Picky Eating in Children
Introduction[edit | edit source]
Picky eating (alternatively known as fussy, faddy, choosy, or selective eating) is a common behavior in early childhood. It can cause considerable stress to parents/caregivers and have a negative impact on family relationships.There is no agreement on a formal definition of picky eating, although it is generally accepted to include rejection or restriction of familiar foods and unfamiliar foods, and thus including an element of neophobia.The most commonly accepted definition of picky eating was proposed by Dovey et al. in which picky/fussy eaters are children ‘who consume an inadequate variety of foods through the rejection of a substantial amount of food that is familiar (as well as unfamiliar) to them’. Dovey et al. regard food neophobia (reluctance to eat, or the avoidance of, new foods) as a somewhat separate construct while recognizing that the two factors are interrelated and that both contribute to the rejection or acceptance of foods, particularly of fruits and vegetables. Alternative definitions include specific mention of restriction of intake of vegetables, strong food preferences, provision of meals that are different from those of the caregivers, special methods of food preparation, consumption of inadequate amounts of food, and disruption of daily routines that are problematic to the child, parent or parent–child relationship. It is clear, however, that picky eating is not synonymous with Avoidant/Restrictive Food Intake Disorder (ARFID; previously known as Selective Eating Disorder), which has a very specific definition in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-V, including the presence of nutritional deficiency as a result of inadequate food intake, failure to gain weight in children, a decline in psychological function, and a dependency on supplements to maintain nutritional health.
Prevalence of Picky Eating in Children[edit | edit source]
There is a wide range of prevalence found in different studies (6–50 %), which is likely to reflect differences in study design and assessment tools but may also be due to social or cultural factors. There is more consensus on the relation of prevalence to the child's age: in ALSPAC prevalence was 10 % at age 24 months, peaking at 38 months (15 %) and then declining at 54 and 65 months (14 % and 12 %, respectively). Other studies have also found the peak age to be at about 3 years old although one found the peak age to be at 6 years. 
Causes of Picky Eating in Children[edit | edit source]
Accepting that the peak prevalence of picky eating occurs at about age 3 years, factors that are predictive of a child becoming a picky eater as a pre-schooler can occur during three distinct phases: before and during pregnancy, in the early feeding phase (first year of life, reflecting early feeding practices) and in the second year of life (reflecting parental feeding styles in response to increasing child autonomy). They can alternatively be categorized as factors related to the child, to the parent/caregiver, and to child–parent interaction. Some of these predictors are fixed, but others can inform the development of advice and strategies for parents and caregivers to avert or ameliorate picky eating behavior in their children. It is unlikely, however, that any of these predictors acts in isolation: rather, there is a complex mix of parental and child-related characteristics that interact.
With regard to fixed predictors, picky eating at 38 months in ALSPAC was associated with greater maternal age, maternal smoking (yes), higher maternal social class, lower pre-pregnancy BMI, higher maternal educational attainment, lower parity and the infant being of lighter birthweight and male. Other studies, however, have found boys and girls to be equally affected, with the presence of siblings being protective. Several studies have investigated familial similarity for food neophobia (rather than picky eating per se) and found low to moderate similarity, suggesting a moderate degree of heritability. In a study of more than 5,000 twin pairs and their parents, it was found that neophobia was highly heritable, with a heritability estimate of 0·78 (95 % CI 0·76, 0·79), although about one-quarter of the phenotypic variation was accounted for by environmental factors. Genetic variation in sensitivity to bitterness (classified by being tasters/non-tasters of 6-n-propylthiouracil) may play a role in the development of vegetable acceptance and consumption in early childhood. These studies endorse the call by de Barse et al. that parental picky eating should ideally be accounted for in statistical analyses.
Modeling of positive maternal eating behavior is frequently cited as being important in averting picky eating in the child. Indeed, in a study of Australian mother–child pairs, maternal healthy eating when the child was 1 year old was predictive of vegetable consumption when the child was 2 years old.Further, when the children were 2–4 years old, maternal healthy eating was associated with a lower prevalence of picky eating in the children 1 year later. Maternal pressure to eat in this study was also associated with picky eating, and this was mediated by concern about the child being underweight. In a more detailed study of pressure to eat, data from the Generation R study showed a bidirectional association with picky eating behavior: picky eating in 4-year-olds prospectively predicted parental pressure to eat at age 6 years, and pressure to eat at age 4 years predicted picky eating at age 6 years. This was interpreted as suggesting that parental feeding strategies were developed in response to children's food-avoidant behavior, whilst having a counterproductive effect on picky eating behavior. Combining some of these traits in a study of girls only, mothers who provided a positive model of eating behavior by consuming more fruit and vegetables were less likely to pressure their children, who, in turn, were less likely to be picky eaters.
Occupational Therapy Assessment for Picky Eating in Children[edit | edit source]
There are several questionnaires designed to identify picky eating, which are completed by the parent/carer, in which multiple aspects of the child's feeding behavior are assessed. Several of these questionnaires have been validated. 
- Children's Eating Behavior Questionnaire
- Child Feeding Questionnaire
- Lifestyle Behaviour Questionnaire
- Stanford Feeding Questionnaire
- Preschooler Feeding Questionnaire 
- Assessment of Basic Language and Learning Skills (ABLLS) 
- Short Sensory Profile 
Occupational Therapy Intervention for Picky Eating in Children[edit | edit source]
Sequential Oral Sensory (SOS) Feeding Approach[edit | edit source]
The Sequential Oral Sensory (SOS) Feeding approach focuses on systematic desensitization which breaks down each part of the eating process into steps: Tolerates, Interacts With, Smells, Touches, Tastes, and then finally Eats. Each one of those steps is then broken down again so that every tiny progression is mastered before moving forward. You might be surprised to know that there are 32 steps to eating! Children receive positive reinforcement for every level of food interaction.
Sensory-Behavioural Interventions[edit | edit source]
The main objective of this intervention is to improve the acceptance of grams of food consumed, to reduce inappropriate mealtime behavior,  to improve mouth cleaning, and to reduce the presence of packing (i.e., holding food in the mouth larger than a grain of rice), gagging, and spitting out of food. Sensory integration therapy (SIT) involves carrying out in 15 min pre-meal activities using materials such as a trampoline, a therapeutic mat, or a sensory brush. This program focused, on the one hand, on inappropriate eating behavior caused by environmental factors, and on the other hand, on the use of a food texture hierarchy to address food selectivity.
Family Focused Interventions[edit | edit source]
The main objectives of these interventions were to provide parents with basic skills to manage food selectivity and to implement new tools to reduce food selectivity and improve the acceptance of food consumed. Most of these interventions, in addition to involving the family, included sensory integration activities. The intervention aimed to provide parents with basic skills to manage food selectivity and factors influencing food preferences and to implement new approaches and strategies to address food selectivity. One of the example of family-focused food intervention is called EAT-UP which aims to address both food selectivity and inappropriate behaviors, resulting in an increase in the level of food acceptance and food diversity. Another cognitive–behavioral treatment named “BUFFET”, a food flexibility and exposure treatment program developed by Kuschner et al. (2017) It is based on developing children’s coping skills to deal with anxious situations and thus know how to act flexibly with novel or non-preferred foods.
Resources[edit | edit source]
- Managing Stressful Times with a Picky Eater or Problem Feeder
- Preventing Picky Eating: Strategies to help your family get back on track
References[edit | edit source]
- Goh, D.Y. and Jacob, A., 2012. Perception of picky eating among children in Singapore and its impact on caregivers: a questionnaire survey. Asia Pacific family medicine, 11, pp.1-8.
- Dovey, T.M., Staples, P.A., Gibson, E.L. and Halford, J.C., 2008. Food neophobia and ‘picky/fussy’eating in children: a review. Appetite, 50(2-3), pp.181-193.
- Mascola, A.J., Bryson, S.W. and Agras, W.S., 2010. Picky eating during childhood: a longitudinal study to age 11 years. Eating behaviors, 11(4), pp.253-257.
- Ekstein, S., Laniado, D. and Glick, B., 2010. Does picky eating affect weight-for-length measurements in young children?. Clinical pediatrics, 49(3), pp.217-220.
- Hafstad, G.S., Abebe, D.S., Torgersen, L. and Von Soest, T., 2013. Picky eating in preschool children: The predictive role of the child's temperament and mother's negative affectivity. Eating behaviors, 14(3), pp.274-277.
- Van der Horst, K., 2012. Overcoming picky eating. Eating enjoyment as a central aspect of children’s eating behaviors. Appetite, 58(2), pp.567-574.
- van der Horst, K., Eldridge, A., Deming, D. and Reidy, K., 2014. Caregivers’ perceptions about picky eating: associations with texture acceptance and food intake (379.3). The FASEB Journal, 28, pp.379-3.
- Zimmerman, J. and Fisher, M., 2017. Avoidant/restrictive food intake disorder (ARFID). Current problems in pediatric and adolescent health care, 47(4), pp.95-103.
- Taylor, C.M., Wernimont, S.M., Northstone, K. and Emmett, P.M., 2015. Picky/fussy eating in children: Review of definitions, assessment, prevalence and dietary intakes. Appetite, 95, pp.349-359.
- Cardona Cano, S., Tiemeier, H., Van Hoeken, D., Tharner, A., Jaddoe, V.W., Hofman, A., Verhulst, F.C. and Hoek, H.W., 2015. Trajectories of picky eating during childhood: a general population study. International journal of eating disorders, 48(6), pp.570-579.
- Moroshko, I. and Brennan, L., 2013. Maternal controlling feeding behaviours and child eating in preschool‐aged children. Nutrition & Dietetics, 70(1), pp.49-53.
- Cooke, L.J., Haworth, C.M. and Wardle, J., 2007. Genetic and environmental influences on children's food neophobia. The American journal of clinical nutrition, 86(2), pp.428-433.
- Bell, K.I. and Tepper, B.J., 2006. Short-term vegetable intake by young children classified by 6-n-propylthoiuracil bitter-taste phenotype. The American journal of clinical nutrition, 84(1), pp.245-251.
- de Barse, L.M., Jansen, P.W., Edelson-Fries, L.R., Jaddoe, V.W., Franco, O.H., Tiemeier, H. and Steenweg-de Graaff, J., 2017. Infant feeding and child fussy eating: The Generation R Study. Appetite, 114, pp.374-381.
- Gregory, J.E., Paxton, S.J. and Brozovic, A.M., 2011. Maternal feeding practices predict fruit and vegetable consumption in young children. Results of a 12-month longitudinal study. Appetite, 57(1), pp.167-172.
- Jansen, P.W., de Barse, L.M., Jaddoe, V.W., Verhulst, F.C., Franco, O.H. and Tiemeier, H., 2017. Bi-directional associations between child fussy eating and parents' pressure to eat: Who influences whom?. Physiology & behavior, 176, pp.101-106.
- Galloway, A.T., Fiorito, L., Lee, Y. and Birch, L.L., 2005. Parental pressure, dietary patterns, and weight status among girls who are “picky eaters”. Journal of the American dietetic Association, 105(4), pp.541-548.
- Haroon, S., 2019. OCCUPATIONAL THERAPY FOR CHILDREN WITH FEEDING DIFFICULTIES AND PICKY EATING HABITS-A CASE STUDY. Pakistan Journal of Rehabilitation, 8(2), pp.50-53.
- Peterson, K.M., Piazza, C.C. and Volkert, V.M., 2016. A comparison of a modified sequential oral sensory approach to an applied behavior‐analytic approach in the treatment of food selectivity in children with autism spectrum disorder. Journal of Applied Behavior Analysis, 49(3), pp.485-511.
- Seiverling, L., Anderson, K., Rogan, C., Alaimo, C., Argott, P. and Panora, J., 2018. A comparison of a behavioral feeding intervention with and without pre-meal sensory integration therapy. Journal of autism and developmental disorders, 48, pp.3344-3353.
- Sharp, W.G. and Jaquess, D.L., 2009. Bite size and texture assessments to prescribe treatment for severe food selectivity in autism. Behavioral Interventions: Theory & Practice in Residential & Community‐Based Clinical Programs, 24(3), pp.157-170.
- Reche-Olmedo, L., Torres-Collado, L., Compañ-Gabucio, L.M. and Garcia-de-la-Hera, M., 2021. The role of occupational therapy in managing food selectivity of children with autism spectrum disorder: A scoping review. Children, 8(11), p.1024.
- Managing Stressful Times with a Picky Eater or Problem Feeder
- Preventing Picky Eating: Strategies to help your family get back on track