Prof. Xiao-Yang Sheng - Tackling Picky Eating – Insights from the Clinical Data

Potential consequences of picking eating include caregiver anxiety and poor dietary intake. A clinical trial looking into its management via nutrition counselling and supplementation was conducted.

19 min watch

Picky eating (PE) is a term commonly used to describe the mealtime behaviours and food preferences of young children. While there is no widely agreed-upon definition of this phenomenon, common behaviours that are associated with PE include avoiding the intake of certain food groups, avoiding certain foods based on their sensory characteristics, requiring specific food presentations or preparations, eating a limited variety of food, and not eating an adequate amount of food.1 In China, the prevalence of PE behaviours among pre-schoolers have been reported to range from 36%‒54%.2,3

Risks associated with picky eating behaviours

PE behaviours affect the child, caregivers, family, and healthcare providers, and can create caregiver anxiety about the child’s growth and development.4 It could also lead to a reduction of food intake and dietary variety, and lower protein and dietary fibre, as well as lower iron and zinc intakes. PE is associated with a greater risk of being underweight and having poor growth and has been identified as a risk factor for developing subsequent anorexia nervosa.5 Thus, it is important to address PE behaviours at an early age to support growth, adequate nutrition intake, and positive caregiver-child interactions that contribute to healthy development.4

Managing picky eating behaviours with nutrition counselling and supplementation

A multicentre, open-label, randomized controlled trial conducted in China and Hong Kong investigated the effects of standardized nutrition counselling with and without nutritional supplementation on the growth and nutrient adequacy of children with PE behaviours.4 One hundred fifty-three pre-school children with PE behaviours were randomized to receive either nutritional counselling alone (NC) or a combination of nutritional counselling and nutritional supplementation with a growing-up milk (NC+NS). The intervention period was 120 days, with study visits conducted at days 30, 60, 90 and 120. Nutritional intake at baseline was generally similar between groups.

The increases in mean weight-for-height z-scores (WHZ) were significantly higher in the NC+NS group at days 30 (P=0.047) and 90 (P=0.021), and also for the entire study period (between-group difference, 0.13 [95% CI, 0.01, 0.25]; P=0.029) [Figure 1].4 The increases in the mean weight-for-age z-scores (WAZ) in the NC+NS group were also significantly higher at day 90 (P=0.025) and for the entire study period (between-group difference, 0.08 [95% CI, 0.00, 0.16]; P=0.046) [Figure 2].4 These incremental gains in WHZ and WAZ in the NC+NS group may suggest that nutrition counselling alone may require several months until improved eating habits are established and changes in growth parameters are observed. No significant between-group differences were observed in mean change in height-for age z-scores (HAZ) at any timepoint or for the entire study period, possibly due to the relatively short study period.

Energy, protein and carbohydrate intakes were also higher in the NC+NS group at day 60 and day 120 compared with those in the NC group.4 Additionally, there were significantly greater intakes of several micronutrients, including calcium, phosphorous, iron, zinc, and vitamins A, C, D, E and B6, in the NC+NS group versus the NC group at days 60 and 120 (P<0.001).4

Figure 1. Nutritional supplementation contributes to significantly greater increases in WHZ over the entire study period, at 30 and at 90 days. Adapted from Sheng X, et al. (2014).

Figure 2. Nutritional supplementation contributes to significantly greater increases in WAZ over the entire study period and at 90 days. Adapted from Sheng X, et al. (2014).

The consumption rate was consistent, with more than 75% of the children in the NC+NS group consuming at least one serving of NS daily.4 The mean intake was 344 and 371ml/day respectively at days 60 and 120.4 At day 120, 57.3% of caregivers reported that their child liked the taste of the NS and 68.0% reported that their child was willing to drink the supplement daily.4

The incidence of common illnesses (diarrhoea and upper and lower respiratory tract infections) did not differ between groups.4 A study enrolling children with nutritional or social disadvantages may be necessary to demonstrate significant differences in this parameter.


Nutritional counselling and behavioural modification are essential tools in managing children with PE behaviours. During the early phase of nutritional counselling, when changes in dietary habits may not yet be sufficient to significantly improve nutrient intake, nutritional supplementation can help mitigate the potential risks associated with PE behaviours by increasing the intake of essential nutrients for growth and development.


  1. Patel MD, et al. Nutrients. 2020 Nov 6;12(11):3409.
  2. Li Z, et al. Appetite. 2017 Jan 1;108:456-463.
  3. Xue Y, et al. PLoS ONE. 2015 Apr 13;10(4):e0123664.
  4. Sheng X, et al. Nutr Metab Insights. 2014 Oct 1;7:85-94.
  5. Marchi M, Cohen P. J Am Acad Child Adolesc Psychiatry. 1990 Jan;29(1):112-7.