An appropriate narrative review design was utilized for integrating the literature from different disciplines and approaches, in a field where conceptual heterogeneity hinders the application of standardized, systematic criteria. Emerging diagnostic frameworks and their clinical applicability can be explored with this modality, which proposes healthcare practice-guided recommendations.5,6

A literature search was carried out using the PubMed, Scopus, SciELO, and LILACS databases, taking into account articles published from January 2000 to April 2025. The following terms in English and Spanish were used: Feeding Difficulties, Pediatric Feeding Disorder; interdisciplinary approach, picky eater, food neophobia, avoidant restrictive food intake disorder or ARFID, Trastornos de la alimentación infantil; alimentación selectiva; inapetencia persistente; enfoque interdisciplinario; neofobia alimentaria, trastorno de evitación/restricción de la ingesta de alimentos or TERIA. Based on the core search terms, synonyms and Boolean operators were utilized to produce search strategies adapted to each database. The publications included original articles, narrative reviews, systematic reviews, and relevant articles on diagnostic and therapeutic models. Studies focused exclusively on adolescents and eating disorders according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), such as anorexia nervosa, bulimia nervosa, pica, and rumination, were excluded. Works addressing diagnosis and management from an interdisciplinary perspective were prioritized, including current PFD proposals.1,3

The review and selection of documents was carried out in stages. Article relevance was independently analyzed, according to clinical utility, conceptual clarity, and multidisciplinary team applicability.

Because this is a narrative review, with no interventions on human subjects or use of personal data, approval by an ethics committee was not required. All documents used are publicly accessible and derived from the scientific literature.

FDs affect from 25 to 45% of healthy children and up to 80% in cases with altered neurodevelopment.3 They typically manifest after the first year of life, with signs that include picky eating, limited oral intake, refusal to try new foods, prolonged mealtimes, and disruptive mealtime behavior. In chronic cases, these symptoms persist beyond 3 months, interfering with the child’s growth, family dynamics, and social participation.1,4

Over the years, numerous authors have attempted to categorize pediatric FDs from different perspectives. Table 1 presents some of the most relevant definitions utilized in the literature, exemplifying the heterogeneity of diagnostic approaches and the need for a unified nomenclature. The DSM-V recognizes avoidant/restrictive food intake disorder (ARFID) as a clinical condition when there is nutritional involvement, weight loss, or marked functional impairment, in the absence of an identifiable organic cause.7 The incorporation of the International Classification of Diseases version 11 (ICD-11) has also been proposed as a public health reference framework.8 The term “picky eater” lacks a conceptual definition. Those patients have behavioral feeding issues with no dysfunction in medical, nutrional, feeding skill, or psychosocial domains. The most integrative functional definition of PFD, proposed by Goday et al., establishes 4 domains of analysis: medical, nutritional, feeding skill, and psychosocial dysfunction.1 The diagnosis of ARFID may be considered within the psychologic domain of PFD. Importantly, those patients do not have the altered perception of body image that is characteristic of eating disorders.7

The reviewed evidence shows that FDs respond to a multifactorial model. Prematurity, chronic gastrointestinal diseases, and neuromotor disorders stand out among the biologic factors.4,9 Behavioral factors, such as force-feeding, no mealtime structure, use of distractors, and autism spectrum disorder (ASD), are considered risk factors. A family history of eating disorders and/or FDs, highly stressful home environments, and unstable routines that directly influence the caregiver-child dynamics during feeding are also factors.4,13

From a developmental perspective, delay in the transition to textures or the late starting of complementary feeding may negatively impact chewing development, which has been related to later speech disorders and reduced acceptance of new foods.10,14,15

Table 2 summarizes the risk factors associated with FDs, grouped by category and potential clinical impact.

Classifications have evolved from dichotomic models (organic versus nonorganic) to more integrative approaches. Three predominant classification frameworks were identified:

• 1)

  Sensory-based classification: authors, such as Jean Ayres and Ahn et al., propose a classification according to sensory processing (hyper-responsiveness, hyporesponsiveness, or stimulus-seeking).10,23 This typology is useful in children with ASD or sensory integration dysfunctions.

• 2)

  Medical-nutritional classification: the DSM-V defines ARFID, based on specific clinical criteria, which is useful in contexts that require a codifiable diagnosis or psychopathologic assessment.7

• 3)

  Integrative classification/PFD: with the classification proposed by Goday et al., the presence of dysfunction in any of the 4 key domains can be simultaneously evaluated.1 This model has been shown to be operational in different clinical settings and especially useful for multidisciplinary teams.

The aim of the evaluation is to provide a comprehensive approach to identify clinical aspects that warrant specialized intervention. The initial evaluation includes a detailed clinical history, anthropometric assessment, sensorimotor development analysis, feeding history, and complementary studies (laboratory tests, among others).24 Directly observing feeding behaviors, including interaction with the caregiver, response to foods, and use of distractors, provides valuable information. In some cases, complementation with validated questionnaires applied by occupational therapists or psychologists, such as the Montreal Children’s Hospital Feeding Scale25 and Sensory Profile 2 test,26 is recommended.

The clinical evaluation may lead to the referral to other specialties, if there are alarm symptoms, such as dysphagia, persistent oral accumulation, aspiration-related pneumopathy, weight loss, or pesistent rejection of liquids.3,4 In such cases, a coordinated interdisciplinary approach is essential.1Table 3 summarizes the alarm symptoms that alert to referral to the different specialties of the health professionals involved.

Table 3.

Alarm symptoms for referral to different health profesional specialists.

Fig. 1 presents a clinical algorithm designed to identify alarm symptoms, guide classification according to the affected domains, and define interdisciplinary therapeutic strategies, to facilitate a structured and comprehensive approach to FDs in childhood.

Figure 1.

Clinical algorithm: pediatric feeding difficulties.

Treatment should be planned in stages and adapted to the clinical course of the patient. The strategies are described in 4 axes27:

• 1

  Medical treatment: address organic causes, manage pain, evaluate medications that can affect appetite or cause gastrointestinal discomfort,4,22 and consider the use of oral supplementation. Likewise, it is important to treat the digestive conditions of vomiting and constipation.

• 2

  Nutritional treatment: improve nutritional status without forcing intake. Progressive exposure to new foods, correction of specific nutritional deficiencies, and consideration of macro and micronutrient supplementation are recommended. Feeding should be offered 4–6 times a day, in pressure and distractor-free environments, with mealtimes limited to 20−30 min.4,21,24

• 3

  Psychosocial treatment:

  3.1. Behavioral intervention: establish routines, reduce avoidance behaviors, and promote autonomy.28 Desireable conducts should be reinforced during meals. The management of conditions, such as autism and other psychologic and psychiatric disorders, should be incorporated into the plan.

  3.2. Family intervention: educate the caregivers about adequate feeding practices, avoiding pressure or punishment during meals and promoting the active participation of the child in the preparation and selection of foods. Reinforce the idea that the adult defines what, when, and where food is offered and the child determines the quantity.

• 4.

  Complementary therapies: carry out sensory integration and fine motor skill development; phoniatrics and logopedia evaluate swallowing mechanics, oral motor function, and adapt textures or utensils, as needed.28,29.

Follow-up should be continuous and adjusted to the clinical response. The re-evaluation of individualized goals makes it possible to adjust the therapeutic plan without overburdening the family.