Picky eating: the current state of research

Impact of parent child interaction therapy on child eating behaviors

BACKGROUND

Picky eating commonly co-occurs with disruptive behaviors in young children. While feeding interventions exist, it remains unknown whether unmodified behavioral parent training (BPT) improves maladaptive child eating. As coercive feeding practices may exacerbate picky eating, BPT could ameliorate associated behaviors by increasing authoritative parenting.

METHODS

Caregiver-child dyads (N = 194, ages 2-8) received 18 weeks of Parent-Child Interaction Therapy (PCIT). Caregivers completed the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) at pre-, mid-, and post-treatment. The BPFAS overall picky eating frequency and number of problems was examined, as well as the subscale of mealtime misbehaviors, and overall caregiver feeding practices.

RESULTS

From pre-to post-treatment, reductions occurred in frequency/problems scales across overall BPFAS child behaviors. Mealtime misbehaviors significantly declined at all checkpoints - early skill acquisition may drive this early change, whereas changes in frequency/problem scales occurred after mid-treatment, suggesting later skill acquisition may be driving these changes. On the coercive caregiver feeding subscale, multivariate regression identified a significant race by time interaction (p = .02) - multiracial caregivers improved while others showed no difference.

CONCLUSION

Standard PCIT, not adapted for feeding concerns, decreased maladaptive child eating behaviors across all caregivers and coercive feeding practices in multiracial caregivers. Authoritative parenting principles may generalize to eating contexts for certain cultural groups. PCIT shows promise as an early upstream intervention potentially changing trajectories without needed feeding content modifications. Assessment of long-term maintenance is warranted. Coupling with nutrition education could optimize impact.

Eating disorder in children: Impact on quality of life, with a spotlight on autism spectrum disorder

Eating behavior, which includes eating habits and preferences, frequency of eating, and other features related to diet, is a major characteristic not only of a person's nutritional status, but also of health in general. In recent years, the prevalence of eating disorders in children has tended to increase; they also require cross-system approaches in diagnosis by a variety of specialists and correction requires appropriate selection of optimal methods. Maladaptive eating attitudes formed at an early age can contribute to the formation of eating disorders, which can lead to or worsen various neuropsychiatric diseases, digestive diseases, and other related conditions. In children with autism spectrum disorder (ASD), eating disorders often appear earlier than other major symptoms of the condition. However, the clinical manifestations of eating disorders in children with ASD are varied and differ in severity and duration, whereas these disorders in neurotypical children might present as short-lived and may not lead to serious consequences. Nevertheless, cases of progressive eating disorders accompanied by a child presenting as under- or overweight and/or with macronutrient and micronutrient deficiencies cannot be excluded. Given the high prevalence of eating disorders in children, many researchers have highlighted the lack of a valid and universally accepted instruments to assess atypical eating behaviors in this population. Therefore, in this review, we wanted to highlight the problems and causes of eating disorders in children, and also to analyze the existing approaches to the validation of these problems, taking into account the existing behavioral features in children with ASD.

A qualitative inquiry of parents of extremely picky eaters: Experiences, strategies and future directions

BACKGROUND/AIM

Picky eating is a common childhood phenomenon in younger children, impacting family relationships and mealtimes. Limited qualitative studies have explored parents' experiences of parenting an extremely picky eater. This study aimed to address this gap.

METHODS

This exploratory qualitative research design included participants who were Australian-based parents (n = 10) of children aged 2-6 years with a minimum picky eating score of 3.33, indicating extreme picky eating, on the Food Fussiness subscale of the Child Eating Behavior Questionnaire (CEBQ). Parents were interviewed online via Zoom using semi-structured interviews focused on their experiences of having a child who is a picky eater. Reflexive thematic analysis was used to analyze the data.

RESULTS

Five themes were identified: 1: The picky eating journey for parents. 2: Picky eating impacts families and mealtimes. 3: Parents have attempted multiple strategies to manage picky eating. 4: Emotions associated with parenting an extremely picky eater. 5: Parents of extremely picky eaters have a positive outlook for the future.

CONCLUSION

This qualitative study demonstrates that parents' experiences of parenting an extremely picky eater are varied. Parents desire health professionals who listen to their concerns and provide evidence-based knowledge around parent feeding practices to positively impact picky eating.

Reliability and validity of a Korean version of the children's eating behavior questionnaire in anorexia context

Background

Although childhood anorexia is a common clinical disorder, there is no established tool for evaluating it. The Children's Eating Behavior Questionnaire (CEBQ) is a parent-reported measure designed to assess the eating behavior of children. We aimed to investigate the reliability and validity of the Korean version of the CEBQ (K-CEBQ) for children with anorexia.

Methods

Parents of children with anorexia aged between 2 and 9 years participated in a survey conducted twice at 1-month intervals. The general characteristics and K-CEBQ scores of the children were recorded. To assess the reliability of the K-CEBQ, the internal consistency and test-retest methods were used. Furthermore, correlation analysis was performed for each item and factor, and the discriminant validity was determined through comparison with the normal group. Optimal cut-off scores, which are based on the maximum area under the curve of the receiver operating characteristic curve, were calculated in two categories.

Results

A total of 336 participants responded to the first survey, and the responses from 171 participants from the second survey were included in the analysis. The K-CEBQ showed relatively high internal consistency reliability (Cronbach's alpha = 0.738), and the retest demonstrated sufficient temporal stability. The relationship between each item of the K-CEBQ and the factor to which the item belongs showed a high correlation. There were significant differences between the anorexia and normal groups in two categories of the K-CEBQ: 'food approach' (p = 0.0063) and 'food avoidant' (p < 0.0001). The optimal cut-off values for the 'food approach' and 'food avoidant' category scores were 39.50 and 58.50 points, respectively.

Conclusion

This study demonstrated that the K-CEBQ may be a reliable and valid tool for assessing the eating behavior of children with anorexia.

Child characteristic correlates of food rejection in preschool children: A narrative review

Dietary habits formed in early childhood are key for establishing a healthy diet later in life. Picky eating and food neophobia - the two main forms of food rejection in young children - form an important barricade to establishing such healthy habits. Understanding these types of food rejection is thus essential for promoting healthy eating behaviour in both children and adults. To this end, the present narrative review aims to provide an overview of food rejection research in preschool-aged children, focusing on recent advances in the cognitive literature. Specifically, we evaluate the link between children's cognitive development, chemosensory perception and affective evaluation of food, food knowledge, decision-making strategies, anxiety and disgust sensitivity, and food rejection behaviour. Longitudinal and experimental studies are necessary to establish how the relationships between food rejection and cognitive processes develop over time and to determine their causal directions.

Longitudinal changes in home food availability across the first 3 years of life and associations with family context predictors

Background

There is limited research tracking changes in home food availability during the first 3 years of life and whether the family context influences these changes.

Objective

This study examined changes in and predictors of home food availability across the first 3 years of life.

Design

This study utilized longitudinal data from the STRONG Kids2 birth cohort from the target child at 6 weeks to 36 months postpartum.

Participants

Mothers of 468 children were surveyed at 6 weeks, 3, 12, 24, and 36 months postpartum.

Methods

Home observations were completed by trained research assistants to complete the presence of foods in the home. The primary outcomes were the availability of 10 food groups and scores from the Home Food Inventory (HFI), including dairy (regular fat), dairy (reduced fat), processed meats, other meats and non-dairy protein, savory snacks, vegetables, vegetables (no potatoes), and three obesogenic scores. Repeated measures ANOVA were used to examine changes in the HFI food groups and obesogenic scores over time. Multilevel regressions were conducted to examine whether the presence of an older sibling, entry into childcare, and mother's return to full-time work were associated with the HFI.

Results

Significant changes were detected for dairy (regular fat), other meats and non-dairy protein, savory snacks, vegetables, vegetables (no potatoes), and all obesogenic scores across time. A linear trend occurred for most HFI groups, however, the third obesogenic score (without milk and cheese) was highest at 3 months, declined at 12 months, and then slowly increased from 12 to 36 months years. The presence of an older sibling was a consistent predictor of the HFI groups over time. Entry into childcare was only associated with the availability of processed meats.

Conclusion

The availability of food types shift as children age and their dietary needs alter. It is important to consider the whole family context such as the presence of older siblings whose dietary needs may differ from younger children. Future efforts are warranted to consider changes in food availability among diverse samples and different family structures.

Association of picky eating around age 4 with dietary intake and weight status in early adulthood: A 14-year follow-up based on the KOALA birth cohort study

INTRODUCTION

A relatively common deviant type of eating behaviour among children is picky eating. Research on associations between picky eating and dietary patterns later in life is limited, and studies examining long-term effects on growth have yielded mixed results. The present study aimed to examine longitudinal associations of picky eating in early childhood with consumption of various foods, and weight status (body mass index, BMI) in young adulthood.

METHODS

Data from the Dutch KOALA Birth Cohort was used. Picky eating was determined around age 4 (range 3-6 years) by a questionnaire completed by parents. At follow-up around children's age 18 (range 17-20 years), weekly food intake frequencies, weight and height were assessed with a questionnaire completed by the grown-up young adult children. In total, 814 participants were included. Multiple regression analyses were performed for food intake frequencies and weight status (BMI) with picky eating score as predictor, controlling for parental and child covariates.

RESULTS

The mean picky eating score at age 4-5 was 2.24 (range 1-5). A 1-point higher picky eating score was associated with eating fruit 0.14 days less per week, raw vegetables 0.14 days less per week, cooked vegetables 0.21 days less per week, fish 0.07 days less per week and dairy products 0.23 days less per week (P-values all <0.05). Associations between picky eating and intake frequencies of meat, eggs, various snacks, sweet drinks, and weight status (BMI) were not significant.

CONCLUSION

Picky eating in childhood is associated with lower intake frequencies of various healthy foods among young adults. It is therefore recommended to pay sufficient attention to picky eating in young children.

Investigating the prevalence and risk factors of picky eating in a birth cohort study

This study aimed to investigate the prevalence of childhood picky eating (PE) and to identify risk factors associated with different PE trajectories using data from the Growing up in Scotland research survey. PE was operationalised using three items across three study sweeps, at ages 2, 5 and 10 years respectively. We found 13.5 % of children with PE at age 2, 22.2 % at age 5, and 6.4 % at age 10. From these, we defined three PE categories: transient PE in early childhood (23.3 %), persistent PE into late childhood (3.7 %) and PE absent (73.0 %). Using multinomial logistic regression, we investigated associations between child and family characteristics and transient and persistent PE, adjusting for potential confounders. Various factors were associated with increased risk of persistent pickiness, including mothers who smoked during pregnancy and children whose mothers reported feeding challenges at 9-12 months. These findings support the view that PE behaviours are common and tend to remit by adolescence although a small number of children are at risk of experiencing longer term problems. Families of children who are exposed to such risks may benefit from preventative interventions.

Picky eating in children: Current clinical trends, practices, and observations within the Australian health-care context

BACKGROUND/AIM

Childhood picky eating occurs when there is limited intake or variety of food and/or unwillingness to try new foods. Within research settings, standardised assessments are used to describe picky eating behaviours in children. However, little is known about assessment practices of occupational therapists. Similarly, occupational therapy interventions for picky eating in the literature focus on; providing strategies for parents, and working with the child on self-feeding skills. Despite this, interventions and strategies utilised by occupational therapists in clinical practice within an Australian health-care context are unknown. This study examines Australian health professionals' observations of picky eating behaviours, the use of childhood picky eating assessments and interventions, and differences between occupational therapists and other professionals.

METHODS

Health professionals (n = 179) were recruited through professional organisations, such as Occupational Therapy Australia. Participants completed an online survey between March and May 2021. Independent variables were reported using descriptive statistics, with logistic regression used to consider differences between occupational therapists and other health professionals. Conventional content analysis was used to analyse responses to open-ended questions.

RESULTS

The final sample included 109 eligible participants, with an average of 8.5 years working with picky eaters. Results indicated picky eating behaviours aligned with those reported in the literature. Participants relied on clinical observations and workplace designed assessments. The most common interventions were education, coaching, and the sequential oral sensory approach to feeding. Occupational therapy participants were significantly more likely than other health professional participants to report always using coaching and education.

CONCLUSION

Although few health professionals used standardised or validated assessments, the use of education and coaching by occupational therapists aligned with the literature. Results highlight the need for more rigorous investigation to determine the sensitivity of current assessments to differentiate between clinical and typical picky eating, and the effectiveness of interventions for childhood picky eating.

Parental concerns about picky eating and undereating, feeding practices, and child's weight

OBJECTIVE

Parents' concerns about their child's feeding may lead parents to pressure their child to eat, which may lead to a greater risk for obesity. We aimed to assess if parental concerns for picky eating and undereating are associated with pressure to eat and increased child BMI z-score (BMIz).

METHODS

We performed a cross-sectional study of 328 parents of healthy preschoolers assessing parent concerns about picky eating (Child Eating Behavior Questionnaire) and child undereating ("Are you concerned …doesn't eat enough?"), parent pressure to eat (Child Feeding Questionnaire), and covariates. Dyads' heights and weights were measured. Structural equation modeling (SEM) was performed to examine the relationships between parental concerns, pressure to eat, and child BMIz. Measurement models were tested and refined, and the structural model was tested. Model fit was determined using multiple goodness-of-fit indices.

RESULTS

Dyads were racially and socioeconomically diverse. The SEM model demonstrated good goodness-of-fit. Children who were perceived as not eating enough had significantly higher picky eating scores (β 0.756; p < 0.001). Parents had higher pressure to eat scores if children were more picky (β 0.148; p = 0.02) or were perceived as not eating enough (β 0.654; p < 0.001). Parental pressure to eat was not associated with the child's BMIz.

CONCLUSIONS

In a cohort of diverse preschoolers, parent concerns about eating were associated with increased pressure to eat, but pressure to eat was not associated with BMIz. Identifying these relationships is important to develop effective interventions to improve feeding practices in young children.

Avoidant/restrictive food intake disorder and severe food selectivity in children and young people with autism: A scoping review

AIM

To assess the extent of the scientific literature on avoidant/restrictive food intake disorder (ARFID) in children and young people with autism in order to evaluate and synthesize the evidence on (a) the nature of feeding and eating difficulties in children and young people with autism; (b) the consequences of a severely restricted diet; and (c) what is known about effective treatment approaches.

METHOD

PubMed and PsycInfo databases were searched, identifying 56 studies and a narrative synthesis was effected.

RESULTS

The literature suggested that ARFID-like presentations are common in children and young people with autism, with severe consequences for physical and mental health. The three drivers mentioned in the DSM-5 criteria, namely a sensory-based avoidance, fear- or phobia-based restriction, and a lack of interest in eating, are present in this population, although sensory sensitivities are currently the most commonly described. Research suggests that ARFID symptoms in children and young people with autism can be amenable to treatment, with evidence that behavioural interventions are feasible and potentially effective in this population.

INTERPRETATION

ARFID is a common and impactful problem among young people with autism but is currently under researched. Work is required to (a) identify the prevalence of ARFID in children and young people with autism; (b) uncover the key drivers of ARFID in this population; (c) adapt currently available interventions for use with children and young people with autism; and (d) rigorously test these interventions in clinical trials.

WHAT THIS PAPER ADDS

Significant food restriction is common in children and young people with autism. Sensory sensitivities are frequently cited as a reason for food restriction. The prevalence and causes of avoidant/restrictive food disorders in children and young people with autism need further research.

Parental Feeding Practices and Child-Related Factors are Associated with Overweight and Obesity in Children and Adolescents with Autism Spectrum Disorder

Atypical eating behaviors displayed by children with autism spectrum disorder (ASD) predispose them to unhealthy weight gain. We determined the factors associated with body weight status among 261 children with ASD (3-18 years) at nine autism intervention centers. Their mothers completed a self-administered questionnaire on sociodemographic background, parenting style, parental feeding practices, parenting stress, sleep habits, eating behaviors, and autism severity. Children with older age, non-full term gestational age, high maternal perceived weight, high maternal concern about child weight, and low pressure to eat were more likely to be overweight and obese. Obesity is a major concern among children with ASD. Healthy weight management programs for parents should incorporate appropriate feeding practices and a healthy perception of body weight.

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.

Psychometric evaluation of the Eating Disorders in Youth-Questionnaire when used in adults: Prevalence estimates for symptoms of avoidant/restrictive food intake disorder and population norms

OBJECTIVE

Restrictive eating behaviors occur across ages, but little is known about symptoms of avoidant/restrictive food intake disorder (ARFID), especially in adults. This study sought to examine the prevalence of symptoms of ARFID in the adult population, providing a psychometric evaluation of the Eating Disorders in Youth-Questionnaire (EDY-Q) and population norms.

METHOD

In a representative survey of the German population, N = 2,424 adults (1,297 women, 1,127 men; age 49.5 ± 17.5 years) were assessed with the EDY-Q and measures of eating disorder and general psychopathology for divergent validation.

RESULTS

The point prevalence of self-reported symptoms of ARFID amounted to 0.8% (20/2,424), with 0.8% of women (10/1,297) and 0.9% of men (10/1,127) being affected. Adults with symptoms of ARFID were significantly more likely to have underweight or normal weight, were more likely to report restrictive behaviors and lower levels of eating disorder psychopathology and binge eating than noneating-disordered controls and adults with symptoms of an eating disorder, but did not significantly differ in levels of compensatory behaviors, or depression and anxiety. The EDY-Q revealed favorable item statistics, heterogeneity, and satisfactory construct validity, including factorial, discriminant, and divergent validity. Weight-status specific norms were provided.

DISCUSSION

Both women and men from the population reported symptoms of ARFID with an anthropometric and psychopathological profile similar to that seen in youth with symptoms of ARFID, however, with lower prevalence estimates, and distinctive from that in other eating disorders. Interview-based assessment of this symptomatology is required to confirm the prevalence of ARFID diagnosis.

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.

Child attachment behavior as a moderator of the relation between feeding responsiveness and picky eating behavior

BACKGROUND

Picky eating (PE) behavior is common in early childhood, but persistent PE is associated with unhealthy development and caregiver-child stress during feeding. Identifying modifiable feeding and parent-child relationship factors that impact PE is important for decreasing risks associated with PE.

OBJECTIVE

This study examined associations between caregiver Feeding Responsiveness (FR) and child PE behaviors using caregiver reports and observations of family mealtimes. An additional aim examined whether children's attachment behavior moderates this association.

METHODS

The analysis sample consisted of 110 families participating in a larger longitudinal study of nutrition and child health. Home observations were conducted when children were 18-24 months (52% females) to assess caregiver-child interactions. Caregivers were, on average, 30.9 years old and mostly White (73.6%). Family mealtimes were videotaped and coded for FR and child PE behaviors. Caregivers completed surveys regarding FR and PE behaviors.

RESULTS

Caregiver-reported FR was significantly correlated with observed FR, r (107) = 0.26, p = 0.007; and caregiver-reported PE was associated with observed PE, r (107) = 0.21, p = 0.029. Caregiver-reported FR was inversely related to observed PE, but only when children were characterized by observers to have more positively toned and smooth interactions with caregivers. Using observational data, child attachment significantly moderated the relationship between FR and PE behaviors.

CONCLUSIONS

The quality of caregiver-child interactions may impact the degree to which FR is effective in reducing PE. Future longitudinal studies that include more diverse populations, multiple caregivers, and potential mechanisms accounting for these associations are needed.

Childhood fussy/picky eating behaviours: a systematic review and synthesis of qualitative studies

Fussy/picky eating behaviours are common across childhood. Recent reviews of the fussy eating literature focus on quantitative research and do not adequately account for families' subjective experiences, perceptions and practices. This review aims to synthesise the increasing volume of qualitative work on fussy eating. A systematic search of relevant databases was carried out. Studies were included if they were qualitative, published since 2008, with a primary focus on families' experiences, perceptions and practices regarding fussy eating, food neophobia, or food refusal in children (aged one to young adult). Studies with clinical samples, or relating to children under one year were excluded. Ten studies were eligible for this review and were synthesised using meta-ethnography (developed by Noblit and Hare). This review provides a comprehensive description and definition of fussy eating behaviours. A conceptual model of the family experience of fussy eating was developed, illustrating relationships between child characteristics (including fussy eating behaviours), parent feeding beliefs, parent feeding practices, mealtime emotions and parent awareness of food preference development. Our synthesis identified two ways in which fussy eating relates to mealtime emotions (directly and via parent feeding practices) and three distinct categories of parent beliefs that relate to fussy eating (self-efficacy, attributions and beliefs about hunger regulation). The model proposes pathways which could be explored further in future qualitative and quantitative studies, and suggests that parent beliefs, emotions, and awareness should be targeted alongside parent feeding practices to increase effectiveness of interventions. The majority of studies included in this review focus on pre-school children and all report the parent perspective. Further research is required to understand the child's perspective, and experiences of fussy eating in later childhood. PROSPERO Registration: CRD42017055943.

Fussy eating behaviours: Response patterns in families of school-aged children

BACKGROUND

Fussy eating is the unwillingness to eat both familiar and novel foods. Childhood fussy eating can be a barrier to a healthful diet and is associated with mealtime stress and conflict. Research has primarily focused on parenting practices in response to fussy eating in pre-schoolers. Less is known about parenting practices and family processes such as setting goals and managing emotions in relation to fussy eating in older children. This research aims to explore how families respond to fussy eating behaviours in school-aged children and based on parents' retrospective accounts, to investigate how responses change over time.

METHODS

16 parents from 14 families of school-aged children (6-10 years) participated in semi-structured qualitative interviews. Interviews were analysed using inductive thematic analysis.

RESULTS

Three family process themes were identified which explain how families respond to fussy eating behaviours: 1) Dynamic and Evolving Feeding Goals, 2) Managing Negative Emotions and 3) Parenting Practices: Figuring out What Works. Three distinct patterns were identified regarding how parent responses change over time: 1) Resistance-to-Acceptance Response, 2) Fluctuating Response and 3) Consistent Response.

DISCUSSION

The family response to fussy eating behaviours is complex, dynamic and contextual. This has implications for the design and interpretation of quantitative studies, and for the development of guidelines and interventions.

"It's always on the safe list": Investigating experiential accounts of picky eating adults

Previous research into severely restricted eating for reasons which are not cultural, medical, due to a lack of food or due to concerns about body image has focused predominantly on "picky/fussy eating" in children. Despite evidence that picky eating does continue into adulthood and recognition in the new diagnostic category Avoidant Restrictive Food Intake Disorder (ARFID) that problematically avoidant and restrictive patterns of eating affect people across the lifespan, relatively little is known about the challenges and consequences faced by older adolescents and adults. This research employs qualitative methods to explore the experience of living as an adult with picky eating behaviours. Semi-structured interviews were undertaken with thirteen adults who identify as picky eaters and eat a highly limited diet, as determined by a checklist food questionnaire. Data were analysed using interpretative phenomenological analysis (IPA). Two themes are presented in this paper: "Constructions of food" and "Motivators for and barriers to change". These themes show the importance of how individuals perceive food, their diet and themselves, and implications for clinical practice and future research in light of these findings are considered.

Feasibility of Including Behavioral Feeding Training Within a Parent Intervention for Young Children With Type 1 Diabetes

Young children with T1D frequently display challenging eating behaviors interfering with diabetes management. The current study explored the feasibility and acceptability of a behavioral parent feeding training session with young children with type 1 diabetes. As part of a larger intervention pilot focused on healthy eating and physical activity, 9 young children (M_age = 4.22) with type 1 diabetes (T1D) and their mothers participated in a novel/non-preferred food training session. Parents were taught strategies and then were given an opportunity to use the strategies with their child. The paradigm was video recorded and content was coded for parent and child behavior. Feasibility was high, and all parents rated the feeding session as acceptable. All parents demonstrated using at least one behavioral feeding skill (M = 3.38, SD = 1.60). All 9 (100%) children touched at least one of their non-preferred foods (M = 2.05, SD = 0.75), and 5 (56%) ate at least one novel/non-preferred food (M = 1.65, SD = 0.87). Parents of young children with T1D demonstrated use of parenting skills after receiving brief instructions, with more children than not trying at least one novel/non-preferred food.

Age-based norm-reference values for the Pediatric Eating Assessment Tool

BACKGROUND AND OBJECTIVES

Differentiating problematic feeding from variations of typical behavior is a challenge for pediatric providers. The Pediatric Eating Assessment Tool (PediEAT) is a parent-report measure of symptoms of problematic feeding in children 6 months to 7 years old with evidence of reliability and validity. This study aimed to determine age-based, norm-referenced values for the PediEAT.

METHODS

Parents of children between 6 months and 7 years old (n = 1110) completed the PediEAT. Descriptive statistics were calculated for subscale and total scores of the PediEAT within 11 age groups.

RESULTS

The PediEAT total scores followed a general downward trajectory with increasing age. Physiologic Symptoms were relatively steady from 6 to 15 months, and then rapidly declined in 15-18 month olds and continued to decline thereafter. Problematic Mealtime Behaviors increased from 6 to 9 months to a peak in 24-30 month olds and then declined with increasing age. Selective/Restrictive Eating increased from 6 to 9 months to a peak at 12-15 months and then decreased over time thereafter. Symptoms of difficulty with Oral Processing were highest in 6-9 month olds and decreased with age.

CONCLUSIONS

The PediEAT now has age-based norm-reference values to guide score interpretation and clinical decision-making.

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.

Picky Eaters Improved Diet Quality in a Randomized Behavioral Intervention Trial in Youth with Type 1 Diabetes

BACKGROUND

Children who are picky eaters typically demonstrate persistent food refusal and poor diet quality and may be resistant to intervention.

OBJECTIVE

This study tested whether pickiness moderated the effect of a nutrition intervention on diet quality in youth with type 1 diabetes, hypothesizing that the intervention effect would be smaller among picky relative to nonpicky eaters.

DESIGN

The study was an 18-month randomized clinical trial.

PARTICIPANTS

Youth age 8.0 to 16.9 years (n=136) with type 1 diabetes duration ≥1 year, receiving care at an outpatient diabetes center in Boston, MA, and a parent, participated from 2010 to 2013.

INTERVENTION

The intervention integrated motivational interviewing, active learning, and applied problem solving to increase whole plant food intake.

MAIN OUTCOME MEASURES

Whole plant food density (WPFD, cup/oz equivalents per 1,000 kcal target food groups), Healthy Eating Index-2005 (HEI2005, measures conformance to US dietary guidelines), and dietary variety were calculated from 3-day food records completed at six different times. Parents completed the pickiness subscale of the Child Feeding Questionnaire.

STATISTICAL ANALYSES PERFORMED

Mean WPFD and HEI2005 were estimated using the population ratio method; standard errors were computed using jackknife variance-covariance estimation. Overall P value comparing groups across visits was derived using the χ2 test.

RESULTS

Baseline diet quality was lower in picky than in nonpicky eaters. No intervention effect on pickiness or dietary variety was seen. In stratified analyses, the intervention effect on diet quality was significant for picky eaters only (WPFD P=0.0003; HEI2005 P=0.04). Among picky eaters, diet quality in the treatment group improved, whereas diet quality in the control group remained low. Diet quality of nonpicky eaters in the intervention group changed to a lesser degree.

CONCLUSIONS

The intervention resulted in increased diet quality in picky eaters, whereas no intervention effect was seen in nonpicky eaters. Findings suggest that diet quality of picky eaters can be improved without changing their underlying pickiness.

Treatment of eating disorders in child and adolescent psychiatry

PURPOSE OF REVIEW

Recent research on the multimodal treatment of eating disorders in child and adolescent psychiatry has yielded a significant increase in randomized controlled trials and systematic reviews. This review aims to present relevant findings published during the last 2 years related to medical and psychological treatment of anorexia nervosa, bulimia nervosa and avoidant/restrictive food intake disorder (ARFID).

RECENT FINDINGS

For anorexia nervosa, recent reports described the efficacy of different treatment settings, lengths of hospital stay and high vs. low-calorie refeeding programmes. For both anorexia and bulimia nervosa, a number of randomized controlled trials comparing individual and family-oriented treatment approaches were published. For the newly defined ARFID, only very preliminary results on possible treatment approaches implying a multidisciplinary treatment programme were obtained.

SUMMARY

Although there is some evidence of the effectiveness of new child and adolescent psychiatric treatment approaches to eating disorders, the relapse rate remains very high, and there is an urgent need for ongoing intensive research.

Child and parent predictors of picky eating from preschool to school age

BACKGROUND

Picky eating is prevalent in childhood. Because pickiness concerns parents and is associated with nutrient deficiency and psychological problems, the antecedents of pickiness need to be identified. We propose an etiological model of picky eating involving child temperament, sensory sensitivity and parent-child interaction.

METHODS

Two cohorts of 4-year olds (born 2003 or 2004) in Trondheim, Norway were invited to participate (97.2% attendance; 82.0% consent rate, n = 2475) and a screen-stratified subsample of 1250 children was recruited. We interviewed 997 parents about their child's pickiness and sensory sensitivity using the Preschool Age Psychiatric Assessment (PAPA). Two years later, 795 of the parents completed the interview. The Children's Behavior Questionnaire (CBQ) was used to assess children's temperament. Parent- child interactions were videotaped and parental sensitivity (i.e., parental awareness and appropriate responsiveness to children's verbal and nonverbal cues) and structuring were rated using the Emotional Availability Scales (EAS).

RESULTS

At both measurement times, 26% of the children were categorized as picky eaters. Pickiness was moderately stable from preschool to school age (OR = 5.92, CI = 3.95, 8.86), and about half of those who displayed pickiness at age 4 were also picky eaters two years later. While accounting for pickiness at age 4, sensory sensitivity at age 4 predicted pickiness at age 6 (OR = 1.25, CI = 1.08, 2.23), whereas temperamental surgency (OR = 0.88, CI = 0.64, 1.22) and negative affectivity (OR = 1.17, CI = 0.75, 1.84) did not. Parental structuring was found to reduce the risk of children's picky eating two years later (OR = 0.90, CI = 0.82, 0.99), whereas parental sensitivity increased the odds for pickiness (OR = 1.10, CI = 1.00, 1.21).

CONCLUSIONS

Although pickiness is stable from preschool to school age, children who are more sensory sensitive are at higher risk for pickiness two years later, as are children whose parents display relatively higher levels of sensitivity and lower levels of structuring. Our findings suggest that interventions targeting children's sensory sensitivity, as well as parental sensitivity and structuring, might reduce the risk of childhood pickiness. Health care providers should support parents of picky eaters in repeatedly offering unfamiliar and rejected foods to their children without pressure and acknowledging child autonomy.

Behavioral outcomes of picky eating in childhood: a prospective study in the general population

BACKGROUND

Picky eaters in the general population form a heterogeneous group. It is important to differentiate between children with transient picky eating (PE) and persistent PE behavior when adverse outcomes are studied. We analyzed four PE trajectories to determine the associations with child mental health prospectively.

METHODS

From a population-based cohort, 3,748 participants were assessed for PE at 1.5, 3, and 6 years of age using maternal reports. Four trajectories were defined: persistent (PE at all ages); remitting (PE before 6 years only); late-onset (PE at 6 years only); and never (no PE at any assessment). Child's problem behaviors were assessed with the Teacher's Report Form at 7 years of age. We examined associations between picky eating trajectories and emotional problems, behavioral problems and pervasive developmental problems using logistic regressions. Analyses were adjusted for child, parental, and socioeconomic confounders. We also adjusted for maternal-reported baseline problem behavior at age 1.5 years; the never picky eating group was used as reference.

RESULTS

Persisting PE predicted pervasive developmental problems at age 7 years (OR = 2.00, 95% CI: 1.10-3.63). The association remained when adjusted for baseline pervasive developmental problems at 1.5 years (OR = 1.96, 95% CI: 1.10-3.51). Persistent PE was not associated with behavioral (OR = 0.92, 95% CI: 0.53-1.60) or emotional problems (OR = 1.24, 95% CI: 0.74-2.07). Other PE trajectories were not related to child behavioral or emotional problems.

CONCLUSIONS

Persistent PE may be a symptom or sign of pervasive developmental problems, but is not predictive of other behavioral problems. Remitting PE was not associated with adverse mental health outcomes, which further indicates that it may be part of normal development.

Qualitative Analysis of Dietary Behaviors in Picture Book Fiction for 4- to 8-Year-Olds

OBJECTIVE

Picture books may facilitate parents' efforts to decrease pickiness and other undesirable food habits in children. This study conducted a content analysis of dietary behaviors and feeding strategies featured in fictional picture books compared with those discussed in the research literature.

DESIGN

Several databases were searched for fictional picture books about dietary behavior, published between 2000 and 2016, accessible in the US, available in print format, and designated for 4- to 8-year-olds.

PHENOMENON OF INTEREST

Messages about dietary behavior in picture book fiction.

ANALYSIS

Stories were systematically coded using holistic, data-driven, and evaluation coding methods. The final set of codes was examined for themes and patterns.

RESULTS

Of the 104 books, 50% featured a specific eating behavior, 21% lifestyle/eating patterns, 20% food-related sensations and emotions, and 9% table manners.

CONCLUSIONS AND IMPLICATIONS

Books about dietary behaviors are abundant but the topic coverage is unbalanced. Problem behaviors portrayed in books overlap those discussed in the research literature. However, problem-solving strategies and actions do not align with those endorsed by nutrition professionals. Messages vary in their complexity (in terms of their plot and/or language), ranging from clear and direct to vague, sophisticated, unresolved, conflicting, or controversial. Recommendations for practitioners are discussed.

Prevalence and correlates of picky eating in preschool-aged children: A population-based study

OBJECTIVE

The present study, conducted with a population-based preschool children sample, aimed to examine the prevalence rates of picky eating according to the presence of the avoidance or restriction of food intake, searching for picky-eating correlates.

METHODS

959 children from 1.5 to 6years old were evaluated by their parents and caregivers/teachers. Picky eating was assessed by CBCL 1.5-5 and C-TRF, following Cano et al.'s (2015) procedure.

RESULTS

The prevalence of picky eating was 25.1%. The comparison of the picky-eating group and the non-picky-eating group indicated that picky eating was more common in older children and in children from lower-income families with younger parents. Significant associations were found between picky eating, pregnancy and birth delivery complications. Emotional and behavioral problems were also found to differentiate picky eaters and non-picky eaters using DSM-5-oriented subscales. The results of a binary logistic regression analysis revealed that children with somatic complaints and attention problems were more likely to be picky eaters.

DISCUSSION

Picky eating in preschool children should be considered together with sociodemographic features, pregnancy and delivery issues, and the presence of emotional and behavioral problems. Our results support the possibility that picky eating, as a specific eating pattern, could also be part of a broader pattern of behavioral problems in children.

Influencing factors of children's fruit, vegetable and sugar-enriched food intake in a Finnish preschool setting - Preschool personnel's perceptions

INTRODUCTION

A large proportion of young children spend most of their weekdays at preschool in Western countries. In Finland, three meals are included in a full day at preschool. These meals have the potential to promote healthy eating. This study aimed to obtain the personnel's (preschool teachers, day-care nurses) views on the factors influencing children's fruit, vegetable, and sugar-enriched food intake at preschool.

STUDY DESIGN

Four focus groups, in all 14 preschool personnel. Two researchers independently analysed the data using a socio-ecological framework.

RESULTS

At the child level, age, peers, and the child's personality were recognized as factors influencing the fruit and vegetable (FV) and sugar-enriched food intake. At the preschool level, both the physical and social environments were discussed thoroughly, whereas at the societal level, policies of the EU, the state, and the municipality were mentioned as factors that influence what children eat in preschool. The personnel also discussed the interactions between factors both between levels and within levels.

CONCLUSIONS

In Finnish preschools, children's food intake is influenced on and within several levels of the socio-ecological model. The identification of the factors influencing food intake allows different methods of intervention at multiple levels to promote healthy eating behaviours in preschools.