Sensory Differences in Pediatric Feeding: Over and Under Responders

Pediatric feeding therapy is an intervention that many therapists, including speech-language pathologists and occupational therapists, regularly provide to children facing feeding challenges. How many times have parents or caregivers come to you describing mealtime battles? Or have you observed a child in your clinic grimacing at the sight of food, refusing to even touch it or gagging at a new texture?

These behaviors are common signs of the sensory-related challenges that therapists see frequently. What’s often misunderstood is that these reactions are not just about “picky eating”—they’re part of how the child’s sensory system processes the world around them, especially during mealtime.

This article will explore sensory differences, focusing on how to identify over- and under-responders and providing you with practical, evidence-based approaches for enhancing pediatric feeding therapy outcomes.

Understanding sensory over-responders

Sensory over-responders are children with heightened sensitivity to sensory input. These children may react intensely to sensations that others would find harmless or even enjoyable, such as the texture of food or the feeling of wetness on their skin. 

In pediatric feeding therapy, different sensory inputs can affect each system uniquely. For example, the texture of food or a feeling of wetness may overwhelm a child’s tactile system, while strong flavors and smells can heighten responses in the gustatory and olfactory systems. Vibrant colors may overstimulate their visual system, and sounds like crunching or chewing might be overwhelming to the auditory system. Poor body positioning can also activate the proprioceptive system, making it harder for the child to focus on eating.

When one or more of these sensory systems are overly sensitive, mealtime can become challenging, impacting the child’s ability to enjoy and engage with a variety of foods.

Common characteristics and recommendations for over-responders

Visual

• Sensitivity to sight: Over-responders may avoid foods with vibrant colors. This child may miss details when there are competing backgrounds.
• Emotional responses: Children may become anxious or agitated when confronted with non-preferred foods or unexpected sensory input during feeding.

When working with visual over-responders in pediatric feeding therapy, minimize visual input by using simple, plain dishware and cutlery. Reduce clutter by limiting visual materials on walls and ceilings and avoiding bright lights or colorful displays. If needed, provide hats or sunglasses to reduce visual input, and use tools like painter’s tape or labeled placements to help with visual organization. Allow the child some control over their interaction with visual stimuli, such as choosing where they sit, to reduce anxiety.

Tactile

• Sensitivity to touch: Over-responders may avoid touching food with their hands, often preferring utensils to avoid direct contact.
• Aversion to certain textures: Children may reject foods based on texture, preferring smooth or dry foods and avoiding sticky, wet, or mushy textures.
• Excessive wiping and grimacing: They may frequently wipe their hands, grimace, or use their teeth instead of lips to remove food from a utensil, with noticeable discomfort during meals.
• Emotional responses: Children may become anxious or agitated when confronted with non-preferred foods or unexpected sensory input during feeding.

For tactile over-responders, allow the child to use utensils if it makes them feel more comfortable. Introduce new textures gradually, starting with small, manageable amounts to help them adapt without pressure. Incorporate sensory play into therapy, such as food art (e.g., making cucumber “caterpillars”), to introduce new textures in a low-pressure, fun way. Give the child control over how much they interact with the food, whether by using their hands or utensils, to reduce anxiety.

Auditory

• Sensitivity to noise: This client is easily distracted by noise, sensitive to sounds, and may notice subtle background noises that others do not.
• Difficulty filtering sounds: An overresponsive auditory system makes it hard to filter out background noises, which often seem much louder and affect concentration.

To support auditory over-responders, try to minimize distractions during tasks that require focus by positioning the child away from sources of noise (e.g., heaters, windows, doors, pencil sharpeners, or chatty peers). Headphones can help reduce background sounds, and visual cues like a red/green light or a quiet/loud animal symbol can signal when volume adjustments are needed.

If the child isn’t tactilely defensive, a gentle touch on the shoulder can help gather their attention. Keep instructions brief and allow additional processing time, even if this means tolerating longer pauses. Providing choices, like using headphones or moving to a quieter spot, can also give the child a sense of control over their environment.

Gustatory

• Limited food range: Over-responders may have a restricted diet due to heightened sensitivity to taste.
• Specific preferences: These children can be particular about brands, colors, and flavors.

For gustatory over-responders, involve the child in food shopping and preparation to increase familiarity and comfort with different foods. Keep mealtimes calm to reduce stress, and gradually introduce new flavors or foods, using small, manageable changes to expand their tolerance over time. Let the child choose how much of a new food to try or whether they want to interact with it using utensils, which can help build comfort gradually.

Olfactory

• Heightened sensitivity to smells: These children are often highly aware of all surrounding smells, sometimes referred to as “super smellers.” Eating lunch around non-preferred foods or strong scents may be challenging.

To support olfactory over-responders, use fragrance-free products and un-perfumed options in areas the child frequents, such as bathrooms. Teach strategies to manage overwhelming smells, like covering their nose with a tissue, applying mint chapstick, or chewing mint gum, and encourage them to communicate with a teacher or therapist about bothersome scents.

You can also play “hide the smell” games to gradually increase tolerance to strong scents by briefly opening and closing a container with a noticeable smell. Providing some choice around where they eat or which scents to introduce first can help them feel more in control.

Vestibular

• Discomfort with movement: These children often dislike P.E. activities, movement games, or having their feet off the ground due to gravitational insecurity.
• Aversion to fast movement: Fast movements may be especially challenging, and these children are more prone to motion sickness.

When working with vestibular over-responders, incorporate gentle and stable activities like star jumps, hopscotch, or seated tasks on a gym ball. Compression exercises, trampoline jumping, wall push-ups, obstacle courses, scooter board activities, and commando crawling (pulling oneself along the ground) can help increase comfort with movement.

For children prone to motion sickness, strategies like head compression, focusing on a fixed point, or using a weighted blanket may provide relief. Allowing the child to choose which movement activities they engage in first can reduce anxiety and build comfort gradually.

Proprioceptive

• Self-soothing behaviors: Proprioceptive input can be calming for children who experience high sensory input. These children may manage through activities like chest tapping or joint compression.
• Typical actions: They may chew on items, seek tight spaces, enjoy weighted blankets, play rough, intentionally crash into things, jump on furniture, or hold objects (or people) too tightly.

For proprioceptive over-responders, ensure they are seated in a stable 90-90-90 position (hips, knees, and ankles each at 90 degrees) with flat and supported feet. Brushing and joint compression exercises before feeding can also help regulate their sensory input, promoting a calmer mealtime experience. Allowing the child to choose the type of input, such as brushing or weighted compression, can help them feel more secure and in control.

Interoceptive

• Heightened sensitivity to internal sensations: An over-responsive interoceptive system makes a child highly aware of every internal feeling, which can lead to difficulty managing bodily signals.

To support children with heightened interoceptive responses, help them identify and interpret their body’s cues by discussing sensations related to hunger, fullness, and other internal states. Teaching children to recognize these cues can foster better self-regulation and make it easier for them to respond appropriately to their body’s needs. Allow the child to take the lead in identifying body cues and choosing appropriate responses, which can build confidence in managing their internal sensations.

Understanding sensory under-responders

On the other end of the spectrum, sensory under-responders exhibit reduced sensitivity to sensory input. These children may appear indifferent to tactile sensations or not even notice them, so they require more sensory input to feel regulated and engaged during feeding. Unlike over-responders, who actively avoid certain sensations, under-responders might seek more intense sensory experiences.

Common characteristics and recommendations for under-responders

Visual

• Reduced visual alertness: These children may benefit from additional visual stimulation to help maintain alertness and attention.

For visual under-responders, allow access to visual stimulation at designated times throughout the day to increase their levels of focus and engagement. Using brightly colored utensils or textured placemats during meals can further capture their attention and keep them engaged.

Tactile

• Reduced response to touch: Under-responders may not notice being touched and often have a high pain tolerance.
• Low awareness of food in mouth or on hands: These children may not notice food on their face or hands and tend to be less concerned with cleanliness during meals.

To support tactile under-responders, introduce a variety of tactile activities to build their awareness of different textures and sensations, and establish routines to help them recognize physical contact. Encourage them to participate in meal preparation, allowing them to handle and manipulate ingredients, which can enhance their engagement and tactile awareness.

Auditory

• Reduced response to auditory input: These children may appear not to hear or respond to what parents, teachers, or peers are saying.

For auditory under-responders, use visual cues and allow extra processing time. Demonstrations, fidget tools, volume feedback, music breaks, and written instructions can help maintain their engagement and responsiveness. Incorporate pre-meal activities like sensory walks or simple movement exercises to help them become more present and focused before meals.

Gustatory

• Preference for strong sensory input in food: Under-responders often prefer crunchy, highly textured, or strongly flavored foods that provide sensory feedback.

To support gustatory under-responders, offer a range of flavors and textures to engage them. These foods can also be used as a sensory regulation tool to help them stay focused and engaged. Consider offering crunchy snacks or foods with bold flavors to heighten their sensory experience and boost engagement.

Olfactory

• Reduced awareness of smells: These children may need stronger or more noticeable smells to register scents.

When working with olfactory under-responders, introduce a variety of scents in a structured way to increase their awareness and engagement with smells. Allow them to explore stronger-smelling ingredients during meal prep activities to help build olfactory engagement and awareness.

Vestibular

• Constant need for movement: Under-responders are often in motion, as movement helps stimulate brain activity. They may frequently jump out of their seat or wander in structured settings like classrooms.

To support vestibular under-responders, provide regular movement breaks and encourage children to advocate for these breaks as needed. Use cues for appropriate movement activities within structured environments.

Proprioceptive

• High demand for “heavy work”: Under-responders benefit greatly from proprioceptive input, which can be calming and help regulate their sensory needs.
  • Types of heavy work: Active input (self-initiated) provides sensory effects for 2-4 hours, while passive input (provided by another) lasts 90 minutes to 2 hours.

Incorporate both active and passive heavy work into their routines, including activities like pushing, pulling, or carrying weighted items.

Interoceptive

• Reduced sensitivity to internal cues: Under-responders may struggle to recognize bodily needs, such as hunger, thirst, or the need to use the bathroom.
• Lack of response to temperature or pain: These children may eat overly hot food or burn their mouths without showing discomfort.

To support interoceptive under-responders, help them understand their body’s internal signals by discussing sensations associated with hunger, fullness, temperature, and pain. This approach fosters greater self-awareness and regulation. Incorporate reminders and cues for the child to tune into internal signals before meals, helping them recognize hunger and fullness over time.

Supporting both over- and under-responders

Working with over- and under-responders requires flexibility and creativity. Pediatric feeding therapy is rarely straightforward, and you might need to try several approaches before finding what works best for each child. 

As a therapist, you know feeding progress can vary greatly among children. So, how can you build a plan that works across these sensory differences? Here are some universal, evidence-based strategies that can benefit both groups:

1. Play-based interventions

Making feeding fun can reduce anxiety for over-responders and increase engagement for under-responders. For example, encourage children to “make it rain” with peas or small berries, or use cookie cutters to shape soft foods like cheese or melon slices into fun designs​. 

Toddlers with food refusal who participated in sensory-based interventions significantly improved mealtime behavior compared to those receiving only nutritional education.¹ Playful, sensory-focused activities help children gradually explore new textures at their own pace, reducing stress and building positive associations with food.

2. Gradual desensitization

Over-responders benefit from slow exposure to new textures, while under-responders need a gradual increase in sensory input. For example, start by introducing small amounts of sauce next to dry crackers for over-responders, while under-responders might enjoy gradually adding more spices or flavors to their favorite crunchy foods.

3. Parental involvement

Educating parents on how to support their child’s sensory needs at home is essential for helping children overcome feeding challenges. According to the American Speech-Language-Hearing Association, over 1 in 37 children under the age of 5 are affected by pediatric feeding disorders each year.² With these numbers in mind, parental involvement is a necessary strategy for addressing mealtime difficulties and improving feeding behaviors.

You can suggest that parents create a low-pressure mealtime environment by avoiding negative reactions to food refusal and including the child in meal preparation. This helps the child feel more in control and involved, which can reduce mealtime stress and foster positive experiences.

4. Adapt the environment

Over-responders may become overwhelmed by visual or auditory stimuli, so keeping mealtime environments simple—using plain plates and reducing background noise—can help them focus on feeding. Under-responders might benefit from more sensory input, such as colorful utensils or a pre-meal movement break​.

Research on mealtime environments and control of food intake in children shows that distractions, such as watching TV or bringing toys to the table, are a common coping mechanism for parents, but they can impede self-regulation during meals, especially in children with feeding issues.³ Creating a calm, distraction-free environment helps children focus on the task of eating, promoting better self-regulation and healthier mealtime behaviors.

Integrating sensory-based pediatric feeding in your practice

Sensory differences significantly impact feeding challenges, making it essential to understand these variations for effective intervention. By determining whether a child is an over-responder or an under-responder to sensory input, you can customize pediatric feeding therapy strategies to address each child’s unique needs. The goal is not only to help children tolerate a wider range of foods but also to ensure they feel safe, supported, and empowered during mealtimes.

For clinicians looking to expand their understanding of sensory-based feeding therapy, Medbridge’s Pediatric Feeding course series offers evidence-based strategies for addressing pediatric feeding challenges, equipping you to create meaningful interventions in your practice. The series includes the following courses:

• Pediatric Feeding: Foundational Knowledge
• Pediatric Feeding: A Guide to Functional Frenectomy
• Pediatric Feeding: Sensory Knowledge
• Pediatric Feeding: Supporting Caregivers Support Progress
• Pediatric Feeding: Systematic Assessment

References

1. Kim, A. R., Kwon, J. Y., Yi, S. H., & Kim, E. H. (2021). Sensory Based Feeding Intervention for Toddlers With Food Refusal: A Randomized Controlled Trial. Annals of rehabilitation medicine, 45(5), 393–400. https://doi.org/10.5535/arm.21076
2. American Speech-Language-Hearing Association. (2023, May 17). ASHA encourages families to learn the signs of pediatric feeding disorder. https://www.asha.org/news/2023/asha-encourages-families-to-learn-the-signs-of-pediatric-feeding-disorder/
3. Sdravou, K., Emmanouilidou-Fotoulaki, E., Printza, A., Andreoulakis, E., Evangeliou, A., & Fotoulaki, M. (2021). Mealtime Environment and Control of Food Intake in Healthy Children and in Children with Gastrointestinal Diseases. Children (Basel, Switzerland), 8(2), 77. https://doi.org/10.3390/children8020077