Feeding difficulties in childhood: A narrative review

It has been estimated that between 25% and 40% of healthy children show symptoms of feeding difficulties (FDs) during their growth and development; many times, these are not adequately diagnosed. The objective of this study was to conduct a narrative review that collected the available information on feeding difficulties. Assessment and management algorithms were developed based on the bibliographic evidence. Most feeding problems in young children (feeding selectivity, loss of appetite, fear of feeding) are often concurrent, and a clinical risk assessment is necessary to plan an individualized intervention. Having standardized definitions and common terms to address these difficulties in an appropriate and multidisciplinary manner is one of the ways to optimize their treatment. The involvement of different health care providers and parents is critical to address feeding difficulties.

Cognitive-behavioral therapy for avoidant/restrictive food intake disorder: A proof-of-concept for mechanisms of change and target engagement

BACKGROUND

Cognitive-behavioral therapy for avoidant/restrictive food intake disorder (ARFID; CBT-AR) theoretically targets three prototypic motivations (sensory sensitivity, lack of interest/low appetite, fear of aversive consequences), aligned with three modularized interventions. As an exploratory investigation, we: (1) evaluated change in candidate mechanisms in relationship to change in ARFID severity, and (2) tested if assignment (vs. not) to a module resulted in larger improvements in the corresponding mechanism.

METHOD

Males and females (N = 42; 10-55 years) participated in an open trial of CBT-AR.

RESULTS

Decreases in scaled scores for each candidate mechanism had medium to large correlations with decreases in ARFID severity-sensory sensitivity: -0.7 decrease (r = .42, p = .01); lack of interest/low appetite: -0.3 decrease (r = .60, p < .0001); and fear of aversive consequences: -1.1 decrease (r = .33, p = .05). Linear mixed models revealed significant weekly improvements for each candidate mechanism across the full sample (ps < .0001). There were significant interactions for the sensory and fear of aversive consequences modules-for each, participants who received the corresponding module had significantly larger decreases in the candidate mechanism than those who did not receive the module.

DISCUSSION

Sensory sensitivity and fear of aversive consequences improved more if the CBT-AR module was received, but lack of interest/low appetite may improve regardless of receipt of the corresponding module. Future research is needed to test target engagement in CBT-AR with adaptive treatment designs, and to identify valid and sensitive measures of candidate mechanisms.

PUBLIC SIGNIFICANCE

The mechanisms through which components of CBT-AR work have yet to be elucidated. We conducted an exploratory investigation to test if assignment (vs. not) to a CBT-AR module resulted in larger improvements in the corresponding prototypic ARFID motivation that the module intended to target. Measures of the sensory sensitivity and the fear of aversive consequences motivations improved more in those who received the corresponding treatment module, whereas the lack of interest/low appetite measure improved regardless of if the corresponding module was received.

[Sensory food aversion in the context of a modern approach to eating disorders in early childhood]

Sensory food aversion, an early childhood eating disorder, is a serious, permanent form of picky eating, in which the infant or the child consistently and persistently refuses certain foods based on specific characteristics, following one or more previous aversive experiences. Biological (sensory processing disorder, taste sensitivity) and environmental factors contribute to its development. Due to limited diet, specific dietary deficiencies may occur but weight gain is usually normal. Behavioral problems, anxiety disorder, autism spectrum disorder are often associated. Diagnosis can usually be made based on a detailed history, but further assessment may include pediatric examination, nutritionist consultation, and psychologic and occupational therapy assessment. Treatment is based on parent education and support in order to minimize mealtime battles and anxiety and to think together about strategies for expanding the child's diet and to help them to accept new foods. As part of the interdisciplinary team, the pediatrician's role is to monitor appropriate growth and development, exclude dietary deficiencies or prescribe supplementation if necessary. In our article, the screening and treatment of sensory processing disorder as part of the assessment of eating problems are introduced as an example of good clinical practice at the Early Childhood Eating and Sleep Disorder Outpatient Clinic at the Heim Pál National Institute of Pediatrics. Orv Hetil. 2023; 164(45): 1767-1777.

Looking Beyond the Growth Curve: A Retrospective Study on Nutrient Deficient Diets in Children with Severe Food Selectivity

Severe food selectivity places children at risk for nutrient deficiencies and long-term medical complications, if unaddressed. However, poor nutrition in highly selective eaters is often overlooked when considering other behavioral or medical concerns. Additionally, studies regarding food selectivity are sparse and limited to children with developmental delays. This study further investigates the nutritional deficiencies and growth characteristics of children with severe food selectivity to assist pediatricians in the earlier identification of patients for nutrition screening. A retrospective chart review was completed for 13 patients admitted to a pediatric feeding program solely for table-textured food selectivity. Nutrition and anthropometric data from the medical record were analyzed. All patients were determined to be following an age-appropriate growth curve but had multiple micronutrient deficiencies. Additionally, 6 children were typically developing outside of the feeding context. Results suggest that children with food selectivity may require more intensive and earlier nutrition screening beyond their growth patterns.

Higher meal disengagement and meal presentation are uniquely related to psychological distress and lower quality of life in undergraduate students

Objective: Picky eating, which occurs in emerging adulthood and is associated with psychological distress and quality of life, has historically been conceptualized as unidimensional despite research suggesting it is a multifaceted construct. Participants: An undergraduate sample (N = 509; Mage = 19.96). Methods: A cross-sectional survey assessed picky eating facets (food variety, meal disengagement, meal presentation, and taste aversion), disordered eating, anxiety, depression, stress, obsessive compulsive disorder (OCD), and social phobia symptoms, and quality of life. Results: Meal disengagement was uniquely related to higher anxiety, depression, stress, and social phobia symptoms and lower quality of life, whereas meal presentation was uniquely related to higher anxiety, stress, and OCD symptoms, beyond covariates and disordered eating. Food variety and taste aversion were not uniquely related to outcomes. Conclusions: Considering picky eating multidimensionally may yield important insights beyond the broader construct in terms of its relationship with psychological well-being in undergraduates.

Picky eating is associated with lower life satisfaction and elevated psychological distress and psychosocial impairment in Chinese pregnant women

OBJECTIVE

This study assessed picky eating in pregnant women by exploring whether picky eating is associated with pregnant women's well-being, including life satisfaction, psychological distress, and psychosocial impairment.

METHOD

Data collected were from 345 Chinese pregnant women (M age = 29.95 years, SD = 5.58). Pearson correlation analyses were conducted to examine zero-order correlations between picky eating and well-being variables (i.e., life satisfaction, psychological distress, and psychosocial impairment). Hierarchical multiple regressions were conducted to examine the unique associations of picky eating with well-being variables, adjusting for demographic and pregnancy-related characteristics and thinness-oriented disordered eating.

RESULTS

Picky eating was significantly and negatively correlated with life satisfaction (r = -.24, p < .001) and positively correlated with psychological distress (r = .37, p < .001) and psychosocial impairment (r = .50, p < .001). When adjusting for covariates and thinness-oriented disordered eating, picky eating was still significantly associated with lower life satisfaction, higher psychological distress, and higher psychosocial impairment.

DISCUSSION

The findings suggest that picky eating may be a significant correlate of pregnant women's poorer well-being. Future research with longitudinal designs is warranted to further examine the temporal associations between picky eating and pregnant women's well-being.

PUBLIC SIGNIFICANCE

Picky eating behaviors are poorly understood in pregnant women. Our results revealed that higher picky eating behaviors were associated with lower life satisfaction and higher psychological distress and psychosocial impairment in Chinese pregnant women. Researchers and clinicians may consider picky eating in the assessment and treatment of mental health and disordered eating in pregnant women.

Arfid Genes and Environment (ARFID-GEN): Study Protocol

Background

The Avoidant Restrictive Food Intake Disorder Genes and Environment (ARFID-GEN) study is a study of genetic and environmental factors that contribute to risk for developing ARFID in children and adults.

Methods

A total of 3,000 children and adults with ARFID from the United States will be included. Parents/guardians and their children with ARFID (ages 7 to 17) and adults with ARFID (ages 18+) will complete comprehensive online consent, parent verification of child assent (when applicable), and phenotyping. Enrolled participants with ARFID will submit a saliva sample for genotyping. A genome-wide association study of ARFID will be conducted.

Discussion

ARFID-GEN, a large-scale genetic study of ARFID, is designed to rapidly advance the study of the genetics of eating disorders. We will explicate the genetic architecture of ARFID relative to other eating disorders and to other psychiatric, neurodevelopmental, and metabolic disorders and traits. Our goal is for ARFID to deliver "actionable" findings that can be transformed into clinically meaningful insights.

Trial registration

ARFID-GEN is a registered clinical trial: clinicaltrials.gov NCT05605067.

Interrelated development of autism spectrum disorder symptoms and eating problems in childhood: a population-based cohort

Eating problems, such as food selectivity or picky eating, are thought to be an epiphenomenon of autism spectrum disorders (ASD). Yet eating problems are also common in the general pediatric population and overlap with ASD symptoms. However, the temporal association between ASD symptoms and eating problems is poorly understood. This study examines the bidirectional association between ASD symptoms and eating problems across child development, and investigates whether these associations differ by child sex. Participants (N = 4,930) were from the population-based Generation R Study. Parents reported their child's ASD symptoms and eating problems using the Child Behavior Checklist at 5 assessments from toddlerhood to adolescence (1.5 to 14 years, 50% girls). A Random Intercept Cross-Lagged Panel Model was used to examine the lagged associations between ASD symptoms and eating problems at the within-person level, controlling for stable, trait-like differences at the between-person level. At the between-person level, there was a strong correlation between ASD symptoms and eating problems (β = .48, 95% CI: 0.38 to 0.57). Controlling for these between-person effects, there was limited evidence for consistent, predictive effects of ASD symptoms and eating problems at the within-person level. Associations did not differ by child sex. Findings suggest that ASD symptoms and eating problems may represent a cluster of traits that are highly stable from early childhood to adolescence, which have a minimal reciprocal effect at the individual-level. Future research could focus on these trait-like qualities to inform the development of supportive, family-focused interventions.

Describing and Predicting Feeding Problems During the First 2 Years Within an Urban Pediatric Primary Care Center

We conducted a prospective cohort study with children aged 6 to 18 months to identify predictors of feeding problems in an urban sample. Parent-reported child feeding problems (Montreal Children's Hospital Feeding Scale) and picky eating, parental anxiety (Generalized Anxiety Disorder 7), and family meal structure (Meals in Our Household) were assessed via a Web-based survey at 3 time points. Data analysis included descriptive statistics, correlations, and mixed-effects regression modeling. Eighty parents completed the survey. Child picky eating (r =.51) and resistance to try new foods (r = .30), parental anxiety (r = .34), rushed mealtimes (r = .28), and child age (r = .32) were significantly associated with child feeding problems. Feeding Scale scores were, on average, 6 points higher among picky eaters than those who were not over time (p < .001). Parent reports of picky eating early in life may warrant additional clinical investigation and referral to feeding specialists.

Family Feeding Practices of Parents on Prince Edward Island: A Focus on Responsive Feeding

The home environment and parental influence are strong predictors of eating behaviours in young children and can influence healthy development. The objective of this study was to describe the feeding practices of a sample of families on Prince Edward Island. Eleven parent participants were recruited, one-on-one interviews were held, and a thematic analysis was conducted. Conversations with parents revealed that the family feeding environment is influenced by a multitude of factors that change daily and need to be navigated based on the age of the child. Parents saw family meals as time together and an opportunity to model healthy eating behaviours; however, they faced several challenges at mealtimes, including perceived picky eating. Parents recognized their children's hunger and satiety cues, although they respected satiety signals more often if children ate what they perceived as a lot of food. Many parents used food as a reward to encourage their children to eat more but recognized that it could lead to the development of undesirable habits. Despite the complex factors that influence feeding, dietitians can work with families to foster a responsive feeding environment by encouraging family meals, recognizing and respecting hunger and satiety cues, and understanding typical changes in eating behaviours as children age.

Picky Eating in Childhood: Associations With Obsessive-Compulsive Symptoms

OBJECTIVE

To test whether childhood picky eating (PE)-a behavior previously linked to many forms of psychopathology-is specifically associated with symptoms of obsessive-compulsive disorder (OCD).

METHODS

We investigated the relationship between PE and symptoms of several forms of psychopathology in two separate observational samples: a sample of 110 children (5 and 6 years old) and a sample of 210 children (8 and 9 years old) drawn from a longitudinal study. In each sample, regression models based on psychiatric symptoms or diagnoses were used to assess the specificity of PE associations while accounting for cooccurring symptoms or comorbidities.

RESULTS

Although bivariate associations emerged between PE and multiple forms of psychopathology, multivariate analyses revealed these associations were driven by a strong and specific association between PE and symptoms of OCD in both samples. Moreover, PE among 8- and 9-year-olds in the longitudinal study predicted emergence of additional later psychopathology, specifically attention-deficit/hyperactivity disorder (ADHD).

CONCLUSIONS

Findings suggest that PE, an easily identifiable clinical presentation, is also a specific marker for obsessive-compulsive symptomatology in school-age children and may impart risk for ADHD later in childhood.

Oral Sensory Sensitivity Influences Attentional Bias to Food Logo Images in Children: A Preliminary Investigation

Background

Children's sensory processing patterns are linked with their eating habits; children with increased sensory sensitivity are often picky eaters. Research suggests that children's eating habits are also partially influenced by attention to food and beverage advertising. However, the extent to which sensory processing influences children's attention to food cues remains unknown. Therefore, we examined the attentional bias patterns to food vs. non-food logos among children 4-12 years with and without increased oral sensory sensitivity.

Design

Children were categorized into high (n = 8) vs. typical (n = 36) oral sensory sensitivity by the Sensory Profile-2. We used eye-tracking to examine orientation and attentional bias to food vs. non-food logos among children with high vs. typical oral sensory sensitivity. We used a mixed model regression to test the influence of oral sensory sensitivity to attentional biases to food vs. non-food logos among children.

Results

Results showed that children with high oral sensory sensitivity showed attentional biases toward non-food logos; specifically, children with high oral sensory sensitivity oriented more quickly to non-food logos as compared to food logos (p < 0.05), as well as spent more time looking at non-food logos as compared to food logos (p < 0.05). Findings were in the opposite direction for children with typical oral sensory sensitivity.

Conclusion

Sensory sensitivity may be an individual characteristic that serves as a protective mechanism against susceptibility to food and beverage advertising in young children.

Consumption of Added Sugar among Chinese Toddlers and Its Association with Picky Eating and Daily Screen Time

Objectives: This study aimed to examine the relationship between daily screen time, picky eating, and consumption frequency of sugared foods and sugar-sweetened beverages (SSBs). Methods: The research data came from the Young Investigation (YI) study conducted in 10 cities in China. This study used sociodemographic information, feeding behavior, picky eating reported by parents, and the consumption frequency of sugared foods and SSBs of 879 toddlers aged 1−3 years. The relationship between daily screen time and picky eating behavior was assessed using logistic regression. The zero-inflated negative binomial (ZINB) model was used to fit the consumption frequencies of sugared foods and SSBs. Results: In all, 13.1% (n = 115) of toddlers did not have sugared foods 1 month before the survey, while 73.3% (n = 644) of toddlers did not have SSBs 1 month before the survey. The consumption rate of sugared foods was relatively higher than SSBs (χ2 = 661.25, p < 0.001). After adjusting for social demographic information, no relationship was found between daily screen time and picky eating (OR = 1.437; 95% CI: 0.990,2.092). The ZINB model showed that, among children who ate sugared foods, children who were picky eaters ate them more often (IRR = 1.133; 95% CI: 1.095,1.172), but no association was found between picky eating and the chance of avoiding sugared foods (OR = 0.949; 95% CI: 0.613,1.471). Children who were picky eaters were less likely not to drink SSBs (OR = 0.664; 95% CI: 0.478,0.921). However, among children who consumed SSBs, picky eaters drank them less frequently (IRR = 0.599; 95% CI: 0.552,0.650). Children with a screen time of no less than 1 h/d ate sugared foods more frequently (IRR = 1.383; 95% CI: 1.164,1.644), and they were less likely to avoid sugared foods (OR = 0.223; 95% CI: 0.085,0.587). The longer the screen time per day was, the less likely children did not have SSBs (<1 h/d: OR = 0.272; 95% CI: 0.130, 0.569; ≥1 h/d: OR = 0.136; 95% CI: 0.057, 0.328). Conclusions: The consumption rate of sugared foods was higher than that of SSBs. Picky eating and daily screen time were related to the consumption frequency of added sugar among Chinese toddlers aged 1−3 years. Picky eaters consumed sugared foods more frequently and were more likely to drink SSBs. Children whose daily screen time reached 1 h/d were more likely to eat sugared foods and drink SSBs.

Eating Behaviors, Caregiver Feeding Interactions, and Dietary Patterns of Children Born Preterm: A Systematic Review and Meta-Analysis

Infants born preterm (<37 weeks of gestation) often experience feeding problems during hospitalization. Whether difficulties persist or have long-term sequelae on childhood eating is unclear. We aimed to describe the oromotor eating skills (e.g., chewing/swallowing), eating behaviors (e.g., food neophobia), food parenting practices (e.g., pressure to eat), and dietary patterns of preterm children during late infancy (6-12 mo) and early childhood (>12 mo-7 y) and to determine whether these differed from those of term-born peers. We identified 67 articles (57 unique studies) for inclusion. We used random-effects meta-analysis of proportions to examine the prevalence of oromotor eating skill and eating behavior challenges among preterm children, standard meta-analysis for comparisons with term-born peers, and the Grading of Recommendations, Assessment, Development and Evaluation approach to assess the certainty of evidence. Forty-three percent (95% CI: 24%, 62%) of infants and 25% (95% CI: 17%, 33%) of children born preterm experienced oromotor eating difficulties and 16% (95% CI: 4%, 27%) and 20% (95% CI: 11%, 28%), respectively, exhibited challenging eating behaviors. During late infancy and early childhood, oromotor eating difficulties (OR: 2.86; 95% CI: 1.71, 4.77; I2 = 67.8%) and challenging eating behaviors (OR: 1.52; 95% CI: 1.11, 2.10; I2 = 0.0%) were more common in those born preterm than in those born term: however, the certainty of evidence was very low. Owing to the low number and heterogeneity of studies, we narratively reviewed literature on food parenting and dietary patterns. Mothers of preterm infants appeared to have heightened anxiety while feeding and utilized coercive food parenting practices; their infants reportedly received less human milk, started solid foods earlier, and had poorer diet quality than term-born peers. In conclusion, meta-analyses show preterm children experience frequent oromotor eating difficulties and challenging eating behaviors throughout the early years. Given preterm birth increases risk of later obesity and diet-related chronic disease, research examining the effects of caregiver-child interactions on subsequent diet is warranted. This review was registered at www.crd.york.ac.uk/prospero/ as CRD42020176063.

Child Autistic Traits, Food Selectivity, and Diet Quality: A Population-Based Study

BACKGROUND

Children with Autism Spectrum Disorders (ASDs) tend to be selective in their food intake, which may compromise their diet quality. While ASD diagnoses capture severe levels of impairment, autistic traits vary on a continuum throughout the population. Yet, little is known about how autistic traits relate to diet quality at the population level.

OBJECTIVES

This study examines the association between autistic traits in early childhood and diet quality in mid-childhood and explores the mediating role of food selectivity.

METHODS

Participants were children (n = 4092) from the population-based Generation R Study. Parents reported their child's autistic traits at 1.5, 3, and 6 years; food selectivity at 4 years; and food intake at 8 years, from which a diet quality score was derived. Associations of autistic traits and the autistic trait trajectory (identified using Latent Class Growth Modelling) with diet quality were examined using multiple linear regression models. The indirect effect of food selectivity in the association between autistic traits at 1.5 years and diet quality was examined using mediation analysis.

RESULTS

Autistic traits were associated with diet quality (e.g., 1.5 years: β = -0.09; 95% CI: -0.13 to -0.06). Two classes captured the autistic trait trajectories from 1.5 to 6 years: children with "low and stable" (95%) and "high and increasing" (5%) mean scores. Children in the high and increasing group had poorer diet quality than those in the low and stable group (β = -0.28; 95% CI: -0.44 to -0.11). Food selectivity mediated the association between autistic traits at 1.5 years and diet quality at 8 years (βindirect = -0.03; 95% CI: -0.03 to -0.02).

CONCLUSIONS

Autistic traits in early childhood are associated with poorer diet quality in mid-childhood, and food selectivity appears to mediate this association. Interventions intended to optimize nutrition in children with elevated autistic traits may integrate behavioral strategies to support parents' responding to their child's food selectivity.

Oral Nutritional Supplementation Improves Growth in Children at Malnutrition Risk and with Picky Eating Behaviors

The problem of poor nutrition with impaired growth persists in young children worldwide, including in India, where wasting occurs in 20% of urban children (<5 years). Exacerbating this problem, some children are described by their parent as a picky eater with behaviors such as eating limited food and unwillingness to try new foods. Timely intervention can help prevent nutritional decline and promote growth recovery; oral nutritional supplements (ONS) and dietary counseling (DC) are commonly used. The present study aimed to determine the effects of ONS along with DC on growth in comparison with the effects of DC only. Enrolled children (N = 321) were >24 to ≤48 months old, at malnutrition risk (weight-for-height percentile 3rd to 15th), and described as a picky eater by their parent. Enrollees were randomized to one of the three groups (N = 107 per group): ONS1 + DC; ONS2 + DC; and DC only. From day 1 to day 90, study findings showed significant increases in weight-for-height percentile for ONS1 + DC and for ONS2 + DC interventions, as compared to DC only (p = 0.0086 for both). There was no significant difference between the two ONS groups. Anthropometric measurements (weight and body mass index) also increased significantly over time for the two ONS groups (versus DC only, p < 0.05), while ONS1 + DC significantly improved mid-upper-arm circumference (p < 0.05 versus DC only), as well. ONS groups showed a trend toward greater height gain when compared to DC only group, but the differences were not significant within the study interval. For young Indian children with nutritional risk and picky eating behaviors, our findings showed that a 90-day nutritional intervention with either ONS1 or ONS2, along with DC, promoted catch-up growth more effectively than did DC alone.

Consequences of Picky Eating in College Students

OBJECTIVE

To examine the relation between young adult picky eating (PE) and psychosocial outcomes (eg, social phobia, quality of life) and dietary intake.

DESIGN

Cross-sectional study including demographic, quantitative, and qualitative measures.

PARTICIPANTS

Midwestern undergraduate convenience sample (n = 488) recruited early 2020.

MAIN OUTCOME MEASURES

Picky eating identity and bias internalization, social phobia, quality of life, and dietary intake.

ANALYSES

Pearson correlations were conducted among study variables. Independent t tests compared picky eaters and nonpicky eaters on key variables. Qualitative data were coded using content analysis.

RESULTS

Picky eaters reported eating less fiber (t[445] = -3.51; P < 0.001; d = 0.34) and vegetables (t[464] = -3.57; P < 0.001; d = 0.33), and reported more social phobia (t[336.84] = 4.04; P < 0.001; d = 0.39) than nonpicky eaters. Picky eating behaviors were positively correlated with PE identity (r[190] = 0.48; P < 0.001; R² = 0.23) and bias internalization (r[190] = 0.44; P < 0.001; R² = 0.19).

CONCLUSIONS AND IMPLICATIONS

Future research might explore additional factors that theoretically overlap with PE behavior (eg, other eating styles, disordered eating patterns) or play a role in PE (eg, anxiety, obsessive-compulsive difficulties). A greater understanding of these factors may lead to intervention to reduce PE in adults. In addition, validation of the PE identity and PE distress measures is essential for future use and to replicate this study's findings.

Picky Eating in Children: A Scoping Review to Examine Its Intrinsic and Extrinsic Features and How They Relate to Identification

The health benefits and importance of family mealtimes have been extensively documented. Picky eating can impact this complex activity and has numerous extrinsic (or external) and intrinsic (or internal) features. Occupational therapists work with children and their families by looking at both intrinsic and extrinsic influences and are therefore well-placed to work within this context. This scoping review comprises a comprehensive search of key health industry databases using pre-determined search terms. A robust screening process took place using the authors pre-agreed inclusion and exclusion criteria. There were 80 studies that met the inclusion criteria, which were then mapped using content analysis. The most common assessments used to identify picky eating relied on parental reports and recall. Often additional assessments were included in studies to identify both the intrinsic and extrinsic features and presentation. The most common reported intrinsic features of the child who is a picky eater included increased sensitivity particularly to taste and smell and the child's personality. Extrinsic features which appear to increase the likelihood of picky eating are authoritarian parenting, rewards for eating, and pressuring the child to eat. Most commonly reported extrinsic features that decrease the likelihood of picky eating are family meals, responsive parents, and involving the child in the preparation of food. In conclusion, there is a lack of published papers addressing the role of occupational therapists in the assessment and identification of picky eating in children. There appears to be a complex interplay between intrinsic and extrinsic features which impact caregiver responses and therefore on the picky eater.

Picky Eating in School-Aged Children: Sociodemographic Determinants and the Associations with Dietary Intake

Children exhibiting picky eating behavior often demonstrate strong food preferences and rejection of particular foods or food texture, which may lead to limited dietary variety and possibly inadequate or unhealthy diet. Yet, the relationship between picky eating and nutrient intake in school-aged children has not been established previously. This study aimed to investigate the sociodemographic determinants of picky eating and the associations between picky eating and dietary intake in children. Data of 424 healthy Saudi children aged 6–12 years were collected from their mothers. A child’s picky eating habits were captured using a validated questionnaire. Sociodemographic characteristics of the children were assessed. Dietary data, including 24 h dietary recalls and frequency of fruit, vegetable, and milk consumption, were collected by dietetic professionals using phone-administered interviews. Compared to those of normal-weight mothers, children of mothers with obesity had higher odds of being in the highest tertile of picky eating (OR = 1.93; 95% CI 1.02, 3.63). Children exhibiting higher levels of picky eating consumed less fruits (B = −0.03; 95% CI −0.06, −0.01), vegetables (B = −0.05; 95% CI −0.07, −0.02), and protein (B = −0.21; 95% CI −0.33, −0.09), and had higher consumption of trans fatty acid intake (B = 1.10; 95% CI 0.06, 2.15). Children with higher levels of picky eating presented unhealthy dietary behaviors. Future studies are needed to examine the long-term effect of picky eating on cardiovascular health. Dietary behaviors of mothers with obesity must be taken into consideration when designing intervention programs aiming to improve eating behaviors of children.

Fussy eating in toddlers: A content analysis of parents' online support seeking

The development of healthy eating habits in childhood is essential to reducing later risk of obesity. However, many parents manage fussy eating in toddlerhood with ineffective feeding practices that limit children's dietary variety and reinforce obesogenic eating behaviours. Understanding parents' feeding concerns and support needs may assist in the development of feeding interventions designed to support parents' uptake of responsive feeding practices. A total of 130 original posts by parents of toddlers (12-36 months) were extracted from the online website Reddit's 'r/Toddlers' community discussion forum over a 12-month period. Qualitative content analysis was used to categorise the fussy eating topics that parents were most concerned about and the types of support they were seeking from online peers. The most frequently raised fussy eating concerns were refusal to eat foods offered, inadequate intake (quantity and quality), problematic mealtime behaviours and changes in eating patterns. Parents were primarily seeking practical support (69.2%) to manage emergent fussy eating behaviours. This consisted of requests for practical feeding advice and strategies or meal ideas. Nearly half of parents sought emotional support (47.7%) to normalise their child's eating behaviour and seek reassurance from people with lived experience. Informational support about feeding was sought to a lesser extent (16.2%). Fussy eating poses a barrier to children's dietary variety and establishing healthy eating habits. These results suggest parents require greater knowledge and skills on 'how to feed' children and support to manage feeding expectations. Health professionals and child feeding interventions should focus on providing parents with practical feeding strategies to manage fussy eating. Supporting parents to adopt and maintain responsive feeding practices is vital to developing healthy eating habits during toddlerhood that will continue throughout adulthood.

The role of food selectivity in the association between child autistic traits and constipation

OBJECTIVE

This study examines the association between child autistic traits and constipation symptoms, and explores whether this association is mediated by food selectivity.

METHOD

The sample included participants (N = 2,818) from the population-based birth cohort, Generation R (Rotterdam, the Netherlands). Parents reported their child's autistic traits at 6 years (using the Social Responsiveness Scale), food selectivity at 10 years (using the Stanford Feeding Questionnaire) and the frequency and severity of constipation symptoms they experienced at 10 years (using the ROME III functional constipation diagnostic criteria). Mediation analyses tested mediation through food selectivity in the association of autistic traits and the number of constipation symptoms, adjusting for covariates.

RESULTS

There was a positive association between parent-reported child autistic traits and constipation symptoms (r = 0.08, p < .001). We identified a significant indirect effect of autistic traits on constipation symptoms through food selectivity (β = 0.008, 95% Confidence Interval: 0.002, 0.014).

DISCUSSION

This study provides empirical support for the mediating role of food selectivity in the association between autistic traits and constipation. Behavioral interventions aimed to target food selectivity and support families of children with autistic traits may bolster conventional medical and nutritional treatments to alleviate gastrointestinal symptoms like constipation.

Picky Eating Is Associated with Lower Nutrient Intakes from Children's Home-Packed School Lunches

The objective was to assess the relationship between children’s picky eating (PE) status and nutrient intake from home-packed school lunches. The lunches of 321 students, aged 7–10 years, were quantified via cross-sectional direct observation. Children were classified as having PE (n = 155) or not (non-PE; n = 166) based on food neophobia scores and parental perceptions of PE. The PE group consumed significantly less protein, folate, magnesium, potassium, zinc, and vitamins B1, B2, B3, B6, D, and E than the non-PE group; however, both groups consumed amounts exceeding Dietary Reference Intakes (DRIs) for protein, carbohydrates, sugar, sodium, iron, and vitamins B1, B2, B3, B6, B12, and C. Conversely, both groups consumed amounts significantly lower than DRIs for calcium, fibre, folate, magnesium, potassium, zinc, and vitamins A, D, E, and K. The PE group ate significantly less meat and alternatives, vegetables and fruit, and fruit than the non-PE group, and did not meet any of Canada’s Food Guide (2007) recommendations. The non-PE group met recommendations for meat and alternatives only. PE impacts the dietary intake of children’s home-packed lunches; however, many packed lunches were of low nutritional quality. Focus should be placed on provision of nutritionally complete school lunches for all children.

Transient Hyperphosphatasemia Due to Pomegranate Juice

In most cases, feeding problems in young children are mild and of no consequence. However, it is one of the situations that generate more anxiety in parents and can lead them to incorrect feeding patterns. We present the case of a 20-month-old male child who came to the emergency room with a pathological elevation of alkaline phosphatase secondary to an error in his dietary pattern.

Infant feeding practices and later parent-reported feeding difficulties: a systematic review

CONTEXT

Early feeding practices may influence the acceptance of new foods and contribute to the development of feeding difficulties later in childhood.

OBJECTIVE

The aim of this systematic review was to evaluate the association of breastfeeding duration, timing of complementary feeding introduction, and feeding techniques with feeding difficulties or their subtypes, namely picky or fussy eating, food refusal, and food neophobia, in children older than 1 year of age.

DATA SOURCES

Guidance from the Cochrane Collaboration and the Centre for Reviews and Dissemination was followed. MEDLINE, Embase, and PsycINFO databases were searched up to December 2019. Additionally, references from included articles were screened.

STUDY SELECTION

Interventional and observational studies were eligible. Of the 3653 records obtained after the search strategy was applied, 21 observational studies (cohort, case-control, cross-sectional), many with important methodological limitations, and 1 randomized controlled trial were included.

DATA EXTRACTION

Three authors extracted data independently.

RESULTS

Results were synthesized narratively. Twelve observational studies assessed the association of breastfeeding duration with parent-reported feeding difficulties. Longer duration of breastfeeding tended to be associated with fewer childhood feeding problems in the majority of studies, but the differences were often small and not significant. Eight observational studies that examined the timing of complementary feeding introduction in relation to parent-reported feeding difficulties showed inconsistent results. Baby-led weaning, as compared with spoon-feeding, was significantly associated with less fussiness at age 12 to 36 months in 1 of 5 studies.

CONCLUSIONS

This review showed no strong evidence to support the hypothesis that early feeding practices contribute significantly to specific parent-reported feeding difficulties in children older than 1 year of age. Additional methodologically rigorous studies are needed to confirm these findings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42018115792.

Considering Nature and Nurture in the Etiology and Prevention of Picky Eating: A Narrative Review

Children are often categorized as picky eaters by parents and caregivers for their rejection of foods, such as vegetables, and for exhibiting other difficult mealtime behaviors. However, there are several factors that contribute to these mealtime behaviors, including early feeding practices (i.e., breastfeeding, introduction to solid food), repeated exposure to novel foods, and genetic taste sensitivity to certain compounds. Using the online database of PubMed, a review of the literature on the development of picky eating in children, its outcomes, and intervention strategies was conducted. This review groups the developmental contributors to picky eating into the categories of nature and nurture and explores the interaction between the two. This paper will also summarize the potential outcomes of picky eating and the various strategies that are currently recommended to mitigate picky eating in young children. However, there is a lack of longitudinal work targeting consistent picky eating behaviors that have the potential to impact long-term food preferences and dietary variety. Future intervention strategies should address the factors that influence the development of picky eating on an individual level.

Health Coaching as an Intervention for Picky Eaters

Although childhood "picky eating" or "fussy eating" or "food neophobia" is well established as a subject of research, commentary, and treatment guidelines, there is very little published research exploring the origins and basis of adult food neophobia, much less its treatment. Existing treatment guidelines for picky eating tend to focus on cognitive behavioral interventions. The consequences of picky eating, although not extensively researched, include inadequate nutrition and weight management difficulties-both significant contributors to the worldwide disease burden. Health coaching has a focus on personal choice, reflection on previous successes and current strengths, as well as identification of a personal health vision and achievable goals. As such, it may play a useful role in supporting behavioral change in adult picky eaters. A structured intervention, rooted in health coaching skills and culinary medicine aimed at supporting such change, is proposed.

'A blender without the lid on': Mealtime experiences of caregivers with a child with autism spectrum disorder in South Africa

Background

Evidence suggests that caregivers of children with autism spectrum disorder (ASD) and associated feeding difficulties have specific mealtime challenges in the home environment because of the limited interventions that are appropriate and responsive to the needs of the child as well as the family.

Objectives

To describe: (1) common feeding difficulties in children with ASD, (2) mealtime challenges for the caregiver and (3) mealtime strategies used by the caregiver.

Method

Forty caregivers were purposively sampled to participate in the study. Participants were recruited through ASD-specific schools in Johannesburg, South Africa. Participants completed an online questionnaire focusing on their mealtime experiences with their child with ASD.

Results

Findings from the data after thematic analysis indicated the multitude of challenges caregivers have when feeding their child with ASD as well as their individualised way of dealing with these difficulties.

Conclusion

The findings emphasised the importance of incorporating the family’s beliefs, values and needs into feeding management and highlight the importance of a holistic approach to intervention. The study also provided information about mealtime strategies that are being used in the home environment to support the child as well as the caregiver. This information can be used to inform management to improve therapeutic outcomes and feeding challenges in the home environment.

Show or tell: Children's learning about food from action vs verbal testimony

BACKGROUND

Childhood obesity continues to be a critical health concern in the United States. Nonetheless, interventions that focus on delivering verbal lessons about food and health to children in preschool classrooms have had only modest effects.

OBJECTIVES

The present study examines the relative effectiveness of showing vs telling children about food to promote healthy eating, with a focus on unfamiliar foods and vegetables.

METHODS

Three- to six-year-old children (n = 71) were tested in a laboratory study in which they watched videos of two people eating apple-broccoli puree. One person took five bites of the food; the other said they liked the food.

RESULTS

Children did not differentiate between the food they saw someone eat and the food they heard someone talk about. Children's food intake was negatively associated with parent reports of children's eating behavior on the Food Fussiness subscale of the Child Eating Behavior Questionnaire. We found similar patterns in an analogous toy task. In an unfamiliar object task, children selected the action demonstration as the right way to use the object.

CONCLUSIONS

We find no evidence that action vs verbal testimony is more persuasive in guiding children's food choices, but action testimony may be persuasive in other domains. The associations between children's food intake and pickiness provide growing evidence of alignment between parent assessments of their children's typical eating behavior and children's food choices in laboratory studies.

Classifying and characterizing Chinese young adults reporting picky eating: A latent profile analysis

OBJECTIVE

Picky eating (PE) is common across the lifespan and related to psychosocial impairment and limited dietary variety. However, research about PE in non-Western countries is limited. Because eating behaviors may differ by culture, operationalizing PE in non-Western countries (e.g., China) is needed. The present study aimed to replicate two previous studies identifying PE profiles in Western countries by using latent profile analysis (LPA) to classify and characterize adults reporting picky eating in a Chinese sample.

METHOD

A sample of 1,068 Chinese young adults completed a battery of questionnaires including the adult eating behavior questionnaire (AEBQ). LPA was utilized to identify eating profiles. The three-step approach was used to examine predictors of latent memberships and profile differences on various self-reported measures.

RESULTS

The best fit was a four-profile solution, with two picky eating profiles emerging: picky eating and severe picky eating. Compared to those in the other two profiles, participants in the picky eating profile (19.4%) and severe picky eating profile (3.3%) had significantly higher scores on self-reported eating disorder symptoms and psychological distress, and lower scores on self-reported food-related life satisfaction. Relative to the picky eating profile, participants in the severe picky eating profile reported significantly greater self-reported eating disorder symptoms, psychological distress, and food-related dissatisfaction.

DISCUSSION

Characterizing PE profiles is an important step toward understanding eating behaviors among Chinese young adults. Identifying various eating profiles has implications for future research related to PE, including the development of diagnostic tools and interventions to address PE in a Chinese context.

The Relationships between Maternal Feeding Practices and Food Neophobia and Picky Eating

Food neophobia and picky eating (FNPE) are dietary behaviors that have been frequently reported to coexist in children. Parental concerns about these dietary behaviors may influence the feeding practices employed. In this cross-sectional study, we investigated the bidirectional associations of maternal feeding practices with children’s FNPE behaviors. Using a convenience sampling technique, mothers of 195 healthy children aged 1–7 years were invited to complete a sociodemographic questionnaire, rate their child’s FNPE, and rate the extent to which each feeding practice was employed with the child. Maternal reports indicated that 37.4% (n = 73) of the children exhibited severe FNPE. Multiple linear regression analyses showed positive two-way associations between the “pressure to eat” feeding strategy and FNPE, and negative two-way associations between a healthy home food environment and FNPE. However, maternal practices of teaching and monitoring were not found to be associated with FNPE. Given the bidirectional relationships observed between FNPE and maternal feeding practices, primary health care providers should address the feeding practices used with a child and indicate that coercive feeding practices are counterproductive. Intervention studies targeting mothers of children with FNPE are needed to investigate whether specific maternal practices are more effective than others.

The Environmental and Bitter Taste Endophenotype Determinants of Picky Eating in Australian School-Aged Children 7-12 years-A Cross-Sectional Pilot Study Protocol

Caregivers’ perceptions of children’s pickiness are relatively scarce in relation to the five core food groups and their importance in providing a nutritionally balanced diet. Furthermore, there is no validated questionnaire that examines child-reported food preferences in an age-appropriate manner, and the use of terms such as a “picky eater” can be attributed to environmental and genetic factors. Despite potential links between children’s food preferences and endophenotype bitter taste, associations between bitter taste sensitivity and picky eating is relatively unexplored. The proposed cross-sectional study aims to develop and validate a parent-reported core-food Picky Eating Questionnaire (PEQ) and child-reported Food Preference Questionnaire (C-FPQ) and simultaneously investigate environmental and phenotype determinants of picky eating. The study will be conducted in three stages: Phase 1, piloting PEQ and C-FPQ questionnaires (15–20 primary caregivers and their children aged 7–12 years); Phase 2 and 3, validating the revised questionnaires and evaluating the 6-n-propylthiouracil (PROP) bitter taste sensitivity to examine perception to bitter taste (369 primary caregivers and their children). Study findings will generate new validated tools (PEQ, C-FPQ) for use in evidence-based practice and research and explore picky eating as a behavioural issue via the potential genetic-phenotype basis of bitter taste sensitivity.

Association between Food Preferences, Eating Behaviors and Socio-Demographic Factors, Physical Activity among Children and Adolescents: A Cross-Sectional Study

The prevalence of overweight and obesity is a serious health issue among children and adolescents worldwide. This study aimed to investigate factors influencing weight status-associated food preferences and eating behaviors. A cross-sectional study was conducted to collect data from 2578 pairs of Chinese children and parents in five cities from December 2018 to March 2019. There was an increase in consumptions of processed seafood, nuts and dried fruit/vegetables, and fruit/vegetable juice, but a reduction of consuming puffed and processed meat products, sugar/artificially sweetened beverages and milk tea, and picky eating. These food preferences differentiate between sexes. Picky eating behavior was greatly presented in children of lower educated mothers or heavy-smoking fathers. Children of the lower educated fathers consumed less processed seafood and dairy products, and those of the heavy-smoking fathers consumed more puffed products, but less fruit/vegetable juice, and had greater snack preference. The father’s body mass index(BMI)status was also positively associated with unhealthy behaviors. Those who exercised daily longer showed better eating behaviors, and picky eating and fast-food lovers likely occurred in higher-income families. Our study provides an insight into that fathers being educated for health-conscious advice and physical activity may be the potential strategies to foster their children’s healthy eating patterns. Their efficacy needs to be further investigated.

Food Disgust Scale: Spanish Version

INTRODUCTION

The Food Disgust Scale (FDS) was recently developed and validated in Swiss adult population. This study aims to: (1) validate the FDS for the first time in a Spanish-speaking Mexican population, (2) correlate food disgust sensitivity with picky eating measures, and (3) explore the association between food disgust sensitivity and body mass index (BMI).

MATERIALS AND METHODS

A Spanish version of the FDS (FDS-Sp) and its short version (FDS-Sp short) were tested with confirmatory factor analysis (CFA) in order to test the original item/factor structure. Bivariate correlations were performed to determine the association between FDS-Sp/FDS-Sp short scores and picky eating. Lastly, hierarchical linear regression analysis was carried out to determine the relationship between food disgust sensitivity and BMI.

RESULTS

The factor structure of the FDS was replicated and acceptable internal consistency values were observed for FDS-Sp subscales (α varied between 0.781 and 0.955). Moreover, FDS-Sp subscales and FDS-Sp short were correlated with picky eating. Higher score in VEGI subscale of the FDS-Sp was a significant predictor for higher BMI, explaining 4% of the variance.

CONCLUSION

FDS-Sp is a useful, reliable and robust psychometric instrument to measure the sensitivity to unpleasant food situations in a Mexican adult Spanish-speaking population. A relationship between food disgust sensitivity and picky eating, selective eating behaviors and neophobia in Mexicans was confirmed. BMI is multifactorial and only one subscale of FDS-Sp is a significant predictor for BMI status. These results are helpful to continue exploring food disgust in diverse populations.

Maternal Depressive Symptoms and Perceived Picky Eating in a Low-Income, Primarily Hispanic Sample

OBJECTIVE

Feeding concerns are common in the first 2 years of life and typically reflect maternal perceptions occurring within the larger context of the parent-child relationship. We aimed to determine whether (1) maternal depressive systems predicted perceived picky eating, mediated by maternal negative perceptions; (2) receipt of the Video Interaction Project (VIP) parenting intervention impacted perceived picky eating through this pathway; and (3) perceived picky eating was associated with child growth or subsequent dietary patterns.

METHODS

We performed a partial longitudinal analysis of 187 low-income, predominantly Hispanic mother-child dyads enrolled in a randomized controlled trial of the VIP. Mother-infant dyads were enrolled postpartum in an urban public hospital. Participants randomized to the VIP met with an interventionist on days of well-child visits; sessions were designed to facilitate interactions in play and shared reading through provision of learning materials and review of videotaped parent-child interaction; the curriculum did not contain feeding-specific elements. We used structural equation modeling to determine direct, indirect, and total effects of maternal depressive symptoms, maternal negative perceptions, and the VIP on perceived picky eating. We then tested associations between perceived picky eating and (1) child growth, using multivariable linear regression and multilevel modeling; and (2) subsequent child dietary consumption, using multivariable multinomial logistic regression.

RESULTS

Maternal depressive symptoms had significant total effects on negative maternal perceptions (β = 0.32, p < 0.001) and perceived picky eating (β = 0.21, p < 0.01) after controlling for potential confounders. This effect was partially mediated by maternal negative perceptions (indirect effect: β = 0.06, p = 0.04). When used in the model as the predictor, the VIP had a significant total effect on perceived picky eating (β = -0.16, p = 0.02), which was partially mediated by maternal depressive symptoms and negative perceptions (indirect effect: β = -0.05, p = 0.02). Perceived picky eating was not associated with child diet at age 2 years or adiposity from 6 months to 3 years.

CONCLUSION

Maternal concerns about picky eating may reflect deeper depressive symptoms and negative perceptions of her child's behavior. Interventions designed to facilitate positive parenting in general may lessen feeding-specific concerns, such as picky eating. Although reassurance about growth and nutritional outcomes for children perceived as picky eaters is appropriate, clinicians should also consider probing for underlying symptoms of depression that could lead to eating concerns.

The central role of disgust in disorders of food avoidance

BACKGROUND

Individuals with extreme food avoidance such as Avoidant Restrictive Food Intake Disorder (ARFID) experience impairing physical and mental health consequences from nutrition of insufficient variety or/and quantity. Identifying mechanisms contributing to food avoidance is essential to develop effective interventions. Anxiety figures prominently in theoretical models of food avoidance; however, there is limited evidence that repeated exposures to foods increases approach behavior in ARFID. Studying disgust, and relationships between disgust and anxiety, may offer novel insights, as disgust is functionally associated with avoidance of contamination from pathogens (as may occur via ingestion) and is largely resistant to extinction.

METHOD

This exploratory, cross-sectional study included data from 1,644 adults who completed an online questionnaire. Participant responses were used to measure ARFID classification, picky eating, sensory sensitivity, disgust, and anxiety. Structural equation modeling tested a measurement model of latent disgust and anxiety factors as measured by self-reported frequency of disgust and anxiety reactions. Mediational models were used to explore causal ordering.

RESULTS

A latent disgust factor was more strongly related to severity of picky eating (B ≈ 0.4) and ARFID classification (B ≈ 0.6) than the latent anxiety factor (B ≈ 0.1). Disgust partially mediated the association between anxiety and picky eating and fully mediated the association between anxiety and ARFID. Models testing the reverse causal ordering demonstrated poorer fit. Findings suggest anxiety may be associated with food avoidance in part due to increased disgust.

CONCLUSIONS

Disgust may play a prominent role in food avoidance. Findings may inform novel approaches to treatment.

Characteristics of outpatients diagnosed with the selective/neophobic presentation of avoidant/restrictive food intake disorder

OBJECTIVE

Although Avoidant/Restrictive Food Intake Disorder (ARFID) has existed since the publication of DSM-5 in 2013, research on the descriptive psychopathology of treatment-seeking patients with formal ARFID diagnoses is sparse, and limited to tertiary eating disorder-focused treatment settings where most patients present with weight loss/malnutrition. In these settings, the selective/neophobic symptom presentation is rare compared to other primary eating restrictions. We aimed provide initial descriptive psychopathology of ARFID primary selective/neophobic symptom presentation in an outpatient setting, and to explore the prevalence of the core ARFID symptoms and clinical differences among patients meeting criteria based on weight/nutritional symptoms versus psychosocial impairment only.

METHOD

We reviewed the charts of 22 consecutive outpatients diagnosed with ARFID caused by selective/neophobic eating, and describe symptoms, impairment, illness trajectory, and demographic features. Patients who met ARFID criteria because of weight loss/nutritional problems were compared to those who met for psychosocial impairment only on demographic and clinical characteristics.

RESULTS

Patients were predominantly male (81.8%) and school-aged (4-11 years). 81.8% had no weight/nutritional symptoms documented by a medical provider. All met criteria for significant psychosocial impairment. There were few differences between patients who did versus did not meet weight loss/nutritional criteria for ARFID; they differed only in age and in the presence of appetite disturbances consistent with another proposed presentation of ARFID.

DISCUSSION

These results provide novel data on the clinical characteristics of individuals who present with a primary presentation of selective/neophobic ARFID, including support for psychosocial impairment as sufficient for fulfilling ARFID criterion A.

Further support for diagnostically meaningful ARFID symptom presentations in an adolescent medicine partial hospitalization program

OBJECTIVE

To identify potential presentations of avoidant/restrictive food intake disorder (ARFID) in a pediatric eating disorder partial hospitalization program (PHP) based on the nature of the eating restriction leading to core symptoms of ARFID.

METHOD

A retrospective chart review of 83 patients ages 8-17 admitted to a PHP and diagnosed with ARFID. Charts were independently reviewed by two coders, with high inter-rater agreement (κ = 0.77). Distinct categories were identified and groups were compared on demographics, anthropometrics, comorbid psychopathology, and core ARFID symptoms.

RESULTS

We identified cases characterized by predominantly selective eating based on aversions to the sensory properties of foods, lack of interest in eating/low appetite, and fear of aversive consequences from eating. We also distinguished a subset of patients with eating restrictions consistent with both selectivity and limited interest/appetite. The four primary ARFID presentation groups differed on core ARFID criteria, symptom trajectory and illness duration, mood and medical comorbidities, age, gender, and parent-reported symptoms of psychopathology.

DISCUSSION

The present findings suggest that there are diagnostically meaningful ARFID subtypes that can be differentiated based on the nature of their eating restrictions, as well as other demographic, illness history features, and psychiatric comorbidity. As treatments for youth with ARFID are developed and refined, it will be important to take into consideration not only demographic differences, but also the variability in symptoms, as this might require distinct interventions and levels of care. Additionally, differing mechanisms that maintain different types of eating restrictions might necessitate unique psychological and psychiatric interventions.

A Narrative Review of Childhood Picky Eating and Its Relationship to Food Intakes, Nutritional Status, and Growth

A main characteristic of children perceived as picky eaters is their tendency to avoid certain foods or food groups. The goal of this narrative review is to provide an overview of published studies that have examined whether picky eating in childhood is in fact associated with measurable differences in food and/or nutrient intakes and growth. While picky eaters appear to consume less vegetables compared to non-picky eaters, no consistent differences were observed for the intakes of other food groups or the intakes of energy, macronutrients and dietary fiber. Although, in some studies, picky eaters had lower intakes of certain vitamins and minerals, the levels consumed generally exceeded the recommended values, suggesting nutritional requirements are being met. No consistent relationship between childhood picky eating and growth status was observed, although significant differences in body weight/growth between picky and non-picky eaters were most discernible in studies where multiple defining criteria were used to identify picky eating. The research area would benefit from the adoption of a uniform definition of picky eating. More longitudinal assessments are also required to understand the long-term impact of picky eating on nutritional status and growth.

Continuation of oral nutritional supplementation supports continued growth in nutritionally at-risk children with picky eating behaviour: A post-intervention, observational follow-up study

Objectives

To evaluate the 120-day post-intervention growth trajectory of picky-eating children aged 2 to 6 years who previously completed a 90-day, randomized, controlled trial of oral nutritional supplementation (ONS) plus dietary counselling (DC) (SDC, n = 98) compared with DC alone (n = 105).

Methods

A total of 203 children were included. Children were free to consume ONS during follow-up. Information on ONS consumption was collected. Weight-for-age percentile (WAP) and height-for-age percentile (HAP) were measured at Day 90 (beginning) and Day 210 (end point).

Results

Despite continued weight gain, there was a significant decline in WAP in both groups during the post-intervention period. However, children who took ONS voluntarily had a smaller loss in WAP compared with those who did not. Children in the SDC group showed no difference in a decline in HAP between those who took ONS during follow-up and those who did not. However, children in the DC group showed a marginally larger decline in HAP in those who did not take ONS during the follow-up compared with those who did.

Conclusions

Continued parental self-administration of ONS to their children slows down the loss of growth percentiles, supporting continued weight gain in picky-eating children at nutritional risk.

Effect of oral nutritional supplementation on growth and recurrent upper respiratory tract infections in picky eating children at nutritional risk: a randomized, controlled trial

Objectives

To evaluate the effect of oral nutritional supplementation (ONS) plus dietary counselling (DC) (intervention) versus DC alone (control) on growth and upper respiratory tract infection (URTI) in nutritionally at-risk, picky eating children in India.

Methods

We performed a 90-day, prospective, randomized, controlled trial. A total of 255 children aged 24–72 months with a weight-for-age z-score ≥−2 and <−1, picky eating behaviour, and acute URTI were randomized to the control (n = 128) or intervention group (n = 127). The outcomes included the change in weight-for-age z-score from days 1 to 90 and the URTI incidence.

Results

The mean age was 44.0 ± 14.3 months. The intervention group showed a significantly greater increase in mean weight-for-age and body mass index-for-age z-scores compared with the control group from day 10 onwards. Higher energy intake in the intervention group was observed at all follow-up visits, except for day 10. The incidence of URTI in the control group was 2.01 times higher than that in the intervention group, controlling for confounding factors.

Conclusions

ONS plus DC is effective for improving weight and reducing the incidence of URTI in nutritionally at-risk, picky eating children with an acute URTI episode.

Association of Picky Eating With Weight Status and Dietary Quality Among Low-Income Preschoolers

BACKGROUND

Picky eating is common in children. Few studies have examined predictors of picky eating, and the association of picky eating with weight status and dietary quality is inconsistent in the literature. We aimed to identify predictors of picky eating and to test the association of picky eating with child body mass index z-score (BMIz), dietary quality, and micronutrient intake.

METHODS

This was a cross-sectional analysis of baseline data from a randomized controlled trial to prevent obesity among 506 preschoolers attending Head Start. Parents completed questionnaires to assess picky eating and child temperament. Three 24-hour dietary recalls were collected to assess dietary intake. Multivariate regression models assessed child, parent, and family predictors of picky eating; additional models tested adjusted associations of picky eating with child BMIz, dietary quality (measured using the Healthy Eating Index-2010), and micronutrient intake.

RESULTS

Picky eating was predicted by male sex, older child age, and more difficult temperament but not race/ethnicity, maternal body mass index, maternal depressive symptoms, household food insecurity, or single parent home. Picky eating was not associated with child BMIz or micronutrient deficiencies; it was inversely associated with total Healthy Eating Index-2010 score and servings of whole fruit, total vegetables, greens and beans, and total protein foods.

CONCLUSIONS

Pediatric providers should support parents in expanding the number of healthy foods the child eats to improve dietary quality, but reassure parents that picky eating is not associated with children's weight status or micronutrient deficiencies.

Association of Picky Eating with Growth, Nutritional Status, Development, Physical Activity, and Health in Preschool Children

BACKGROUND

This study aimed to assess the prevalence of picky eating among preschool children and to evaluate the association between eating behavior and growth, physical activity, development, and health status.

METHODS

A structured questionnaire was used to conduct a cross-sectional descriptive study of 300 primary caregivers of children aged 2-4 years in Taiwan. Data collected included: demographics, food preferences, eating behavior, body weight, and height, development, physical activity, and records of medical illness. Data from children defined as picky or non-picky eaters based on parental' questionnaire responses were analyzed and compared using standard statistical tests.

RESULTS

The mean age of the children was 2.95 years; 162 (54%) were picky eaters. Compared with non-picky eaters, z-score of weight-for-age, height-for-age, and body mass index (BMI)-for-age in picky eaters was 0.91, 0.73, and 0.44 SD lower, respectively. There were significant differences of rates in the weight-for-age, height-for-age, and BMI-for-age percentiles <15, between picky and non-picky eaters (P = 0.04, 0.023, and 0.005, respectively). Fear of unfamiliar places, poor physical activity, constipation, and high frequency (>2 times in the past 3 months) of medical illness were significantly higher in picky eaters (P = 0.01, 0.001, 0.044, and <0.001, respectively).

CONCLUSION

The prevalence of picky eaters in preschool children was high, resulting in significant detrimental impacts on growth, nutritional status, development, physical activity, and health status.

Associations between Parenting Style and Parent and Toddler Mealtime Behaviors

Background: By the time a child is 24 mo old, 50% of parents report experiencing picky eating behaviors with their child. These behaviors include consuming an inadequate dietary variety, eating the same foods repeatedly, and an unwillingness to try either new or familiar foods. Previous research has established relations with regard to the impact of parent feeding strategies on child mealtime behaviors and how parent feeding strategies are influenced by parenting style; however, to our knowledge, no studies have investigated whether there is an association between parenting style and perceived child mealtime behaviors specifically related to picky eating. Objective: The purpose of this study was to investigate whether a relation exists between general parenting style and both parent feeding strategies and perceived picky eater and non-picky eater (NPE) behaviors. Methods: Parents of 2- to 5-y-old children (n = 525) completed 2 online surveys: 1) the Mealtime Assessment Survey, which measures the frequency of parent and child mealtime behaviors, and 2) the Parenting Styles and Dimensions Questionnaire, which measures authoritative, authoritarian, and permissive parenting styles. Spearman's correlation analysis was conducted to determine the relations between parenting style and mealtime behavior. Results: Positive correlations were found between an authoritative parenting style and NPE behaviors, as well as parent mealtime strategies that promote positive eating habits. Authoritarian and permissive parenting styles were positively correlated with child behaviors associated with picky eating and parent mealtime strategies that can negatively influence child feeding. Conclusions: These findings suggest that a relation exists between general parenting style and both parent and child mealtime behaviors; however, the directionality of the relation remains unknown. The positive correlations seen within the authoritative parenting style with regard to NPE behaviors suggest the use of authoritative feeding methods to overcome feeding difficulties.

Association between Picky Eating Behaviors and Nutritional Status in Early Childhood: Performance of a Picky Eating Behavior Questionnaire

Picky eating behaviors are frequently observed in childhood, leading to concern that an unbalanced and inadequate diet will result in unfavorable growth outcomes. However, the association between picky eating behaviors and nutritional status has not been investigated in detail. This study was conducted to assess eating behaviors and growth of children aged 1–5 years from the Seoul Metropolitan area. Primary caregivers completed self-administered questionnaires and 3-day diet records. Differences in the nutrient intake and growth indices between picky and non-picky eaters were tested by analysis of covariance. Children “eating small amounts” consumed less energy and micronutrients (with the exception of calcium intake), but picky behaviors related to a “limited variety” resulted in a significant difference regarding nutrient density for some micronutrients. Children with the behavior of “eating small amounts” had a lower weight-for-age than that of non-picky eaters; especially, the older children with the behaviors of “eating small amounts” or “refusal of specific food groups” had lower height-for-age compared with non-picky eaters. These results suggest that specific picky eating behaviors are related to different nutrient intake and unfavorable growth patterns in early childhood. Thus, exploration of potential interventions according to specific aspects of picky eating and their efficacy is required.

The Impact of Prenatal Parental Locus of Control on Children's Psychological Outcomes in Infancy and Early Childhood: A Prospective 5 Year Study

Locus of control is one of the most widely studied concepts in the history of personality psychology. In spite of its popularity and its associations with numerous relevant outcomes, the ability of locus of control to predict future behaviors involving parenting effectiveness has been under researched. The few parent locus of control children's outcome studies are characterized by cross-sectional methodologies that focus on mothers. The present study uses a prospective methodology to compare data on mothers' and fathers' locus of control with their child's behavior outcomes from a large scale research project, the Avon Longitudinal Study of Parents and Children (ALSPAC). Based on Rotter's Social Learning Theory published in 1954 and past empirical research, it was predicted and found that parent internality was associated with more positive child outcomes than parent externality. More specifically, when both parents were internal, their children had more positive outcomes in sleeping, eating, and tantrum behavior as compared to any other parent locus of control combination. However external parents had a less restrictive attitude which appeared to have a more beneficial effect on picky eating. Results confirmed how important parent locus of control is in the lives of children. Based on the findings, researchers are urged to develop interventions to change advice to parents and promote more internal locus of control among parents.

Differences and Agreement in Perception of Child Picky Eating Among Center- and Home-Based Childcare Providers and Parents and Its Impact on Utilized Mealtime Strategies

Picky eating is a problematic eating behavior caregivers may encounter with children under their care. A picky eater (PE) is typically characterized as consuming a narrow range of food, as well as rejecting several food items. Much of the literature regarding PEs involves parents, although use of nonparental childcare arrangements in the United States has increased in the past several decades. Although data on parental mealtime strategies exist, little is known about how parent and childcare provider pickiness perceptions differ between types of childcare, such as center-based childcare (CBCC) and home-based childcare (HBCC), or how these perceptions influence the mealtime strategies utilized. The objectives of this study were to (1) compare perceptions of child pickiness between parents and childcare providers, (2) compare percent agreement in pickiness perception between the dyads of CBCC parents and providers and HBCC parents and providers, and (3) identify mealtime strategy utilization based on pickiness perception. A total of 52 child, parent, and childcare provider triads participated in the study and completed the Mealtime Assessment Survey and the Parent/Teacher Mealtime Strategy Survey regarding the same child. Results showed that parents are 1.4 times more likely than childcare providers to perceive a child as being picky, HBCC parents and providers are 1.4 times more likely to perceive a child as being picky than CBCC parents and providers, CBCC parents and providers disagree more in their perception of child pickiness than HBCC parents and providers (41% vs 26%), and finally, perception of child pickiness has a greater influence on mealtime strategies utilized by parents. These results can be used to focus intervention efforts aimed at improving child eating habits across the home and childcare location.

Picky Eating Behaviors Linked to Inappropriate Caregiver-Child Interaction, Caregiver Intervention, and Impaired General Development in Children

BACKGROUND

To investigate the differences in eating behaviors between picky and nonpicky eaters, and to correlate parental management of children's eating problems with qualities of general development in children.

METHODS

This was a cross-sectional analysis of parental observations on their children's eating behavior, sampled from three major cities in Taiwan. We used a structured questionnaire during face-to-face interviews to collect information on each child's picky eating habits and behaviors, caregiver-child interaction and intervention during feeding, and the child's qualities of general development. Analysis of variance was used to determine significant differences between picky and nonpicky eaters.

RESULTS

Sixty-two percent of the children were considered to be picky eaters. Lack of appropriate caregiver-child interactions (e.g., repeated food attempt, persuasion, and encouragement) and the presence of inappropriate parental interactions (e.g., threatening, snacking, and nutrient supplementation) were significantly more common in picky eaters. Picky eaters also tended to exhibit low development quality in the domains of learning ability, interpersonal relationships, and physical performance, particularly in their attention span and uncooperativeness.

CONCLUSION

There is a relationship between inappropriate parental interaction and interventions in children's eating problems and the low quality of general development in picky eaters.

Girls' picky eating in childhood is associated with normal weight status from ages 5 to 15 y

BACKGROUND

Picky eating has been associated with lower weight status and limited food intake and variety in childhood. Little is known about how the persistence of picky eating in childhood is associated with changes in weight and food intake from childhood into adolescence.

OBJECTIVE

We determined whether picky eating identified in childhood was related to growth, nutrition, and parental use of pressure over a 10-y period.

DESIGN

Non-Hispanic white girls (n = 181) participated in a longitudinal study and were assessed biannually from ages 5 to 15 y. The Child Feeding Questionnaire was used to classify girls as persistent picky eaters or nonpicky eaters and to assess parental use of pressure to eat. Height and weight were measured to calculate body mass index (BMI) z scores at each occasion. Three 24-h dietary recalls obtained at each occasion were used to determine intakes of fruit and vegetables. With the use of repeated-measures analyses, differences between persistent picky eaters and nonpicky eaters in BMI z scores, dietary intake, and use of pressure were examined.

RESULTS

From ages 5 to 15 y, persistent picky eaters (n = 33; 18%) had lower BMI (tracking at the 50th percentile) than did nonpicky eaters (n = 148; tracking at the 65th percentile) (P = 0.02). Persistent picky eaters were less likely to be overweight into adolescence. Both groups consumed less than the recommended amounts of fruit and vegetables, although persistent picky eaters had lower intakes of vegetables than did nonpicky eaters at all time points (P = 0.02). Persistent picky eaters also received higher amounts of pressure (P = 0.01).

CONCLUSIONS

Findings that persistent picky eaters were within the normal weight range, were less likely to be overweight, and had similar fruit intakes to those of nonpicky eaters suggest that higher parental concerns about persistent picky eaters are unwarranted. All parents and children could benefit from evidence-based anticipatory guidance on alternatives to coercive feeding practices to increase fruit and vegetable consumption.

Macro- and micronutrient intakes in picky eaters: a cause for concern?

BACKGROUND

Picky eating (PE) is characterized by an unwillingness to eat certain foods and by strong food preferences. PE may result in lower intakes of energy and nutrients, which may compromise health.

OBJECTIVES

We quantified nutrient and food group intakes in children identified as picky eaters or nonpicky eaters and compared intakes between groups and with United Kingdom reference nutrient intakes.

DESIGN

PE was identified in an observational cohort (Avon Longitudinal Study of Parents and Children) from questionnaires administered when children were aged 2, 3, 4.5, and 5.5 y. Dietary intake was assessed at 3.5 and 7.5 y with a 3-d food record. The dietary assessment at 3.5 y compared picky eaters with nonpicky eaters identified at age 3 y, and the assessment at 7.5 y compared longitudinally defined PE groups.

RESULTS

Picky eaters aged 3 y had lower mean carotene, iron, and zinc intakes than nonpicky eaters. There were similar differences between the longitudinally defined PE groups. Iron and zinc intakes were most likely to be below recommended amounts, with free sugar intake much higher than recommended. There were no significant differences in energy intakes between the groups, and intakes were adequate relative to estimated average requirements. Nutrient differences were explained by lower intakes of meat, fish, vegetables, and fruits in picky eaters than in nonpicky eaters. There were higher intakes of sugary foods and drinks in older picky eaters.

CONCLUSIONS

PE did not result in compromised macronutrient intakes, although intakes of zinc and iron were more likely to be below recommendations for picky eaters than for nonpicky eaters. Emphasis should be placed on allaying parental concerns about picky eaters being prone to inadequate nutrient intakes and on encouraging all parents to extend their child's diet to include more nutrient-rich items, especially fruits and vegetables, and less nutrient-poor sugary foods.

Update on eating disorders: current perspectives on avoidant/restrictive food intake disorder in children and youth

Avoidant/restrictive food intake disorder (ARFID) is a new eating disorder diagnosis that was introduced in the Diagnostic and Statistical Manual of Mental Disorders (DSM) fifth edition. The fourth edition of the DSM had failed to adequately capture a cohort of children, adolescents, and adults who are unable to meet appropriate nutritional and/or energy needs, for reasons other than drive for thinness, leading to significant medical and/or psychological sequelae. With the introduction of ARFID, researchers are now starting to better understand the presentation, clinical characteristics, and complexities of this disorder. This article outlines the diagnostic criteria for ARFID with specific focus on children and youth. A case example of a patient with ARFID, factors that differentiate ARFID from picky eating, and the estimated prevalence in pediatric populations are discussed, as well as clinical and treatment challenges that impact health care providers providing treatment for patients.