Pediatric feeding disorder in autism spectrum disorder: Preliminary findingsABSTRACT
Purpose: to determine the prevalence of signs suggestive of pediatric feeding disorder (PFD) in patients with autism spectrum disorder (ASD), to characterize their feeding and sensory profiles, and describe the health impacts.
Methods: the study included caregivers of 40 patients (predominantly males, aged 2 to 15 years) undergoing speech-language-hearing therapy. A questionnaire was administered to identify signs of PFD and characterize the feeding profile, the impact of feeding difficulties, nutritional and general health issues, and the family's perception of sensory development. Analysis was both descriptive and analytical, estimating the prevalence of PFD signs and assessing the association between food refusal and sensory difficulties, using Fisher's exact test (p ≤ 0.05).
Results: 70% of participants exhibited signs of PFD. Higher rates of refusal were observed for grains, vegetables, and pureed foods, with no influence from temperature or color. Low dietary variety, nutritional and/or health issues, and social impact resulting from disruptive mealtime behaviors (alongside sensory alterations) were predominant. Low dietary variety was associated with olfactory difficulties.
Conclusion: the prevalence of signs of PFD was high, with specific characteristics in feeding and sensory profiles that should be considered in multidisciplinary interventions, given their impact on health, social interaction, and family management.
Keywords:
Autism Spectrum Disorder; Feeding and Eating Disorders; Perception, Sensation Disorders; Feeding Behavior
RESUMO
Objetivo: verificar a prevalência de sinais sugestivos de distúrbio alimentar pediátrico (DAP) em pacientes com Transtorno do Espectro Autista (TEA), caracterizar o perfil alimentar e sensorial e descrever os impactos à saúde.
Métodos: participaram os responsáveis por 40 pacientes em atendimento fonoaudiológico, predominantemente do sexo masculino, com idades entre 2 e 15 anos. Aplicou-se um questionário para identificar sinais de DAP, caracterizar o perfil alimentar, o impacto das dificuldades alimentares, a presença de problemas nutricionais e de saúde geral e a percepção familiar sobre o desenvolvimento sensorial. A análise foi descritiva e analítica, com estimativa da prevalência de sinais de DAP e verificação da associação entre recusa alimentar e dificuldades sensoriais por meio do Teste Exato de Fisher, p ≤ 5%.
Resultados: 70% dos participantes apresentaram sinais de DAP. Observou-se maior recusa de grãos, vegetais e alimentos pastosos, sem influência da temperatura ou cor. Predominaram baixa variedade alimentar, problemas nutricionais e/ou de saúde e impacto social decorrente de comportamentos disruptivos nas refeições, além de alterações sensoriais. Houve associação entre baixa variedade alimentar e dificuldades olfativas.
Conclusão: a prevalência de sinais de DAP foi elevada, com particularidades no perfil alimentar e sensorial que devem ser consideradas nas intervenções multiprofissionais, devido ao impacto na saúde, no convívio social e no manejo familiar.
Descritores:
Transtorno do Espectro Autista; Transtornos da Alimentação e da Ingestão de Alimentos; Percepção; Transtornos dos Sentidos; Comportamento Alimentar
INTRODUCTION
The diagnostic criteria for autism spectrum disorder (ASD) consist of persistently impaired communication and social interaction, alongside restricted, repetitive patterns of behavior, interests, or activities1. These characteristics limit or impair the individual's activities of daily living.
Sensory alterations are common and often poorly understood due to the communication difficulties they experience2. Also, their eating may be affected by extreme reactions and/or rituals involving the taste, smell, texture, and appearance of food, as well as excessive dietary restrictions. These behaviors are observed more frequently than in typically developing children and often persist throughout life3-5.
Pediatric feeding disorder (PFD) is characterized by impaired oral intake in terms of food quantity or quality, lasting more than 15 days, and associated with medical, nutritional, feeding skill, and/or psychosocial dysfunctions6. It may involve a single area or a combination of these factors7.
A study conducted in the United Kingdom identified an ASD diagnosis in 41% of a cohort of children with PFD8. The factors associated with PFD in ASD are considered multifactorial (sensory, behavioral, psychological, communicative, and familial)4. They may stem from organic issues such as gastroesophageal reflux (GER), oral-motor deficits related to chewing and swallowing, milk protein intolerance, or maladaptive sensory responses, such as the rejection of specific food textures. The latter arises from sensory processing difficulties (i.e., how the central nervous system [CNS] manages information received from sensory organs), including hypersensitivity or hyposensitivity to environmental sensory stimuli (smell, taste, sight, hearing, and touch)9-11. When the CNS fails to process sensory information from the environment, or struggles to do so, sensory integration dysfunctions emerge12.
Between 45% and 96% of individuals with ASD exhibit some form of social integration dysfunction13, including manifestations related to eating12. Consequently, an autistic child may consume only a limited range of food categories, prefer pureed or liquid foods, or maintain specific associations between eating and other particular habits. The severity of food refusal and the persistence of preferences for certain foods are primarily due to specific patterns of oral and gustatory sensitivity and to neuropsychological characteristics typical of ASD, such as behavioral rigidity4,10,14.
Children with ASD referred to nutrition services were highly selective and displayed very restricted food acceptance repertoires, sometimes limited to as few as five items3. Food refusal places these individuals at risk, as potential nutritional deficiencies can lead to developmental delays, short stature, malnutrition, and obesity4,8,10.
Beyond sensory issues, other deficits associated with an ASD diagnosis also impact the act of eating. Sharing a table and eating and drinking together are social bonding rituals in shared meal environments at home, school, work, or leisure activities, thereby strengthening interpersonal ties and emotional bonds15. Thus, children with ASD who exhibit sensory processing disorders may become isolated or excluded during meals, often due to behaviors deemed inappropriate (e.g., shouting, refusing to sit at the table, and being aggressive)4, which also affects family relationships16. Early childhood feeding disorders have been linked to an increased risk of mental health problems in mothers17.
Feeding children with both ASD and PFD poses a major challenge. It is essential to assess sensory aspects and restrictive, repetitive eating patterns to determine intervention approaches as early as possible6. Family involvement throughout the process is also crucial8.
Hence, this study aimed to determine the prevalence of signs suggestive of PFD in children and adolescents presented with ASD, undergoing speech-language-hearing therapy, as well as to outline the dietary and sensory profiles of those showing signs of PFD, and describe potential health impacts.
METHODS
The study was approved by the Research Ethics Committee of the Medical School of the Universidade de São Paulo, Brazil (CAAE 24160919.2.0000.0065; approval number 3.689.420). All parents of the participating children and adolescents signed an informed consent form.
Participants included the mothers and/or fathers of 40 children and adolescents receiving specialized speech-language-hearing therapy within a tertiary healthcare setting. Inclusion criteria were an age range corresponding to childhood and adolescence; being a patient of the said service; and having a medical diagnosis of ASD, regardless of the level of support required. Exclusion criteria were a history of prematurity and other diagnoses or comorbidities.
Male patients were predominant (87.5%), and ages ranged from 2 to 15 years (Table 1).
Age distribution of all patients with autism spectrum disorder, with and without signs suggestive of pediatric feeding disorder
Mothers and fathers were contacted via a messaging app or in person to gauge their interest in participating in the study. Those interested received detailed instructions beforehand on how to complete the informed consent form and the questionnaire, including definitions of terms such as "ultra-processed foods" and "proteins," which were also provided in writing. The questionnaire and the informed consent form were distributed via Google Forms, and the researcher conducting the study was available to answer any questions. Data were collected over the course of one month and involved two rounds of distribution, with the second round targeting only those mothers and fathers who had not initially participated.
Research instrument
The instrument used was a semi-open questionnaire developed exclusively for the study, based on the DSM-51, the Food Guide for the Brazilian Population, and a review of the literature on the subject2,3,9,11-13,15. The instrument was divided into the following sections: Section 1. Indication of whether the child/adolescent with ASD exhibited specific characteristics for more than 15 days, namely: highly limited food intake; extreme resistance to trying new foods; tantrums during meals; slow eating; attempts to negotiate which foods to eat; getting up from the table during meals; a habit of snacking throughout the day; and refusal of specific foods or any food at all, or significant difficulty accepting new foods. The questionnaire ended at that point for those who answered "no," while those who answered "yes" to one or more characteristics proceeded to the next section. Section 2. Description of the variety of foods and food groups the patients accepted (fruits, proteins, grains, ultra-processed foods, sweets, and vegetables); nutritional and health issues such as underweight, obesity, anemia, malnutrition, vitamin deficiencies, low immunity, and high cholesterol; whether feeding difficulties led to social restrictions for the family (e.g., missing parties, outings, or trips); food textures, temperatures, and colors the patients refused; the mealtime environment and whether they had company while eating; and sensory processing difficulties, specifically those related to smell, touch, sight, and hearing (with the option to describe the specific difficulties).
Data analysis
Based on the definition of PFD6 (“impaired oral intake that is not age-appropriate, in terms of quantity or quality, lasting more than 15 days and associated with medical, nutritional, feeding skill, and/or psychosocial dysfunctions that may occur in a single area or a combination thereof"), all children/adolescents with ASD whose parents reported the frequent presence (for more than 15 days) of feeding characteristics described in Section 1 of the questionnaire were considered to exhibit signs suggestive of PFD. Data were tabulated to estimate the prevalence of signs of PFD among participants; additionally, a quantitative and descriptive analysis was conducted regarding feeding aspects, potential health impacts, and sensory difficulties in children and adolescents showing signs of PFD. Fisher's exact test was also used to analyze the association between the variety of foods consumed and difficulties in sensory domains. SPSS software, version 27 (IBM Corp., Armonk, NY, USA), was used, with a 5% significance level.
RESULTS
A prevalence of signs suggestive of PFD was observed in 28 (70%) patients. The age-based distribution showed a range from 33.3% (patients aged 9 years) to 100% (patients aged 3, 10, and 11 years) (Figure 1). When considering early childhood (0 to 6 years), the prevalence was 73.3%, compared to 68% in middle childhood and adolescence (7 years or older).
The number of different foods each patient accepted varied. A large proportion (39.3%) accepted 10 to 30 foods, while a considerable segment (10.7%) accepted fewer than five different types of food. Also, 39.3% of the mothers/fathers reported complete food refusal, characterized by going more than a full day without eating.
The least accepted foods were grains (89.3%) and vegetables (50.0%), and the least accepted texture was puree (42.8%) (Table 2). No refusal pattern was observed regarding food temperature (53.6%), and only five patients (17.9%) restricted foods based on color, showing a slight preference for red and orange foods.
Distribution of data regarding food refusal in children/adolescents with signs suggestive of pediatric feeding disorder
Moreover, the families reported the following regarding the patients' specific food-related behaviors: two patients’ main meal always consisted solely of rice, beans, and tomatoes; one patient ate only soups and chocolate cake; another one refused to eat foods if they were mixed together; another one would not touch food with their hands, even when they liked it, always eating exclusively with a fork; and another patient consistently preferred foods with a more liquid texture, such as those with sauces and broths.
Nutritional or health issues, such as low weight, obesity, anemia, malnutrition, vitamin deficiency, low immunity, and high cholesterol, were reported by 46.4% of the participants.
Feeding difficulties caused social challenges for 57.1% of the families.
At home, the children alternated primarily between eating at the table (78.5%) and in the living room or on the sofa (46.4%). Among the 25 children and adolescents who attended school, 20 (80%) ate in the cafeteria, three (12%) never ate away from home, and two (8%) were accommodated to eat on the school patio; one family noted that, although their child ate in the school cafeteria, they would only accept food brought from home.
Family members accompanied most children and adolescents (89.3%) during meals at home, while 35.7% were accompanied by caregivers, and 10.7% ate alone. One family member mentioned that the child ate alone but frequently got up from the table due to stereotyped behaviors.
Furthermore, the sensory difficulties reported by parents centered mainly on hearing, touch, and smell (Figure 2). The primary complaints involved high-intensity auditory stimuli or reactions to specific sounds (such as a particular doorbell), discomfort or intolerance with direct skin contact, and distress caused by strong odors. To a lesser extent, patients may be bothered by brighter lights or lights of specific colors.
Distribution of the percentage of patients with difficulties in sensory domains, based on the perception of mothers/fathers
The variety of foods consumed was not related to sensory difficulties in any of the domains (Table 3). However, when analyzing by sensory domain, olfactory difficulties were associated with the acceptance of a narrower variety of foods (Table 4).
DISCUSSION
The predominance of male patients in the sample aligns with expectations1,5. However, although ASD remains more common in boys, a recent study shows a reduction in the male-to-female prevalence ratio from 4:1 to 3:118.
Based on the medical diagnosis of ASD combined with characteristics of restricted and prolonged food intake, 28 children and adolescents met the criteria for signs suggestive of PFD6, a 70% prevalence observed across all age groups studied.
PFD in the ASD population has been reported in approximately 40% to 80% of cases19,20, often persisting beyond early childhood2. These figures corroborate the results of the present study. In comparison, the estimated prevalence among typically developing children ranges from 25% to 45%21.
The limited variety of foods consumed by children with ASD and the higher rates of grain and vegetable refusal observed in this research have also been documented in other studies4,8,22-25. Children may be less resistant to ultra-processed foods due to their textures, consistencies, colors, and shapes intentionally designed to enhance acceptance18.
Regarding texture, patients accepted pureed foods less, which is consistent with findings from other studies. The higher rate of refusal for this texture among individuals with ASD may be explained by alterations in oral sensory processing, specifically tactile hypersensitivity, linked to texture-based food selectivity. Pureed foods offer lower sensory predictability and diffuse tactile characteristics, which can trigger discomfort and rejection. Furthermore, restricted behavioral patterns and a preference for predictability may favor the acceptance of foods with more stable properties, such as solids4,10,19.
The diets of children with ASD are often high in fat, sodium, and sugar and low in nutritional value4,19, a pattern that can lead to nutritional and general health issues, as evidenced by the frequently reported occurrence of underweight, obesity, anemia, malnutrition, vitamin deficiencies, low immunity, and high cholesterol. A population-based cohort study involving both neurotypical children and children with neurodevelopmental disorders found a 22% prevalence of nutritional issues8. A study of 144 children found a higher incidence of underweight and obesity among participants diagnosed with ASD compared to the neurotypical group24. The literature also frequently cites gastrointestinal symptoms such as constipation, allergies, diarrhea, and vomiting as common in this population12,18,22,23. Further research aims to investigate and provide a more detailed analysis of these issues and their relationship with the children's dietary habits.
The environment in which a child eats is crucial, especially for children with ASD, requiring attention to potential sensory processing impairments and difficulties in processing environmental stimuli. Ideally, children with PFD and ASD should eat in quiet settings22; however, a significant number of children and adolescents were observed eating in school cafeterias, which are often very noisy environments. Inappropriate rituals and behaviors during meals were noted, such as children avoiding touching food or repeatedly leaving the table due to stereotypies, thereby prolonging mealtime. Such disruptive mealtime behaviors occur less frequently in typically developing children24 and tend to decrease with age, unlike in children with ASD5. These behaviors, combined with food refusal, led more than half of the families to report social difficulties, contributing to increased stress and burden in the family4,5,10,18,26. Early childhood feeding disorders contribute to mental health issues among caregivers, such as depression, anxiety, and insomnia, particularly in mothers17.
Due to the language impairments associated with ASD, families often struggle to understand the child's nutritional needs clearly, including preferences and cues indicating hunger or satiety. Consequently, in an effort to get the child to eat, many parents inadvertently reinforce PFD, for instance, by removing the plate when the child refuses to eat or by preparing alternative foods to replace the rejected ones27. A lack of interest in food among children with ASD was found to be mutually correlated with parental actions, such as preparing special meals in response to food refusal28, underscoring the need for parental involvement in intervention programs8,16.
The prevalence of sensory difficulties was quite high, consistent with findings from another study8, particularly regarding auditory, tactile, and olfactory stimuli. Sensory processing is directly linked to the development of the skills required for eating; disturbances in this system can profoundly affect feeding behaviors8.
Another study also observed an association between a more limited variety of accepted foods and olfactory-related sensory difficulties27. Food refusal may be linked to alterations in olfactory sensory processing, given that aroma is a key modulator of food acceptance. Evidence indicates that children with PFD and ASD exhibit heightened reactivity to sensory stimuli, including aromas, which can trigger avoidance responses even before direct contact with the food. Olfactory hypersensitivity contributes to the perception of aromas as aversive, especially with foods of greater aromatic complexity or intensity, thereby fostering food selectivity patterns8,27. This process can be reinforced by aversive learning mechanisms, cementing food refusal over time.
Since the patients in this study were referred to the service due to language complaints, the data obtained allowed for the preliminary identification of aspects related to signs suggestive of PFD and the need for multidisciplinary care. This included referrals to nutrition and occupational therapy services, as well as the incorporation of a feeding-focused approach into speech-language-hearing therapy.
Further studies on this topic are relevant, given the negative impact of PFD on the health and development of children and adolescents, as well as the emotional distress experienced by their families25.
From a methodological standpoint, it is acknowledged that the cross-sectional design employed, the nature of the data analyzed, and the lack of validated tools may affect the precision with which the severity of PFD is determined. These factors also limit the generalizability of the findings, as the level of autism support correlates directly with the severity of sensory and behavioral feeding dysfunctions.
To overcome these limitations and build upon the initial study results, future research should adopt a multidisciplinary approach to the diagnostic characterization of PFD, utilize standardized assessment instruments, and include orofacial myofunctional assessment covering both structural aspects and feeding functions. Furthermore, data analysis should consider the participants’ ASD support level and other general health information obtained from medical records. This would enable a more robust diagnostic characterization and a deeper interpretation of the results. Such outcomes were not possible in this preliminary study due to time constraints and the diagnostic resources available within the service's workflow at the time of data collection.
Finally, in addition to the early identification of PFD in children with ASD, continuous monitoring26,29 and family-centered interventions8 are recommended. Moreover, signs of PFD can serve as a warning signal, prompting parents to seek professional help regardless of an ASD diagnosis5.
CONCLUSION
The prevalence of signs suggestive of PFD in this population of children and adolescents with ASD was high and observed across all age groups. Grains, vegetables, and pureed foods were the most refused items, whereas proteins and ultra-processed foods were the most accepted. Food temperature and color did not influence patterns of acceptance or refusal.
Approximately half of the sample exhibited social difficulties stemming from disruptive behaviors during meals, as well as nutritional and/or health issues potentially linked to PFD.
The reported sensory difficulties primarily involved hearing, touch, and smell. Furthermore, olfactory difficulties were associated with a more limited variety of accepted foods.
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