609311

research-article2015
PENXXX10.1177/0148607115609311Journal of Parenteral and Enteral NutritionEdwards et al

Tutorial
Journal of Parenteral and Enteral
Nutrition
Interdisciplinary Strategies for Treating Oral Aversions in Volume 39 Number 8
November 2015 899–909
Children © 2015 American Society
for Parenteral and Enteral Nutrition
DOI: 10.1177/0148607115609311
jpen.sagepub.com
hosted at
online.sagepub.com
Sarah Edwards, DO1; Ann McGrath Davis, PhD, MPH, ABPP2,3;
Linda Ernst, MS, CCC-SLP1; Brenda Sitzmann, MA, CCC-SLP, CLC1;
Amanda Bruce, PhD2,3; David Keeler, RN1; Osama Almadhoun, MD2;
Hayat Mousa, MD4; and Paul Hyman, MD5

Abstract
Oral aversion is a frequent diagnosis in the pediatric population. For a minority of children, feeding challenges rise to the level of requiring
clinical evaluation and intervention. Determining the best evaluation and treatment plan can be challenging, but there is a consensus that
treatment for children with a severe oral aversion involves an interdisciplinary approach. Within the team model, multiple strategies have
demonstrated effectiveness, including sensorimotor skill building, behavioral modification, hunger provocation, and sensory integration
therapy. This tutorial reviews the diagnostic and treatment process for a child with oral aversion, including identification of an underlying
etiology, the medical and behavioral evaluation, and formulation of a treatment plan. (JPEN J Parenter Enteral Nutr. 2015;39:899-909)

Keywords
oral aversion; treatment; interdisciplinary; review; tube feeding; children

Oral aversions in childhood are common, with estimates ranging
from 1–4 to almost half of children.1–3 Even typically developing
children frequently experience some form of mild to moderate
feeding problems or food restriction. For a minority of children,
feeding challenges rise to the level of requiring clinical evaluation
and intervention. This type of severe feeding aversion is common
among children with chronic illness, with up to 80% of medically
fragile children experience some form of feeding restriction or dif-
ficulty.1,2 Often, oral aversions and feeding difficulties require
specialized interdisciplinary treatment. An interdisciplinary team
approach has become the standard of care for children with diffi-
cult feeding problems.4 These teams often include a pediatric gas-
troenterologist, psychologist, dietitian, nurse, speech pathologist,
and occupational therapist, and expert consensus has supported
this approach to pediatric feeding treatments.5
This article explores some of the common medical diagno-
ses and psychological/behavioral etiologies for oral aversions
and feeding difficulties in children. We outline the assessment
process important for developing a treatment plan and the roles
of treatment providers. In an interdisciplinary treatment team,
each expert has an area of expertise, but the key to optimal
assessment and treatment is the communication and integra-
tion of expertise across domains.
Etiology
The first step in the treatment of an oral aversion is the diagnosis
and treatment of any underlying medical causes that led to the
orally aversive behaviors. Some previous research suggests the
greatest contributors to oral aversions may be gastrointestinal
(GI) in nature (42.5%6). These primarily include gastroesopha-
geal reflux, followed by food allergy, congenital anomalies
(such as tracheoesophageal fistula), esophageal atresia, and such
syndromes as CHARGE (coloboma, heart defects, atresia of the
choanae, retardation of growth, genital and/or urinary abnormal-
ities, and ear abnormalities) and VATER (vertebra, imperforate
anus, tracheoesophageal fistula, renal anomalies). Another com-
monly identified etiology is GI mucosal disease, such as peptic
disease, Helicobacter pylori, celiac disease, Crohn’s disease,
and bacterial overgrowth.6 Mechanical/structural abnormalities
can also contribute to oral aversion (53%; eg, cleft lip or palate,
dental carries, laryngeal cleft).7–9 These conditions can also
include cerebral palsy, brainstem injury, and muscular dystro-
phies or cranial nerve dysfunctions. Other research suggests that
From the 1Children’s Mercy Kansas City, Kansas City, Missouri;
2
Department of Pediatrics, University of Kansas Medical Center, Kansas
City, Kansas; 3Center for Children’s Healthy Lifestyles & Nutrition,
Kansas City, Missouri; 4University of California in San Diego, Rady
Children’s Hospital, San Diego, California; and 5New Orleans Children’s
Hospital, New Orleans, Louisiana.
Financial disclosure: None declared.
Received for publication June 19, 2015; accepted for publication August
12, 2015.
Corresponding Author:
Sarah Edwards, DO, Department of Pediatric Gastroenterology,
Children’s Mercy Kansas City, 2401 Gillham Rd, Kansas City, MO
64108, USA.
Email: sedwards1@cmh.edu

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900
the greatest contributor to oral aversions may be neurological
(62%) and/or behavioral (43%).7 Previous studies suggest the
highest percentage of patients with complex feeding issues have
a combination of structural, neurological, and behavioral causes
or a combination of neurological and behavioral causes for their
feeding problems.7,9
Feeding difficulties are present in up to 80% of children
with a chronic medical or behavioral diagnosis,1,2 and these
medical diagnoses are often a key factor in the treatment of the
feeding disorder. For example, ex-preterm infants with bron-
chopulmonary dysplasia may breathe so fast that they cannot
comfortably coordinate sucking, swallowing, and breathing
sequences. Infants with heart failure may develop dyspnea and
quit sucking and swallowing. Infants with renal failure may
have no appetite and low energy. Hypotonia and genetic disor-
ders such as Down and Mobius syndromes and cerebral palsy
cause problems with chewing and swallowing due to poor
muscle function in the face and oropharynx, as well as poor
ability to maintain postural stability for these functions.
Sensory/Pain Disorders
Sensory or pain disorders can contribute to oral aversion in
children. In susceptible individuals, early life pain experiences
may store pain memories that return at a later time to be
expressed as a chronic GI pain problem.10–17 The changes
induced in the enteric and central nervous systems responsible
for development of GI tract hyperalgesia are reviewed in detail
elsewhere.18 When intensive behavioral and nutrition treat-
ment resulted in successful transition from tube to oral feeding
in 47% of infants,19 it seemed possible that the infants who did
not advance may have failed because it hurt to eat or they were
afraid it would hurt to eat. In uncontrolled trials, efforts to
reduce pain prior to advancing oral feeding seem to improve
outcomes for tube-fed infants and toddlers4,20 and postopera-
tive cardiac surgery infants in the first months of life.21 Pain
treatment for tube-fed patients included bypassing the stomach
with gastrojejunal tube feeding to avoid distending the stom-
ach and thereby reduce discomfort and retching. Medications
for chronic pain included amitriptyline and gabapentin.
Amitriptyline was initiated at doses ranging from 0.25–0.3 mg/
kg at bedtime. Amitriptyline was increased by 0.25–0.3 mg/kg
weekly to the desired effect (eg, no more retching or gagging)
or to a maximal dose of 1 mg/kg/d.4,20 Gabapentin was initiated
at doses of 10 mg/kg/dose twice daily. If gabapentin was with-
out side effects, it was advanced to 3 times daily.
Behavioral Causes of Oral Aversion
Diagnostic criteria for feeding disorders not associated with
organic disease or failure to thrive have been proposed.22–24
These include the following:
1. Persistent food refusal >1 month
2. Absence of organic disease
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Journal of Parenteral and Enteral Nutrition 39(8)
3. Age of onset <2 years
4. Presence of abnormal feeding or anticipatory gagging
(anticipatory gagging included retching, gagging, or
vomiting with sight of food)
Abnormal feeding has been defined by 1 of 6 infant-caregiver
behaviors:
1. Nocturnal feeding. Feeding an infant who is in twilight
sleep, just dozing off, because the child refuses to eat
or drink or only takes small quantities while awake.
2. Persecutory feeding. Constant, mostly unsuccessful
efforts to feed an infant. There are repeated efforts to
get the child to drink one more swallow or eat one
more bite, despite repeated refusals.
3. Forced feeding. Prying open a child’s jaws to deliver
food against the child’s will.
4. Mechanistic feeding. Scheduled feedings at regular
intervals and required exact volumes irrespective of
hunger cues. The mechanistic feeder is unaware of the
child’s behaviors responding to feeding.
5. Conditional distraction. All meals take place with a
distraction. The child refuses to eat without distraction
and has no interest in food.
6. Prolonged meals. Child eats minute quantities but
caregiver persists despite absence of success with or
without other abnormal feeding behaviors listed above.
These clinical criteria may be used to separate functional
from medical causes of feeding disorders.
Factors that may trigger a feeding disorder may include the
following24:
1. Caregivers perceive their infant as too small (eg, pre-
mature birth or small for gestational age), leading to
persistent efforts to overfeed, beyond the infant’s hun-
ger cues
2. Traumatic transition from one type of feeding to
another (eg, breast to bottle)
3. Early life pain experiences sensitizing the oropharynx,
esophagus, and/or stomach (eg, endotracheal intuba-
tion, orogastric intubation, necrotizing enterocolitis),
creating hyperalgesia associated with odynophagia,
dysphagia, chest pain, or dyspepsia, resulting in food
refusal and consequent intrusive feeding
4. Mechanistic feeding: scheduled feedings without
regard for hunger cues from the infant or a caregiver
who is emotionally detached when feeding the infant
Diagnostic criteria for infants and toddlers with failure to
thrive and feeding problems have also been described25,26 and
include the following:
1. Infant anorexia. Although pediatric gastroenterologists
have written case reports describing, but not naming,
Edwards et al
infant anorexia,27,28 the diagnosis has been developed
out of the psychiatric literature.
The diagnosis of infant anorexia requires that all six of the
following criteria are met:
a. The infant or young child refuses to eat adequate
amounts of food for at least 1 month.
b. Onset of food refusal occurs before 3 years of age.
c. The infant or young child does not communicate
hunger and lacks interest in food, but shows strong
interest in exploration, interaction with caregiver, or
both.
d. There is growth deficiency.
e. Food refusal does not follow a traumatic event.
f. Food refusal is not due to underlying medical
illness.25
2. Feeding disorder of state regulation. The infant is unable
to reach a calm state of alertness necessary for feeding.
The infant is too excited and unfocused or too sleepy.
These infants scream, fuss, wiggle, and arch away from
the nipple after less voluntary oral intake than what
caregivers believe the infant needs. This behavior per-
sists for months. Parents struggle to provide opportuni-
ties for feeding all day and night, and it is common to
see a thriving infant whose caretaker appears exhausted.
Switching formulas and reducing acid secretion with
medicine are ineffective. This group includes “sleep
feeders” whose largest feedings of the day occur during
twilight sleep. Some experts consider these infants as
having a transient central nervous system regulatory
disorder.
3. Fear of new foods. The child rejects new foods.
4. Selectively “picky eaters.” These toddlers accept fewer
foods but enjoy normal intake of calories and grow nor-
mally. The problem for these families is the emotional tur-
moil around eating. Parents may try coercive feeding,
resulting in behavior problems in the child and family
discord.
5. Fear of eating after a sensitizing traumatic event. When an
infant or toddler has an episode of choking due to food, he
or she may stop eating. Some affected children nourish
themselves with formula or other liquid nutrition but
refuse all solids. Others refuse all food and drink and
require nasogastric tube feedings to prevent dehydration
and malnutrition. Progressive desensitization is an effec-
tive treatment of this anxiety-driven, phobic behavior,
which may last weeks or months.
6. Sensory hypersensitivity causing discomfort or pain in oro-
pharynx, esophagus, or stomach. Pain or fear of pain results
in a child with food refusal or early satiety. The child eats a
normal variety of foods but reduced total intake. There may
or may not be a history of an early sensitizing stressful or
painful event. Evaluations for esophagitis or other mucosal
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901
inflammatory conditions are normal. These patients may
improve with medicine for chronic pain such as gabapentin
or amitriptyline.4,21
Experts have also proposed feeding disorders of infant-care-
giver interaction25 such as the following:
1. Controlling. This caregiver fails to recognize or ignore
the child’s behavioral cues regarding feeding. The con-
trolling caregiver pressures the child to eat using
rewards or punishment for not eating. These practices
are ineffective in the long term and are associated with
a risk for both malnutrition and obesity.
2. Indulgent. This caregiver allows the child to determine
when and what the child eats. Caregivers may prepare
multiple meals to satisfy the child’s requests. The care-
giver is unaware of the child’s hunger signals and sets
no limits. The consequences of indulging the child may
include lower milk consumption and an inappropriate
diet. There is increased risk of obesity.
3. Neglecting. This caregiver takes little responsibility
for feeding the child and may forget to offer food.
Neglectful caregivers fail to recognize the infant’s
behavioral cues, not only about hunger but also other
emotional and physical needs. These caregivers often
have mental health issues themselves that make it dif-
ficult for them to nurture others. When neglected tod-
dlers are placed into foster care, they sometimes exhibit
hyperphagia. Thus, early on, neglected infants and tod-
dlers are at risk early for failure to thrive and later at
risk for obesity.
4. Misperceiving. This caregiver is concerned that the tod-
dler does not eat enough. The toddler’s growth and
development are normal. The treatment requires effec-
tive reassurance, including an explanation for the child’s
feeding behaviors: infants must triple birth weight in the
first year, a tremendous feat requiring large meals many
times daily. Growth rate slows in the second year, and
the child does not have to eat as much as during the first
year. As long as the toddler is stable on the growth
curves, the amount of eating is satisfactory.
Evaluation
The first step in evaluation is a thorough history and physical
examination, with special attention to details of neonatal inten-
sive care unit stay, including any procedures involving the face
and mouth, (eg, nasogastric tube, endotrachial tube); medica-
tions, specifically those that could affect gastric motility; bowel
habits; and developmental milestones. A detailed feeding his-
tory probes when the oral aversion began, whether or not the
child has choking and gagging with oral intake, the presence of
chronic vomiting, meal durations, and current diet. Physical
examination should look for signs of deficiency or chronic dis-
ease (eg, finger clubbing, skin texture and turgor).29
902 Journal of Parenteral and Enteral Nutrition 39(8)

Table 1. Commonly Used Assessment Measures by Type.

Type of Assessment Name of Assessment Purpose of Assessment

Behavioral Behavioral Pediatrics Feeding Assessment Evaluates for parent and child factors that may affect
Scale feeding
Behavioral Assessment System for Children A broadband measure of general psychological problems
in children
Parental Stress Index A measure of parent stress
Mealtime observation Parents should feed typical and unfavored foods in order
for the team to observe behaviors of parent and child
relevant to mealtime and feeding
Psychological Diagnostic/Environmental To assess broadly for psychological issues in the family
Interview that may affect feeding
Laboratory Complete blood count Evaluates blood counts and can detect anemia and
infection
Electrolytes Evaluates for electrolyte abnormalities
Vitamin and mineral levels Evaluates for nutritional deficiencies
Thyroid function Assesses thyroid function
Imaging Upper GI Evaluates anatomy of upper GI tract, looking for areas of
stricture/narrowing or malrotation
Videofluoroscopic swallow study Evaluates quality and safety of swallow
Gastric emptying study Evaluates for delay in gastric emptying
Magnetic resonance imaging of the head Evaluates for tumor or structural abnormalities of the
brain or brainstem
Procedures pH study with impedance Evaluates for both acid and nonacid gastroesophageal
reflux
Esophago-gastroduodenoscopy Evaluates for mucosal inflammation, allergy, or infection
of the upper GI tract
Fiberoptic endoscopic evaluation of swallow Evaluates swallow
Esophageal manometry Evaluates pressure in esophagus to determine if it is able
to effectively moving contents through

GI, gastrointestinal.

For children with persistent oral aversion and failure to
thrive, further workup is often warranted but should be based
on the findings of the history and physical. Laboratory studies
(see Table 1) evaluate for potential causes of the aversion and
nutrition deficiencies that have resulted from the oral aversion.
Imaging is targeted at assessing for anatomic defects or motil-
ity abnormalities (Table 1) and procedures that can evaluate for
swallowing dysfunction (when clinical signs or symptoms are
present), such as fiberoptic endoscopic evaluation of swallow-
ing (FEES) and videofluoroscopic swallow study (VFSS), and
those looking for GI mucosal disease or gastroesophageal
reflux disease (Table 1).
A psychological assessment can include parent report
assessments such as the Behavioral Pediatrics Feeding
Assessment Scale (BPFAS), the Behavioral Assessment
System for Children (BASC), and the Parental Stress Index
(PSI) (refer to Table 1 for details of these assessments). This
gives the psychologist a baseline understanding of the child’s
feeding behaviors, as perceived by the parent. It is also impera-
tive that the full multidisciplinary team, including the psychol-
ogist, observe a typical parent-child feeding interaction during
the context of the visit and that the psychologist conduct a thor-
ough diagnostic interview, including behavioral and environ-
mental factors that may affect the child’s feeding.
Supplemental Feedings
The priority for treatment is developing a feeding plan that pro-
motes healthy nutrition and growth. Sometimes supplemental
feedings are necessary to maintain or achieve adequate nutri-
tion during treatment. The child who is unable to gain weight
or has very poor oral skills and is spending all of his or her time
eating in an effort to gain weight (ie, multiple hours a day spent
on oral feedings) should be considered for supplemental feed-
ings. Bridging nutrition requirements with nasogastric, nasoje-
junal, or gastrostomy tube feedings can allow for the team to
focus on oral skills without having the added stress of the
maintenance of nutrition through an oral route. A study by
Troughton et al30 examining the relationship between oral
skills and nutrition status in a subset of patients with cerebral
palsy found a positive association between nutrition status and
oral competency. This supports the importance of identifying
and treating malnutrition as a fundamental step in the acquisi-
tion of better oral motor skills.

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Edwards et al 903

Table 2. Summary of Treatment Approaches.

Treatment Approach Ideal Candidates Precautions/Considerations Comments

Preventative •• Nonorally fed children who
treatment can tolerate oral input
•• May not be safe for oral
feedings; ideally, patient can
tolerate small tastes
Oral sensorimotor •• Children who have had
skill building limited experience with orally
eating foods required to build
skills
Behavioral treatment •• Patients with maladaptive
behaviors or aversive
responses to oral feedings
Hunger provocation •• Children with functional
feeding skills who are
accepting some food by mouth
but not showing signs of
hunger/desire to eat orally
Sensory integration •• Patients who have difficulty
therapy processing the sensory
components (sights, sounds,
feel/touch, tastes, smells)
associated with oral
feedings
•• Patient is not medically stable
•• May increase oral aversion if
not done correctly
•• If skills are not acquired
during the critical period,
patient may need more time to
learn the skill
•• Ensure behaviors are not
secondary to untreated
medical concerns and/or skill
deficits
•• Patient is not medically stable
•• Weight gain must be adequate
to tolerate a plateau or small
weight loss during the trial
•• Monitor closely for signs of
dehydration
•• Research regarding the
effectiveness of this approach
is limited
•• Introduce as soon as the child
is medically stable
•• Most effective with actual food
or liquid
•• Signs of oral aversion and/
or mealtime behaviors may
be related to underlying skill
deficits
•• Frequently combined with
hunger provocation and
skill-building techniques
•• There are a wide range of
techniques, so approach should
be tailored to patient needs
•• Most successful when paired
with behavioral techniques
•• Typically completed with close
medical monitoring
•• Most commonly used with
patients on the autism spectrum

Treatment
Children with feeding difficulties are a highly heterogeneous
population in regard to etiology and underlying strengths and
weaknesses needed for skilled feeding. Current treatment effi-
cacy studies provide very limited insight into the unique needs
of these subgroups of children.5 What we do know is that treat-
ment of oral aversion is best accomplished with an interdisci-
plinary approach that is multifaceted, dynamic, and modified
based on the needs of the patient.31,32 Refer to Table 2 for a
summary of the treatment approaches discussed below.
Preventative Treatment
Common treatments for prevention of oral aversion include the
following:
•• Positive nonnutritive oral stimulation
•• Therapeutic tastes or partial feedings by mouth (if safe)
•• Exposure to mealtime routines, including olfactory and
auditory stimulation
•• Facilitation of positive caregiver-child interactions
related to feeding
There is evidence to support introduction of preventative
therapy as soon as nonorally fed children are medically stable
and able to tolerate it.1,33,34 Children may show signs of oral
aversion within 1 week of introducing gastric feeding.35
Children who are not exposed to a typical variety of tastes and
textures for oral feeding during critical periods of feeding skill
development often require more practice repetitions when
taught these skills at a later age than children who have typical
feeding opportunities and skill acquisition.36–38 Provision of
preventative treatment could have major benefits for a wide
variety of at-risk pediatric patients.39
Considerations for implementing preventative treatment
strategies include awareness that oral stimulation should be
provided by a trusted caregiver or therapist at an appropriate
level to ensure that the program does not increase oral aver-
sion.40 In addition, oral motor stimulation with nonfood items
in a child who is nonorally fed is theoretically not as effective
as therapeutic oral feeding with actual food or liquid.38,41
Sensorimotor Skill Building
Oral motor deficits may be seen in children with oral aversion
because these children often refuse foods required to build
skills. Sheppard38 stated that if a child does not experience
ample practice opportunities for oral feeding, the continuous
sequence of motor learning for feedings tasks, including the
simultaneous development of oral sensory tolerances and

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904 Journal of Parenteral and Enteral Nutrition 39(8)

•• Meals will be at regularly scheduled times with planned snacks only.

•• No food or drink between planned meals and snacks except for water.
•• Solids should be offered before fluids.
•• Meals should last no longer than 30 minutes.
•• The child should be encouraged to self-feed as much as possible.
•• A mat or sheet is placed under the child’s highchair or chair to avoid clean-up during meals. No cleaning up (including wiping
the mouth) will occur until the meal has ended.
•• The caregiver should remain neutral throughout the feeding (without showing signs of approval or disapproval). Do not force
food or liquid into the child’s mouth or comment on the child’s intake.
•• The child should not be given food as a reward. No game playing at mealtimes.
•• If the child does not eat within 10–15 minutes, food should be removed. If the child throws food in anger, the meal should be
terminated.

Figure 1. Suggested mealtime rules. Adapted from Chatoor, I, Dickson, L, Schaefer, S, Egan, J. A developmental classification of
feeding disorders associated with failure to thrive: diagnosis and treatment. In: Drotar D, ed. New Directions in Failure to Thrive:
Implications for Research and Practice. New York, NY: Plenum; 1985:235-238. With permission of Springer Science+Business Media.

capabilities, is interrupted. This interruption may result in
delayed feeding development or dysfunctional movement pat-
terns.38,42 In addition, if oral skill building is delayed beyond
critical periods of development when brain plasticity is opti-
mal, the child may require more intensive and a greater number
of practice opportunities to learn feeding skills.36–38,43,44 This
finding is also supported by Senez et al,45 who found that it was
easier to restart oral feedings in children who were previously
orally fed than to start feedings in children who never ate
orally.
In other cases, a child with an oral aversion may accept
foods that are important for skill development, but due to atyp-
ically hypo- or hypersensitive responsiveness, the child’s abil-
ity to discriminate oral sensory input accurately may be
impaired. This impairment may lead to oral motor deficits.31,44
A third consideration when assessing and treating oral aver-
sion symptoms in the presence of oral motor deficits is the pos-
sibility that the aversion may be a result of the underlying oral
motor deficits.44 For example, children who have inadequate
chewing skills may gag when attempting to swallow inade-
quately chewed food, and because gagging is a powerful aver-
sive event, it may lead to further refusals of solid textures.39
Building feeding skills, such as chewing, may result in
increased acceptance of oral feedings and decreased signs and
symptoms of an oral aversion. This theory is supported by
Clawson and colleagues,46 who reported that a small group of
children demonstrated a significant reduction in inappropriate
aversive and atypical sensory behaviors (expelling food and
overstuffing the mouth with food) when their oral phase swal-
low skills improved with oral motor therapy.
Behavioral Treatment
The use of behavioral treatments (application of operant and
respondent [classical conditioning] learning principles) is one of
the most well-researched areas of feeding intervention.5,35,42,47–49
Some of the most commonly used behavioral treatments include
reinforcement (tangible positive consequences) and extinction
(ignoring).5 Behavioral approaches used by successful programs
also include contingent social attention, reinforcement, punish-
ment, stimulus control (antecedent-based) procedures, system-
atic desensitization, and flooding (ie, escape extinction).5 The
overall goal of behavioral feeding therapy is to increase desired
feeding behavior and to decrease maladaptive behaviors or aver-
sive responses.42 Specific techniques that have been studied for
application to oral aversion symptoms include the following:
•• Antecedent manipulation techniques involve altering
the antecedent of the behavior to decrease its probabil-
ity, such as masking flavors of nonpreferred foods,
altering food texture, altering eating utensils, changing
order or presentation of a preferred food, or modifying
the feeding environment with a change in structure to
mealtime routines.32,42,50 These often include “food
rules” (see Figure 1).
•• Positive reinforcement includes providing verbal
praise or brief access to a preferred activity/toy in
response to the child performing a targeted feeding
behavior.42
•• Negative reinforcement (something is removed that
was present prior to the desired behavior) is rarely used
in isolation, but there have been reports of allowing a
child to escape a feeding room after swallowing a
bite.42,47
•• Punishment refers to a consequence that reduces the
frequency of an undesired behavior. Use of physical
prompting or guidance51 and restraint (ie, force feeding)
have been reported as consequences for feeding refus-
als. A “timeout,” in which a child is removed from a
reinforcing situation, such as social attention or access
to a preferred activity, is another example of a behav-
ioral punisher.42
•• Extinction (a form of flooding or prolonged exposure
therapy) involves blocking/withholding an undesired
consequence (eg, escape from eating), which reinforces
an undesired behavior. Specifically, escape prevention

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Edwards et al
is a technique that aims to prevent a disruptive behavior
(eg, crying, expelling food, or head turning with feed-
ing refusal) from becoming negatively reinforced (ie,
by achieving feeding avoidance or escape from eating
or drinking).5,19,42 A commonly used flooding technique
is to present the child with food on a spoon in front of
his or her mouth and not remove the spoon until the
child tastes the food, at which time the child would be
verbally praised and tangibly rewarded.5,19,47,49,51
•• Consequence manipulation has been suggested for
children whose feeding aversions are maintained by
maladaptive feeding contingencies.51 Consequence
manipulations include positive reinforcement, negative
reinforcement, and punishment. Use of positive rein-
forcement alone has been efficacious in some studies of
children with typical development51 as well as children
with cognitive delays.51,52
Most authors report using a behavioral analysis approach to
determine what interventions are best suited to the child’s
needs. Ongoing behavioral assessment and evaluation with
adjustments to treatment strategies as indicated by evaluation
of objective treatment data is paramount to effective behav-
ioral treatment.53 When positive reinforcement is not sufficient
to effect a change in food refusals, a more intrusive procedure
may be required.47,50,51 However, the least restrictive, effective
form of intervention should be used.51,53 Some authors report
increased acceptance for oral feeding when using a combina-
tion of positive reinforcement and punishment/timeout (ie, def-
erential attention, also known as contingent social attention),
during which preferred behaviors (eg, acceptance of bites or
sips) are reinforced with positive attention and nonpreferred
behaviors (eg, expelling food) are ignored.54,55
Use of escape prevention techniques is recommended for
children who have persistent disruptive behaviors during feed-
ing attempts that are not eliminated with use of positive rein-
forcement and deferential attention techniques.42,56 In some
instances, use of timeout techniques may actually serve to rein-
force disruptive behaviors rather than decrease their frequency,
if the child’s motivation is to escape a feeding situation.42
Escape prevention has been demonstrated to be an effective
treatment.50,51,56–58 Escape prevention alone and escape preven-
tion plus noncontingent reinforcement have been demonstrated
to be more effective in increasing acceptance of food and
decreasing inappropriate behavior (including negative vocal-
izations) than noncontingent reinforcement alone for 4 children
with food refusal feeding disorders.58,59 A combination of
escape prevention and positive reinforcement has been shown
to be more effective than positive reinforcement alone for
decreasing inappropriate behaviors and increasing food accep-
tance.47,56 Escape prevention plus nutrition counseling has been
shown to be more effective in increasing oral intake during tube
weaning than nutrition counseling alone, although long-term
maintenance of oral feeding was not studied.19 Use of combined
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905
escape and attention extinction techniques has been demon-
strated to be more effective in decreasing inappropriate meal-
time behaviors and increasing oral acceptance of food than use
of either technique in isolation. Furthermore, when the attention
extinction technique was used independently, it did not result in
significant changes in acceptance or negative behaviors.57
Although behavioral feeding therapy techniques have pri-
marily been studied in isolation or comparison to 1 or 2 other
techniques, behavioral treatment for oral aversions must take
into account the highly varied presentation of symptoms, eti-
ologies, and dynamic behaviors of the individual child being
treated.60 Several guiding principles of operant learning are
used by the behavioral feeding therapist to implement system-
atic change in behavior that continues to occur in a variety of
environments beyond the treatment session. These principles
include the following:
•• Systematic desensitization is a form of exposure ther-
apy, in which the child is exposed to a graduated hierar-
chy of anxiety-producing stimuli while the child is
simultaneously rewarded with competing positive/relax-
ing stimuli. In the context of oral aversion, this hierarchy
may progress from minimal to no interaction with food
to seeing, smelling, tasting, and then eating the foods.5
Hierarchies of avoidant oral stimulation experiences,
foods, or feeding contexts are typically individualized to
each child’s pattern of avoidant behavior. Therefore,
treatment stimuli may vary significantly from one indi-
vidual with oral aversion symptoms to another.
•• Shaping involves reinforcing behaviors that are pro-
gressively closer approximations to a desired target
behavior.61 This may be combined with a systematic
desensitization approach.
•• Prompt fading is a process in which prompts or cues
provided by the caregiver or therapist are gradually
eliminated.
•• Generalization refers to systematic introduction of a
newly learned skill (eg, tolerance for a new food) to
nontreatment environments and contexts. There are few
references to systematic parent training or attempts to
induce generalization of newly acquired behaviors in
the literature.
Hunger Provocation
Children with oral aversion often require help establishing
motivation to eat through both behavioral and appetite manipu-
lation techniques.42 Children who have been nonorally fed for
prolonged periods of time often have poor perception of hun-
ger.62 Some authors have proposed approximating meal size
and timing for tube feedings with developmentally appropriate
meal schedules and quantities.33,45,63 It has been suggested that
tube feedings prevent the development of normal biological
rhythms and alter perceptions of hunger.62,64
906
Based on research conducted by Birch et al,65 Shea et al,66
and Mason and colleagues,33 it is more effective to provoke
hunger by reducing the overall number of calories in a 24-hour
period rather than changing the timing of bolus tube feedings
without reducing calories. However, increased oral intake will
occur only if the child is ready to accept some food by
mouth.33,38
The use of appetite manipulation has been demonstrated to
be safe in medically complex children during gastrostomy-tube
weaning if fluids are provided as necessary and the treatment is
completed in a medical setting with adequate medical monitor-
ing and oversight.62,67 Wilken68 reported that 35 of the 39 chil-
dren (ages 7–51 months) enrolled in their rapid home-based
weaning program transitioned to oral feedings with no change
in growth velocity from their initial evaluation to a follow-up
completely on average 2 years later. Hunger provocation
appears to be more successful when paired with behavioral
treatment. Research has shown that nutrition counseling to pro-
voke hunger is less effective than nutrition counseling for appe-
tite manipulation paired with escape extinction procedures.19
Disadvantages to hunger provocation include cost and the
risk of medical harm if the patient experiences rapid weight
loss. Hunger provocation is typically completed via an inpa-
tient program and is often paired with intensive behavioral
treatment services.69 Some protocols have been developed for
rapid home-based weaning68 with home-based behavioral
treatment. There is increased concern for complications related
to rapid weight loss or dehydration with home-based programs
since the patient typically is less closely monitored for medical
complications.68
Sensory Integration Therapy
Another widely used approach in children with oral aversion is
sensory integration therapy.70–73 There is limited evidence to
support that behavioral interventions may be more beneficial
than sensory integration therapy for at least a subset of children
with oral aversion feeding disorders. Addison et al58 compared
a combination treatment approach, including use of escape
extinction procedure, noncontingent reinforcement, and sen-
sory integration therapy. The combined behavioral approach
was more effective for outcomes of food acceptance, reduced
inappropriate behavior, and increased quantity of oral intake
than sensory integration therapy alone. Cornwell et al31
describe using sensory integration treatment as part of an inpa-
tient treatment program. However, sensory integration tech-
niques were combined with other treatments. Therefore,
improvements in oral intake could be attributed to a number of
confounding variables.
Inpatient vs Outpatient Treatment
Studies suggest that outpatient therapy may be effective in
increasing total caloric intake by mouth within 3 months of
treatment for 90% of children with oral aversion and primary
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Journal of Parenteral and Enteral Nutrition 39(8)
nutrition via tube.67 Blackman and Nelson74 reported that 4
children who entered an inpatient feeding therapy program
were successful at weaning tube feeding within 2–3 weeks for
3 patients and within 2 months for a fourth patient, while 5
children who were treated as outpatients required up to 2.5
years (range, 4–31 months) of treatment to achieve full or
nearly full oral feeding status.
Children who fail to make progress in outpatient treatment
programs may benefit from an intensive inpatient behavioral
treatment program with close medical supervision.67 A retro-
spective study of 77 children who had failed previous outpa-
tient attempts to decrease oral aversion behaviors and increase
oral intake to wean gastrostomy tube reliance indicated that
fifty-one percent of enrollees were taking all of their calories
by mouth at discharge with an increase of an additional 12% of
patients requiring no enteral feedings at the 1-year follow-up.
A pattern of weight loss was seen in all patients, but authors
judged the degree of weight loss to be insufficient to cause
medical risk. Therapists provided intensive behavioral and
appetite manipulation with treatment for oral sensorimotor
skill deficits. However, psychologists working with the chil-
dren in this study were assured that behavioral goals were real-
istic and attainable based on a physician and speech-language
pathologist’s assessments of each child’s abilities as part of an
interdisciplinary approach to treatment.
Intensive inpatient programs have demonstrated success in
weaning a child from tube feeding.31,46 Interventions varied
from behavior modification and parent education46 to compre-
hensive multidisciplinary assessment, skill building, and
behavioral interventions31 to multicomponent interventions
that include appetite provocation strategies.49,75 These pro-
grams offer promising results for reduced oral aversion symp-
toms and improved oral intake. Davis and colleagues5 cited
concerns about the ability to generalize these findings, as well
as the feasibility of implementing such an intensive program.
The authors noted that these kinds of programs cause signifi-
cant family inconvenience and require ample financial
resources and pointed out the lack of a control group to ensure
that the treatment effect was due to the intervention being
studied.
Role of Team Members
The treatment of children with feeding problems can be
extremely complicated and requires the experience of an inter-
disciplinary team.76 Typical providers may include a physician
or nurse practitioner, a psychologist, a speech-language pathol-
ogist, an occupational therapist, a dietitian, a nurse, and a
social worker.77 Experts agree that these teams should value
the perspectives of all participating providers and allow for the
patient and parent perspective as well. Typically, these teams
provide an initial assessment process followed by ongoing
consultative care, with some programs having both inpatient
and outpatient components to their treatment programs. Goals
for these programs can vary from helping the patients
Edwards et al 907

Table 3. Role of Interdisciplinary Team Members.

Team Member Role

Medical provider
Psychologist
Speech-language pathologist (SLP)
Occupational therapist (OT)
Registered dietitian (RD)
Registered nurse (RN)
The physician or nurse practitioner is responsible for the overall health of the child, including
any medical issues related to feeding, as well as informing the rest of the team on how
other medical diagnoses/issues may affect recommendations and care by the team. This
may include ordering specific tests based on presenting symptoms, assessing the need for
medications, and other medical care of the child.
The psychologist is responsible for all behavioral aspects of feeding. This should always
include a detailed psychological assessment of both child and family as well as a focus
on behavioral parent training (reward systems, contingency management, etc), helping
children to overcome previous negative learning around feeding, assisting the parents
and child with stress management issues, instructing the families in the use of relevant
behavioral constructs (ie, shaping), and assisting the team with implementing their
recommendations in a behaviorally informed fashion.
The SLP is responsible for evaluating oral motor feeding in general, specifically around how
the oral issues of the child may interfere with oral feeding. This typically includes a clinical
assessment of swallowing, as observed during the visit, and a determination for whether
any follow-up testing in this area should be recommended.
The OT evaluates oral sensory, oral motor, and positioning aspects of the child. This may
include recommending certain processes or utensils that promote safer feeding or more
successful self-feeding.
The RD typically assesses the anthropometric status of the child via height and weight and
also conducts a 3-day diet record analysis as primary methods of assessment. This provider
is typically focused on the caloric intake of the child, as well as the nutrition value of the
consumed calories. Goals typically include adequate caloric intake to promote growth, with
a secondary focus on the nutrition quality of the intake.
The nurse conducts physiologic assessments, manages enteral access devices, evaluates
tolerance of therapy along with other team members, provides education to the patient and
family, identifies barriers to success, and facilitates communication between the care team
and the patient’s family.78 The nurse educates the patient’s family on enteral access device
placement, management, and complications using the teach-back method.79 For those
patients requiring enteral nutrition, the nurse will assist the family and care team in safe
and effective delivery of nasoenteric tube or gastrostomy tube feedings.80

to protect their airway, to safely introducing oral tastes, to
moving the child toward full oral eating. For more information
on the interdisciplinary team logistics, see Miller et al.77
As described, the interdisciplinary feeding team is com-
posed of several providers. Each provider covers a unique area
of expertise that is key to the evaluation and treatment of the
child with feeding difficulties. Refer to Table 3 for complete
list of providers and their roles. It is also important to note that
the team must have excellent communication to best care for
the child/family, since viewpoints of providers cover unique
areas of feeding and may therefore, at times, conflict. All pro-
viders should also have (or gain) experience in pediatric feed-
ing disorders prior to serving as the discipline lead on an
interdisciplinary feeding team.
Summary
The most critical component in the successful treatment of oral
aversion in children is the interdisciplinary nature of the treat-
ment team. An accurate assessment should be conducted that
considers the etiology of the feeding difficulties, as well as the
psychosocial and environmental contributors to the oral
feeding aversion. Treatment approaches should be individually
tailored to the child and family and will likely need to be con-
tinually modified over time due to developmental, medical,
nutrition, and skill-related factors.
Statement of Authorship
S. Edwards, A. M. Davis, L. Ernst, B. Sitzmann, A. Bruce, and P.
Hyman contributed to the design of the research; P. Hyman con-
tributed to the conception of the research; S. Edwards, A. M.
Davis, L. Ernst, B. Sitzmann, and P. Hyman contributed to the
acquisition and analysis and interpretation of the data; D. Keeler
and O. Almadhoun contributed to the acquisition of the data. H.
Mousa contributed to the analysis of the data. All authors drafted
the manuscript, critically revised the manuscript, agree to be fully
accountable for ensuring the integrity and accuracy of the work,
and read and approved the final manuscript.
Glossary
Classical conditioning: process of behavioral analysis in
which an innate response to a potent biological stimulus
becomes expressed in response to a previously neutral
stimulus

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908
Critical period of feeding: period of time when chewing is
most readily acquired (typically around 6–9 months of age)
Flooding: behavioral technique that exposes someone to
his or her fears and phobias, with the intent to bring
about less fear over time
Hunger provocation: the act of provoking or inciting hun-
ger by reducing enteral calories in an effort to increase
oral calories
Oral aversion: reluctance or fear of eating, drinking, or
accepting sensation in or around the mouth
Systematic desensitization: graduated exposure to the
anxiety-provoking event, which, in the case of oral aver-
sion, is feeding
Teach-back method: method of teaching where the clini-
cian teaches a concept to the patient and then asks the
patient/parent to recall and demonstrate the skill
Further Reading List
1. Davis AM, Bruce AS, Cocjin J, Mousa H, Hyman P. Empirically supported
treatments for feeding difficulties in young children. Curr Gastroenterol
Rep. 2010;12(3):189-194.
2. Chatoor I. Diagnosis and Treatment of Feeding Disorders Infants,
Toddlers and Young Children. Washington, DC: Zero to Three; 2009.
3. Kerzner B, Milano K, MacLean WC, Berall G, Stuart S, Chatoor I. A prac-
tical approach to classifying and managing feeding difficulties. Pediatrics.
2015;135(2):344-353.
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