Picky eating: When is the time to act?

The answer to this is very individualized, says Megan Pesch, MD, MS, who specializes in congenital diseases and childhood obesity at the University of Michigan Institute for Healthcare Policy and Innovation in Ann Arbor. Pesch coauthored a study in 2020 exploring picky eating habits in children of low-income families.

“Is the child limited [regarding] the variety or amount they eat, or willingness to try new foods?” Pesch asks. “What crosses that threshold?”

This question varies by socioeconomic group and household, she notes. A family who relies on public assistance to purchase food may be happy their child finishes their plate and meets their calorie needs. Another family may want their child to try a new organic vegetable.

The 2020 study, published in Pediatrics, concluded that all children are picky eaters at some point during childhood. It’s a means of demonstrating independence. For the study, mothers answered questions about their child’s baseline behavior and eating patterns, and investigators reviewed the child’s growth. The team looked for patterns in children who were judged as being more picky than others.¹

Children with higher emotional lability and lower self regulation were ranked among the pickiest eaters. Parents who were very strict or demanding in regard to their child’s eating habits also tended to have pickier eaters, the authors noted.

“Feeding is cultural,” Pesch explains. “There’s no right way to do things. Where picky eating is concerned, I think there is something inherent—maybe even evolutionary—in parents, especially mothers, that feels like an instinct to feed your child well.”

That very definition though, has evolved over time. Whereas at one point, feeding your child well simply meant providing them with food, today it means so much more.

“These days, there’s even more pressure on parents to make the Instagram-perfect meal for their child to eat.” she says. “The pressures on parents to feed their children to this high standard is real.”

When the research team investigated the eating and feeding behaviors of children aged 4 to 9 years in low-income groups, Pesch says the overall finding was that kids were “stably picky.” There were really only 5 children in the study group of 300 that ever “grew out” of their picky eating,¹ and the team couldn’t find any reason. “There was no real reason. They just stopped,” Pesch says.

This may not be good news for parents looking to find an answer on how to change their child’s picky eating behaviors. However, Pesch notes that parents have to realize their own role in these behaviors, too. “The mother’s approach to feeding was also stable, but mothers of picky eaters tended to be more demanding.”

Considerations to take during assessment

Demanding behavior by parents is really just a way to get their kids to eat, but these demands and rewards for eating come at a price, Pesch cautions. The children in the study who were less picky and gave in to parents’ demands had a higher risk of obesity than the children who were more picky,¹ she says. She also noted that none of the children in the picky eating group were underweight. “Maybe picky eating in kids is what we’re trying to achieve when we try to be mindful eaters as adults,” she suggests.

“Maybe we should not stress so much about fixing picky eating. Maybe we need to just focus more on positive experiences with food that families deem to be healthy and that they usually eat.”

Parents will always worry whether their children are eating well enough, and sometimes there is cause for concern. There may be physical or mental problems that complicate feeding and impair growth and development. In most cases, however, children are not being harmed by their picky eating and it’s more of a frustration for both them and their parents.

“Parents can have permission to just not fight that battle if that’s not a priority for them,” Pesch says.

The main concern is that children are growing and developing. Most picky eaters don’t have macronutrient deficiencies, she adds.

“You don’t want to feed them nuggets for dinner every night, but there is a happy medium to work toward,” Pesch says. “The needle on picky eating moves so slowly. Things that backfire are forcing kids to eat and making it a power struggle.”

An exception to this is when picky eating turns into a more serious medical issue. Avoidant/restrictive food intake disorder is the term now used to describe “extreme picky eating.” This eating disorder affects thousands of people, mostly children, and involves a true fear of food, unlike other eating disorders. The person is scared knowing they must eat while also worrying about choking or becoming sick, or just having no interest at all in eating. These children may get full quickly or have physical problems eating or even sensory avoidance, Pesch says.

For problems of this nature, pediatricians should involve someone in child psychology who specializes in treating eating or feeding disorders. Dieticians and nutritionists may also be helpful, she adds. Close follow-up of these children is necessary to make sure they keep gaining weight or at least are not losing any.

“You have to treat it like an eating disorder,” Pesch says. “A child’s No. 1 job is to grow.”

According to a 2014 paper in the Singapore Medical Journal on behaviors of picky eaters, 20% to 50% of parents perceived their children as picky, yet the majority of these children were not deficient in terms of either growth or nutrition.² However, telling parents there is nothing to be concerned about when discussing picky eating isn’t usually helpful.

Red flags for picky eating

Pediatricians need to look for feeding problems or other serious issues that could be causing picky eating or failure to absorb nutrients. Advice on helpful feeding practices and nutritional requirements based on age and size are helpful in terms of tempering parental anxieties and frustrations. “Picky eaters” can be tricky to define, but the issues that lead parents to this complaint usually involve low food consumption, a tendency to only eat certain foods­ refuse food, or be unwilling to eat certain foods or try new foods. Others have strong food and drink preferences. These behaviors are most common in children up to age 10 years, according to the 2014 paper. The biggest worry among parents is whether their children are getting the nutrition they need to meet their development needs.²

A starting point for education from the pediatrician might focus on a discussion about normal growth benchmarks and nutrition requirements²:

• For infants, a tripling of birth weight by 50% from birth weight in the first year of life.
• In the second year, a growth in height of about 12 cm and an increase in weight of 2 to 3 kg is expected.
• Beyond age 2 through puberty, average increases between 6 to 8 cm in height and 2 kg in weight are expected.

Pediatricians should also advise parents not to take these benchmarks too literally, and inform them that genetics play a big role in how a child’s height and weight develop. Parents should also keep in mind that children often refuse new foods at first, but increase acceptance with repeated exposure. The authors of the 2014 study note that it’s not a question of the food being offered, but rather the avoidance of new foods in general. The child’s personality, temperament, culture, and family dynamics also play a big role in feeding practices.

Additionally, the amount a child consumes at each meal can vary, sparking parents’ concern. Parents should be reminded to consider the entire day’s consumption when measuring their child’s intake.²

References

1. Fernandez C, McCaffery H, Miller A, Kaciroti N, Lumeng J, Pesch M. Trajectories of picky eating in low-income US children. Pediatrics. 2020;145(6):e20192018. doi:10.1542/peds.2019-2018

2. Ong C, Phuah K, Salazar E, How C. Managing the ‘picky eater’ dilemma. Singapore Med J. 2014;55(4). doi:10.11622/smedj.2014049