Feeding difficulties, resulting from refusal to eat certain foods, are a frequent complaint in pediatric clinical practice. In many instances the initial situation is not necessarily serious but ongoing issues around feeding may lead to the adoption of inappropriate feeding practices that can have long lasting consequences. An extremely selective food choice, or picky eating, has been linked to sensory reactivity difficulties. In the general population it is estimated that between 5-10% of children experience sensory reactivity issues. Understanding how this can affect participation in feeding and mealtime is critical. This article presents a case report of a 22-month year old girl with selective food choices and feeding refusal. Occupational Therapy intervention based on Ayres Sensory Integration®, in the context of collaboration with the child’s pediatrician, was used to address the sensory issues underlying this child’s feeding and mealtime participation difficulties. From the results of the assessment, the following hypothesis were made; a) over-reactivity to oral and tactile sensory input was affecting acceptance of new foods and textures, b) vestibular processing difficulties and tactile over-reactivity were impacting this child´s ability to regulate level of alertness and the ability to stay sitting at the table during appropriate periods of time. Following the Occupational Therapy intervention this child showed improved feeding and mealtime participation and was also able to adequately sit at the table for the duration of the meal.