" and "concerned" should be noted)

  • Family disharmony (with or without overt reference to the 'picky eater' child) must be factored into judging severity of all stages

  • Careful plotting of anthropometric measurements (including body mass index and growth velocity) and focus on growth pattern

  • Assessment of clinical signs of possible micro-nutrient deficiencies

Attention to the diagnosis of other chronic illnesses that may interfere or cause eating behavior disorders are required.

Growth faltering and micro-nutrient deficiencies are related to severity of eating disorders [13, 18] (Table 5).

Table 5
Staging Assessment of Severity

CLINICAL SUSPICION OF MICRO-NUTRIENT DEFICIENCIES

Iron, zinc and vitamin A are the most common micro-nutrients which could be affected in eating disorders [31, 32].

Symptoms of iron deficiency range from fatigue and inability to concentrate to impaired physical and cognitive development of children. The most common reason for iron deficiency is insufficient iron intake from food [32].

The health consequences of zinc deficiency include poor immune system function, growth retardation. Diets with poor meat and fish intake increase the risk of zinc deficiency, because zinc in cereals is poorly bioavailable [31].

Vitamin A is another essential nutrient in the human diet, contributing to the functioning of the retina, the growth of bone and the immune response [33]. Beta-carotene is a precursor of vitamin A found in fruits and vegetables. However, investigations have shown that beta-carotene is not as bioavailable as once thought [34].

MANAGEMENT PLAN

Whilst therapy will have to be individualized, it seems prudent to a select management plan based on the severity of the eating disorder (Table 6) [8]. Whilst vitamin, mineral and nutritional supplements are helpful in treating or preventing macroand micro-nutrient deficiencies, these should be seen as transient supportive interventions. They may allow time for dietary and behavioral modification. These supplements should not be given during the main meals. Pharmacological therapy has not been shown to be of any efficacy in improving eating behavior and is thus not recommended [35].

Table 6
Management Plan for Eating Behaviour Disorder Early Childhood [8]

Table 7 summarizes the tools and interventions that may be of benefit in children with eating behavior disorders [36].

Table 7
Tools in the Management of Eating Behaviour Disorder Early Childhood [36]

Dietary management

The role of a dietician or nutritionist is critical in these children [35, 37, 38, 39, 40]. The dietician will analyse the specificities of the composition of the diet, including quality, quantity, nutritional content and type.

Nutritional management of an eating behavior disorder plays a major role in determining health outcome.

The determinants of a successful nutritional intervention revolve around three main concepts:

  1. A systematic method of nutritional assessment (gathering objective data)

  2. A thorough evaluation of nutritional intake

  3. A solid, structured (nutritional counseling) plan

GATHERING OBJECTIVE DATA

Anthropometric assessment is important in assessing nutritional status of children [40]. Weight and height should be measured using standardized methods and the evaluation of these parameters should be plotted on appropriate curves. In addition, results from objective measurements (serum, bone density, etc.) can be used to further complete the assessment.

EVALUATING NUTRITIONAL INTAKE

Several methods are available to assess dietary intake [35]. At the initial visit a 24-hour recall is noted. This is followed by a 3-day to 1-week food prospective diary (which should include a weekend day) for further assessment.

Food logs or 24-hour food recalls are important for dieticians to collate and must include:

  • All food groups

  • Well defined meal times

  • Food textures at each meal

  • Certain behaviors during meal-time such as gaging or spitting out food should also be noted

NUTRITIONAL COUNSELING AND SUPPLEMENTATION

The important elements to be stressed in nutritional counseling are [41]:

  • Developing a meal-time routine

  • Planning three main meals and 2-3 snacks, avoiding food fillers

  • Encouraging new foods (remembering that it may take up to 15 offerings before a child can be confidently determined to be refusing that food and giving up)

  • Considering nutritional supplementation

Behavioral treatment

Early intervention is important. Treatment of highly selective or low overall eating may prevent the development of more serious feeding difficulties. Caregiver-friendly intervention strategies that can be implemented with children in their community environments (e.g., in the child's home or school) may reduce the need for tertiary care [42]. A psychotherapeutic approach that addresses dysfunctional emotions, behaviors, and cognitions through a goal-oriented, systematic process is required. Several researchers have suggested that behavioral mismanagement (i.e., inadvertent reinforcement of inappropriate eating patterns) frequently contributes to the onset and maintenance of feeding problems [43, 44, 45]. For example, negative reinforcement may be created if a caregiver typically removes undesired food items or terminates meals when a child refuses to eat or to consume age-appropriate quantities of food, the child may be more likely to display inappropriate behavior during meals to escape or avoid less preferred food items or larger quantities of food.

Behavioral interventions have been demonstrated to be effective for treating feeding problems in children. A multi-component treatment package consisting of positive reinforcement and escape extinction is the most commonly used intervention [44, 46, 47, 48]. The positive reinforcement component typically involves providing the child with access to preferred stimuli (e.g., food, toys, praise, tokens) for desired eating behavior (i.e., accepting or swallowing bites). Escape extinction which is implemented when a child's feeding problem is presumed to be maintained by negative reinforcement, is a procedure in which escape from, or avoidance of, the demand of eating is no longer permitted. Non-removal of the spoon is an example of an escape extinction procedure that involves positioning the spoon in front of the child's mouth until the bite is accepted, thus preventing escape from or avoidance of the bite presentation [44, 46, 47, 48]. An alternative escape extinction procedure, physical guidance, consists of exerting gentle pressure on the child's mandibular joint or chin so that the mouth is guided open and the food is placed in the child's mouth [47, 48].

Although a common component of interventions for childhood feeding problems, escape extinction has been associated with a number of undesirable side effects, including response bursts (i.e., initial increases in problem behavior), extinction-induced aggression, and emotional responding (e.g., crying) [49]. Moreover, meals may become difficult for caregivers if they must physically prevent escape from or avoidance of eating while managing the side effects of extinction, particularly if increases in desired behaviors (e.g., bite acceptance) do not occur immediately. Thus, escape extinction procedures may not be ideal for treatment programs conducted in natural settings (e.g., in the child's home or school) or by inexperienced care givers (e.g., parents, teachers, paraprofessionals).

Differential (positive) reinforcement of alternative behaviors involves providing the child with access to preferred stimuli contingent on desired behaviors, such as accepting or swallowing bites of food.

An alternative to providing preferred foods or liquids contingently is to provide other types of preferred stimuli continuously throughout the meal. Preferred toys or activities are the most common stimuli used when non-contingent (positive) reinforcement is utilized in the treatment of feeding problems [50, 51].

Simultaneous presentation involves presenting a less preferred food at the same time as a more preferred food. The foods may be presented together on the spoon or blended together, or the non-preferred food may be inside or covered by the preferred food.

Stimulus fading is a technique of gradually changing the ratio or concentration of paired preferred and non-preferred foods or liquids which may reduce the risk associated with pairing non-preferred and preferred foods [52].

High-probability instructional sequence involves presenting a series of instructions for which compliance is highly likely followed by a request for which compliance is unlikely (i.e., a low-probability instruction). The high-probability sequence consists of three presentations of an empty spoon; the low-probability instruction is the presentation of a spoon with food. Results of this study suggest that a high-probability instructional sequence may be effective in increasing compliance (acceptance) with food in the absence of escape extinction if a child demonstrates high levels of compliance with a similar request such as acceptance of an empty spoon [53].

Parents of children with eating behavior disorders should learn the key points of behavioral management of their children as shown in Table 8 [54].

Table 8
Tips for Nutritional and Behavioral Management by Parents of Children with Eating Behaviour Disorder Early Childhood [54]

CONCLUSION

The term eating behaviour disorders of early childhood is meant to be the umbrella under which all problems of eating are listed at this specific age. Diagnostic features are proposed and a difference from the DSM5 classification of "Avoidant/Restrictive Food Intake Disorder: 307.59" is shown. Detailed history taking from parents and a thorough clinical examination by the health care worker are essential. A classification of severity is proposed to separate children with meal-time abnormal behavior only from those who have associated risk, or actual consequences, of growth disturbance and micro-nutrient deficiencies. Following staging, therapy, although required to be tailored to children and families, should incorporate dietary and behavioral education and/or therapy. Nutritional supplements are a useful but transient addition to the management of such a condition.

References

    1. American Psychiatric Association. DSM-5 Development [Internet]. Arlington: American Psychiatric Association; [accessed 2014 Oct 21].
    1. Leung AK, Marchand V, Sauve RS. Canadian Paediatric Society, Nutrition and Gastroenterology Committee. The 'picky eater': The toddler or preschooler who does not eat. Paediatr Child Health 2012;17:455–460.
    1. Zangen T, Ciarla C, Zangen S, Di Lorenzo C, Flores AF, Cocjin J, et al. Gastrointestinal motility and sensory abnormalities may contribute to food refusal in medically fragile toddlers. J Pediatr Gastroenterol Nutr 2003;37:287–293.
    1. Murray SB, Thornton C, Wallis A. Selective eating in a 9-year-old boy: family therapy as a first-line treatment. Clin Child Psychol Psychiatry 2013;18:270–275.
    1. Goëb JL, Azcona B, Troussier F, Malka J, Giniès JL, Duverger P. Food avoidance emotional disorder in 3 to 10-year-old children: a clinical reality. Arch Pediatr 2005;12:1419–1423.
    1. Wright B, Beverley D. Pervasive refusal syndrome. Clin Child Psychol Psychiatry 2012;17:221–228.
    1. Smith AM, Roux S, Naidoo NT, Venter DJ. Food choice of tactile defensive children. Nutrition 2005;21:14–19.
    1. Dovey TM, Staples PA, Gibson EL, Halford JC. Food neophobia and 'picky/fussy' eating in children: a review. Appetite 2008;50:181–193.
    1. Chatoor I, Ganiban J, Hirsch R, Borman-Spurrell E, Mrazek DA. Maternal characteristics and toddler temperament in infantile anorexia. J Am Acad Child Adolesc Psychiatry 2000;39:743–751.
    1. American Academy of Pediatrics Steering Committee on Quality Improvement and Management. Classifying recommendations for clinical practice guidelines. Pediatrics 2004;114:874–877.
    1. Piazza CC. Feeding disorders and behavior: what have we learned? Dev Disabil Res Rev 2008;14:174–181.
    1. Mascola AJ, Bryson SW, Agras WS. Picky eating during childhood: a longitudinal study to age 11 years. Eat Behav 2010;11:253–257.
    1. Carruth BR, Ziegler PJ, Gordon A, Barr SI. Prevalence of picky eaters among infants and toddlers and their caregivers\' decisions about offering a new food. J Am Diet Assoc 2004;104 1 Suppl 1:s57–s64.
    1. Jacobi C, Agras WS, Bryson S, Hammer LD. Behavioral validation, precursors, and concomitants of picky eating in childhood. J Am Acad Child Adolesc Psychiatry 2003;42:76–84.
    1. Goh DY, Jacob A. Perception of picky eating among children in Singapore and its impact on caregivers: a questionnaire survey. Asia Pac Fam Med 2012;11:5.
    1. Briefel R, Hanson C, Fox MK, Novak T, Ziegler P. Feeding Infants and Toddlers Study: do vitamin and mineral supplements contribute to nutrient adequacy or excess among US infants and toddlers? J Am Diet Assoc 2006;106 1 Suppl 1:S52–S65.
    1. Saarilehto S, Lapinleimu H, Keskinen S, Helenius H, Talvia S, Simell O. Growth, energy intake, and meal pattern in five-year-old children considered as poor eaters. J Pediatr 2004;144:363–367.
    1. Dahl M, Sundelin C. Feeding problems in an affluent society. Follow-up at four years of age in children with early refusal to eat. Acta Paediatr 1992;81:575–579.
    1. Douglas JE, Bryon M. Interview data on severe behavioural eating difficulties in young children. Arch Dis Child 1996;75:304–308.
    1. Shim JE, Kim J, Mathai RA. STRONG Kids Research Team. Associations of infant feeding practices and picky eating behaviors of preschool children. J Am Diet Assoc 2011;111:1363–1368.
    1. Nicklaus S. Children's acceptance of new foods at weaning. Role of practices of weaning and of food sensory properties. Appetite 2011;57:812–812.
    1. Chatoor I, Ganiban J. Food refusal by infants and young children: Diagnosis and treatment. Cognitiv Behav Prac 2003;10:138–146.
    1. McDermott BM, Mamun AA, Najman JM, Williams GM, O'callaghan MJ, Bor W. Preschool children perceived by mothers as irregular eaters: physical and psychosocial predictors from a birth cohort study. J Dev Behav Pediatr 2008;29:197–205.
    1. Micali N, Simonoff E, Treasure J. Infant feeding and weight in the first year of life in babies of women with eating disorders. J Pediatr 2009;154:55–60.
    1. Carruth BR, Skinner J, Houck K, Moran J 3rd, Coletta F, Ott D. The phenomenon of "picky eater": a behavioral marker in eating patterns of toddlers. J Am Coll Nutr 1998;17:180–186.
    1. Skinner JD, Carruth BR, Bounds W, Ziegler P, Reidy K. Do food-related experiences in the first 2 years of life predict dietary variety in school-aged children? J Nutr Educ Behav 2002;34:310–315.
    1. Dubois L, Farmer A, Girard M, Peterson K, Tatone-Tokuda F. Problem eating behaviors related to social factors and body weight in preschool children: A longitudinal study. Int J Behav Nutr Phys Act 2007;4:9.
    1. Marchi M, Cohen P. Early childhood eating behaviors and adolescent eating disorders. J Am Acad Child Adolesc Psychiatry 1990;29:112–117.
    1. Douglas PS. Diagnosing gastro-oesophageal reflux disease or lactose intolerance in babies who cry a lot in the first few months overlooks feeding problems. J Paediatr Child Health 2013;49:E252–E256.
    1. Nadon G, Feldman DE, Dunn W, Gisel E. Association of sensory processing and eating problems in children with autism spectrum disorders. Autism Res Treat 2011;2011:541926.
    1. Lask B, Fosson A, Rolfe U, Thomas S. Zinc deficiency and childhood-onset anorexia nervosa. J Clin Psychiatry 1993;54:63–66.
    1. Buchanan GR. The tragedy of iron deficiency during infancy and early childhood. J Pediatr 1999;135:413–415.
    1. National Institutes of Health. Vitamin A: fact sheet for health professionals [Internet]. Bethesda: National Institutes of Health; 2013 [accessed 2014 Dec 1].
    1. Basti S, Schmidt C. Vitamin a deficiency. Cornea 2008;27:973.
    1. Rosen DS. Eating disorders in children and young adolescents: etiology, classification, clinical features, and treatment. Adolesc Med 2003;14:49–59.
    1. Owen C, Ziebell L, Lessard C, Churcher E, Bourget V, Villenueve H. Interprofessional group intervention for parents of children age 3 and younger with feeding difficulties: pilot program evaluation. Nutr Clin Pract 2012;27:129–135.
    1. Hurley KM, Black MM. Commercial baby food consumption and dietary variety in a statewide sample of infants receiving benefits from the special supplemental nutrition program for women, infants, and children. J Am Diet Assoc 2010;110:1537–1541.
    1. Evans A, Seth JG, Smith S, Harris KK, Loyo J, Spaulding C, et al. Parental feeding practices and concerns related to child underweight, picky eating, and using food to calm differ according to ethnicity/race, acculturation, and income. Matern Child Health J 2011;15:899–909.
    1. Galloway AT, Fiorito L, Lee Y, Birch LL. Parental pressure, dietary patterns, and weight status among girls who are "picky eaters". J Am Diet Assoc 2005;105:541–548.
    1. Ekstein S, Laniado D, Glick B. Does picky eating affect weight-for-length measurements in young children? Clin Pediatr (Phila) 2010;49:217–220.
    1. Alarcon PA, Lin LH, Noche M Jr, Hernandez VC, Cimafranca L, Lam W, et al. Effect of oral supplementation on catch-up growth in picky eaters. Clin Pediatr (Phila) 2003;42:209–217.
    1. Kedesdy JH, Budd KS. In: Childhood feeding disorders: bio-behavioral assessment and intervention. Baltimore: Paul H. Brookes; 1998.
    1. Palmer S, Thompson RJ Jr, Linscheid TR. Applied behavior analysis in the treatment of childhood feeding problems. Dev Med Child Neurol 1975;17:333–339.
    1. Babbitt RL, Hoch TA, Coe DA. Behavioral feeding disorders. In: Tuchman DN, Walter R, editors. Disorders of feeding and swallowing in infants and children: pathophysiology, diagnosis, and treatment. San Diego, CA: Singular Publishers; 1994. pp. 77-95.
    1. Piazza CC, Carroll-Hernandez TA. Assessment and treatment of pediatric feeding disorders. In: Tremblay RE, Barr RG, Peters RDeV, editors. Encyclopedia on early childhood development [online]. Montreal, Quebec: Centre of Excellence for Early Childhood Development; 2004. pp. 1-7.
    1. Cooper LJ, Wacker DP, McComas JJ, Brown K, Peck SM, Richman D, et al. Use of component analyses to identify active variables in treatment packages for children with feeding disorders. J Appl Behav Anal 1995;28:139–153.
    1. Kerwin ME, Ahearn WH, Eicher PS, Burd DM. The costs of eating: a behavioral economic analysis of food refusal. J Appl Behav Anal 1995;28:245–260.
    1. Ahearn WH, Kerwin ML, Eicher PS, Shantz J, Swearingin W. An alternating treatments comparison of two intensive interventions for food refusal. J Appl Behav Anal 1996;29:321–332.
    1. Lerman DC, Iwata BA, Wallace MD. Side effects of extinction: prevalence of bursting and aggression during the treatment of self-injurious behavior. J Appl Behav Anal 1999;32:1–8.
    1. Reed GK, Piazza CC, Patel MR, Layer SA, Bachmeyer MH, Bethke SD, et al. On the relative contributions of noncontingent reinforcement and escape extinction in the treatment of food refusal. J Appl Behav Anal 2004;37:27–42.
    1. Wilder DA, Normand M, Atwell J. Noncontingent reinforcement as treatment for food refusal and associated self-injury. J Appl Behav Anal 2005;38:549–553.
    1. Rivas KD, Piazza CC, Patel MR, Bachmeyer MH. Spoon distance fading with and without escape extinction as treatment for food refusal. J Appl Behav Anal 2010;43:673–683.
    1. Patel M, Reed GK, Piazza CC, Mueller M, Bachmeyer MH, Layer SA. Use of a high-probability instructional sequence to increase compliance to feeding demands in the absence of escape extinction. Behavior Interven 2007;22:305–310.
    1. Brown JF, Spencer K, Swift S. A parent training programme for chronic food refusal: a case study. Br J Learn Disabil 2002;30:118–121.

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