Picky eating in children: Should we be concerned?

’Picky eating’ is a loosely used term to describe features such as having a small appetite (eating small or perceived small quantities of food), being selective about the types of foods eaten, and fussy mealtime behaviours. Studies have shown that picky eaters tend to have lower intake of meat and protein-rich foods, less vegetables and less energy from mixed dishes. Picky eaters also tend to have a lower overall food consumption and skewed nutritional intake because of the lack of variety in the food they eat. Thus, these children tend to have lower mean BMI, were more often underweight and tend to have micronutrient deficiencies. One of the important factors in managing picky eaters is the relationship between the child and the parent or caregiver at mealtimes. Clinicians should remind parents to cultivate good eating behaviours and provide a pleasant environment for meals and snacks. Children with picky eating behaviours should be closely monitored to ensure adequate nutrition to support the rapid growth and development that occur during infancy and early childhood. It is well known that early nutritional status is linked to health later in life; appropriate dietary intake throughout childhood is critical in reducing the risk of noncommunicable diseases.

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One of the important factors in managing picky eaters is the relationship between the child and the parent or caregiver at mealtimes. Clinicians should remind parents to cultivate good eating behaviours and provide a pleasant environment for meals and snacks.

Dr Michelle Tan

Consultant, Division of Paediatric Gastroenterology, Nutrition, Hepatology and Liver Transplantation,
Department of Paediatrics, Khoo Teck Puat – National University Children's Medical Institute, National University Hospital

What does ‘picky eating’ mean?

There is no internationally accepted definition, but generally, ‘picky eating’ is a loosely used term to describe features such as having a small appetite (eating small or perceived small quantities of food), being selective about the types of foods eaten, and fussy mealtime behaviours. It is usually a transient problem which requires attention at the primary care level. When this behaviour becomes more severe and causes substantial adverse health, nutritional, or emotional consequences, it is referred to as a ‘feeding difficulty or disorder’.¹

What are the implications of picky eating on a child's health and development?

Studies have shown that picky eaters tend to have lower intake of meat and protein-rich foods, less vegetables and less energy from mixed dishes.¹ Picky eaters also tend to have a lower overall food consumption and skewed nutritional intake because of the lack of variety in the food they eat.²

Thus, these children tend to have lower mean BMI and were more often underweight.³ Additionally, they also tend to have deficiencies in iron, zinc, and vitamins A, C, E, B1, B2 and B3 – all of which play important roles in growth and development.^4,5,6,7

Do feeding difficulties warrant intervention?

Although parents may not be able to identify true feeding difficulties, parental concerns regarding their children’s feeding should not be ignored. A study conducted in three well-baby clinics in Malaysia and Singapore found a strong association between parental concern regarding feeding issues of their child and growth faltering.⁸

Clinicians should look out for underlying conditions that could be contributing to the picky eating behaviour, such as dysphagia, uncoordinated swallowing, feeding-associated pain, vomiting and/or diarrhoea, atopic conditions and congenital abnormalities, etc. Clinicians also need to investigate if there are behavioural red flags, such as food fixation, forceful feeding, abrupt cessation of feeding after a trigger event, and anticipatory gagging.⁹

What can be done to optimise the nutrition of children with picky eating patterns?

Feeding guidelines for all children⁸

Avoid distractions such as the television and cellphones during mealtimes
Keep the atmosphere neutral or pleasant at mealtimes
Families should eat together
Encourage appetite by limiting meal duration (20-30 minutes) and frequency (3 main meals and 2-3 snacks a day)
Serve food that is age appropriate
Encourage self-feeding
Repeatedly and systematically introduce new foods
Be tolerant of age-appropriate mess during eating

In some children, vitamin and mineral supplementation should be considered. Parents should be advised that high-energy beverages, including calorie-dense milk formulas, are convenient but should not be used as a meal replacement for picky eaters.¹⁰

Children with picky eating behaviours should be closely monitored to ensure adequate nutrition to support the rapid growth and development that occur during infancy and early childhood. It is well known that early nutritional status is linked to health later in life; appropriate dietary intake throughout childhood is critical in reducing the risk of noncommunicable diseases in adulthood, such as obesity, diabetes mellitus and other metabolic diseases.¹¹

Disclaimer:
The doctor who participated in the development of this article does not have financial relationships with any entities that have an interest related to the published work. The participation of the doctor in the development of this article does not constitute or imply an endorsement or recommendation. The content of this article is intended to be used for informational purposes only, and not intended to impart any medical or other advice.

References:

van der Horst K, Deming DM, Lesniauskas R, et al. Picky eating: Associations with child eating characteristics and food intake. Appetite. 2016;103:286-93.
Taylor CM, Wernimont SM, Northstone K, et al. Picky/fussy eating in children: Review of definitions, assessment, prevalence and dietary intakes. Appetite. 015;95:349-59.
Tharner A, Jansen PW, Kiefte-de Jong JC, et al. Toward an operative diagnosis of fussy/picky eating: a latent profile approach in a population-based cohort. The international journal of behavioral nutrition and physical activity. 2014;11:14.
Galloway AT, Fiorito L, Lee Y, et al. Parental pressure, dietary patterns, and weight status among girls who are “picky eaters”. Journal of the American Dietetic Association. 2005;105(4):541-8.
Samuel TM, Musa-Veloso K, Ho M, et al. A Narrative Review of Childhood Picky Eating and Its Relationship to Food Intakes, Nutritional Status, and Growth. Nutrients. 2018;10(12):1992.
Taylor CM, Northstone K, Wernimont SM, et al. Macro- and micronutrient intakes in picky eaters: a cause for concern? The American journal of clinical nutrition. 2016;104(6):1647-56.
Guo M, Zhu J, Yang T, et al. Vitamin A and vitamin D deficiencies exacerbate symptoms in children with autism spectrum disorders. Nutritional neuroscience. 2018:1-11.
Lee WS, Tee CW, Tan AG, et al. Parental concern of feeding difficulty predicts poor growth status in their child. Pediatr Neonatol. 2019 Dec;60(6):676-683.
Kerzner B, Milano K, MacLean WC, Jr., et al. A practical approach to classifying and managing feeding difficulties. Pediatrics. 2015;135(2):344-53.
Lampl M, Mummert A, Schoen M. Promoting Healthy Growth or Feeding Obesity? The Need for Evidence-Based Oversight of Infant Nutritional Supplement Claims. Healthcare (Basel, Switzerland). 2016;4(4):84.
Peneau S, Giudici KV, Gusto G, Goxe D, Lantieri O, Hercberg S, et al. Growth trajectories of body mass index during childhood: associated factors and health outcome at adulthood. J Pediatr. 2017;186:64-71.e1.