DHN 374: Research and Writing in Dietetics

Literature Review Composition Assignment

Author:

Hillary McLean

Affiliation:

Dietetics Student, University of Kentucky, Lexington, Kentucky

Date:

December 23, 2015

Title:

Identification, Classification, and Treatment of Picky Eaters: A Systematic

Literature Review

ABSTRACT:
Picky eating behavior is apparent in approximately 50% of children during early
childhood. Although picky eating is fairly common, the long-term effects on the development of
children who exhibit this food selectivity are less understood. With no standard definition or
classification system, studies have serves as an analysis of conflicting results from studies
pertaining to picky eaters. The focus of this analysis will be on conflicting effects and growth
and development from various studies. Reasons for the differing results will be discussed.
Finally, proposed classification systems will also be compared and contrasted in order to
determine the best choice. The aim of this review is to bring attention to the need of a structured
definition and classification system for picky eating practices in children. The added structure
could eliminate contrasting research data and decrease anxiety of caregivers, leading to increased
well-being of children who display selective eating symptoms.

INTRODUCTION:
In the world of science, there are carefully outlined regulations, checklists, guidelines,
and procedures for almost everything. Oftentimes, minute details seem unnecessary; however,
they formalize and standardize navigation through various health care fields. Confusion abounds
without such comprehensive specifications, resulting in a decrease in the effectiveness of patient
care and treatment.
The lack of protocol regarding how to diagnose children who are picky eaters provides a
fitting example of the confusion can result from disorganization. There have been few research
based findings about which characteristics that signal the need of picky eating diagnosis;
furthermore, the limited results regarding possible long-term effects from these studies stand in
direct opposition of each other [19]. Some studies results support the conclusion that picky
eating has no effect on future eating behavior or development; whereas other studies data affirm
a connection between the three.
One possible explanation for this variation is that there is not a concrete definition or
classification system that is broadly recognized for standard evaluation and diagnosis [1]. A
second possible explanation is the use of parental perception of picky eating as the marker for
whether various studies labeled certain children as picky eaters or not. Although each study
informs the parent of their own interpretation of what it means to be a picky eater, the guardian
still has an opportunity to respond subjectively as opposed to objectively. Parents may provide
slightly inaccurate information, particularly if they have high anxiety as it relates to their childs
eating habits. This leads to yet another complication, as proposed classification systems have not
taken parental misconceptions into account [3]. All of these factors play a role in distorting the
results, causing confusion on every front.

Each research study seems to adopt their own version of what it means to be a picky
eater. For example, a questionnaire survey - titled Perception of picky eating among children in
Singapore and its impact on caregivers by Daniel Goh and Anna Jacob - begins with a
description of picky eating being more about having insufficient varieties of food [4]. Picky
eating was grouped together with problem feeders and neophobics (in this context, those who
have a fear of trying new foods), to describe children who refuse to eat specific kinds of foods
[2]. However, another article by Van der Horst classifies children who refuse to eat certain kinds
of foods as children with a feeding disorder. In this article, picky eating is qualified as a
scientifically unofficial name that has varied definitions, particularly from a cross-cultural
perspective [5]. A more specific demarcation only includes children who consume a small
amount of foods, refuse to sample foods that they are not used to, have limited intake of
vegetables and other food groups, experience intense food likes and dislikes, and need their food
to be prepared in a specific way more often [5]. The lack of a consistent scientific definition of
picky eating contributes to variable results in clinical trials.
Both parents and physicians can identify a child as a picky eater. However, what one
person calls picky eating might be called healthy eating by another person. If picky eater is
used as an umbrella term to classify all children with the eating problems previously mentioned,
then children with less severe symptoms may be treated in the same way as children with severe
symptoms are treated. Additionally, parents concerns are still existent with children who have
lower levels of picky eating and are not in danger from a nutritional standpoint. Without a proper
support system, many parents will be excessively and, consequently, some children may be mislabeled and mistreated.

Data from a study by Klazine van der Horst found that there is a positive correlation of 0.517 points between pickiness and pressure/restriction [3]. According to this Pearson correlation
from their structural model, a score of 0.01 is considered to be significant; so although this score
is negative, the results are significant [3]. As a concerned caregiver pressures or restricts the
child to eat or abstain from eating certain foods, picky eating behavior is unintentionally
encouraged.
Additionally, a questionnaire survey of 407 caregivers revealed that pressure to eat and
forcing the child to eat until the boy or girl consumed all of his or her food were the statistical
signs that were most positively associated with continued behavior [4]. How the caregiver
responds to the childs eating problem can either benefit the child or can be destructive by
causing the child to not enjoy eating and possibly have traumatizing memorize tied to mealtimes.

PURPOSE OF CURRENT REVIEW:

Although picky eating is common, a universal classification system should be in place to
help physicians and parents properly categorize children with feeding problems. Once a child has
been properly classified, caregivers can be provided with appropriate ways in which they can
help the child maintain optimal nutritional health status. This literature review compares and
contrasts various studies to showcase how differences in definition are likely to contribute to
varying and inaccurate findings. Based on current knowledge of the topic, proposed systems are
analyzed to determine which may function best as a prototype to build new and consistent
experiments off of. Additionally, the importance of educating caregivers is analyzed to enhance
emotional health and nutrient intake.

METHODS:
All studies for this review were found through searching on PubMed. Key words used to
find relevant articles include: picky eating, picky eating children, adult picky eating, toddlers and
diet, and irregular preschool eaters. This brought a few relevant articles; however, a majority of
the papers came from reference pages of the few articles I found from PubMeds search engine.
Articles utilized in this review are recently published, so that the literature could accurately be
based off of current findings. Studies involving picky eating with children who had diseases
were excluded.

Discussion:
In a cross-sectional study that involved 911 Chinese school-aged children, researchers
provided questionnaires to the primary caregiver. The researches informed the caregiver that
they should fill out the assessment using the following definition of a picky eater: a child who
does not have adequate intake of types and quantity of foods due to rejection of both familiar and
unfamiliar foods. This rejection should be caused by issues the children have with the taste,
texture, smell, or appearance of the foods. After this clarification, researchers relied on the
primary caregivers judgment to categorize the child as a current picky eater or a non-picky
eater. Parents identified 54% of their children as picky eaters, leaving 46% of the children
defined as non-picky eaters. Children considered to have picky eating behavior for more than
two years had body mass indexes (BMIs) that were below the average of all the childrens BMIs.
Those who were picky eaters for two to three years had decreased weight for age (z score was
0.22 lower than the mean of all the childrens BMI scores). Children who were still picky eaters
after three years were also more thin, with a z score that was 0.25 points below the mean of the

total weight-for-age measurements. There were not any notable distinctions between levels of
intelligence for the picky eaters [1].
In contrast, a longitudinal study that followed 120 two-year-olds up until they reached the
age of 11 and found that only 22% of the group were considered picky eaters by the end of the
study [7]. The low percentage is expected since picky eating usually occurs during the time that
young children [Northstone]. In this longitudinal study, a caregiver also decided whether or not
each child would be considered a picky eater or not. The definition of picky eating that these
researchers stated, which may or may not have been stated to the caregiver before the
assessment, is a toddler or child that consumes a small amount of food and most notably avoids
eating vegetables. Additionally, the toddler or child refuses to try new foods and has particular
food preferences that oftentimes forces the caregiver(s) to prepare a separate meal for the child.
At certain points throughout the nine-year study, a caregiver was simply asked if their child is a
picky eater on a scale from one to five, one being never a picky eater and five always being a
picky eater. Interestingly, the average BMI of the picky eaters were equivalent to that of nonpicky eaters [7].
Although most articles address the fact that there is not a standard definition, researchers
must still choose a definition to go by in order to perform their study. Consequently, studies
performed to outline the risks of picky eating result in different inconclusive conclusions and
may even be misleading. These varied findings of the long-term health effects of picky eating do
not help to decrease parents anxieties. This is important to consider because parental anxieties
surrounding eating can oftentimes impair relationships with their child [Garg]. Out of fear that
their child is not consuming sufficient nutrition, parents oftentimes develop poor mechanisms to
cope with the issue at hand, only serving to exasperate the situation. Parents of children who they

consider to be a picky eater usually turn to the application of pressure to eat some foods or to the
restriction of other foods in efforts to try to make sure the child is eating a well-balanced diet.
As shown in the graph below, studies are still conflicting regarding the long-term effects
of picky eating.

Table 1. Existence of Long-Term Health Effects

Title of the Article (Author)

Perception of picky eating among children in Singapore and its impact
on caregivers: a questionnaire survey (Goh)
A practical approach to classifying and managing feeding difficulties
(Kerzner)
A pilot study to assess the utility and perceived effectiveness of a tool
for diagnosing feeding difficulties in children (Garg)
Growth and development in Chinese pre-schoolers with picky eating
behavior: A cross-sectional study (Xue)
Effects of multiple herb formula SEC-22 supplementation on dietary
intake, picky eating behaviors, and growth indices in thin preschool
children (Kim)
Counseling on early childhood concerns: sleep issues, thumb-sucking,
picky eating, school readiness, and oral health (Nasir)
Association between serum cholesterol and eating behaviours during
early childhood: a cross-sectional study (Persaud)
Overcoming picky eating. Eating enjoyment as a central aspect of
childrens eating behaviors. (Van der Horst)
Children with early refusal to eat: Follow-up in adolescence (Rydell)
Feeding disorders related to nutrition
Longitudinal correlates of the persistence of irregular eating from age 5
to 14 years (McDermott)
Preschool children perceived by mothers as irregular eaters: Physical
and psychosocial predictors from a birth cohort study (McDermott)
Characteristics of school children who are choosy eaters (Rydell)
Picky eating during childhood: A longitudinal study to age 11-years
(Mascola)
Feeding disorders of infancy: A longitudinal study to middle childhood
(Ammaniti)

Does Picky Eating

Lead to LongTerm Health
Effects
(Yes/No/Maybe)
Maybe
No
Yes
Maybe
Yes

Maybe
Yes
Yes
No
Yes
Maybe
Maybe
Yes
No
Yes

Five studies had results that are somewhat inconclusive, but show that long-term effects
can ensue under certain circumstances. Only three studies reported that picky eaters experience
healthy, normal lives. The majority of the studies (six) proposed that picky eating does result in
serious long-term problems, such as stunted growth, incomplete brain development, decreased
weight and BMI, and low levels of HDL.
The variance in these studies definitions of picky eating and their results are obvious.
For example, Gohs questionnaire included thirty-six questions that mostly focused on the
behavior, attitudes, and perceptions of the guardians regarding picky eating and how they usually
feed their child. In this study, picky eaters is broadly defined and includes children who eat
slowly or hold food in their mouth, refuse food, eat sweets and foods high in fats, do not like
trying new foods, eat snacks instead of meals, and only consume a limited number of types of
food. No differences in body size between picky eaters and non-picky eaters were found from
this study, but further research was recommended, particularly because there has been such a
strong history of conflicting results on this topic.
Including so many different types of picky eaters in the grouping could be the reason for
such a finding. Children who eat snacks instead of meals are likely to have distinct nutritional
differences from those who leave out entire food groups each day. Someone who simply snacks,
depending on what they snack on, could be considered healthy. Comparatively, a person who
leaves out one or more of the food groups is more likely to be deficient in certain essential
vitamins and nutrients that are mainly found in the respective food groups. Additionally, eating
fruits probably will not help someone gain weight, but helps meet the daily recommended
intakes. For this reason, its quite possible that no difference was found between picky eaters and
non-picky eaters because the level of nutrient deficiency was not taken into consideration.

Although this is a large limitation, the study was just a questionnaire via telephone; a clinical
experimentation may have yielded different results.
In comparison, an experiment by rn and his associates was performed via
questionnaire in order to find the prevalence of problematic eating behavior and its effect on
childrens size and proportions. In this study, problematic eaters were defined as children whose
guardian was not satisfied with the childs eating status. With this classification system, 40.8%
of 331 total guardians stated that their child is a problematic eater. A significant difference was
found between problematic eaters and normal eaters: problematic eaters had a lower mean
weight-for-age z-score of -0.021.10 (indicating that this group had weight measurements
slightly below, at, and slightly above the mean weight). Meanwhile, non-problematic eaters
mean z-score was 0.441.21, slightly above the mean weight. Because the p-value was 0.01 (less
than 0.05), the data is considered to be statistically significant since they are less than 0.05 (5%)
of [rn].
If childrens growth and development are (or are not) negatively impacted by picky
eating, the results from these experiments should be reflective of such a fact. Since the studies
data are in stark contrast, there must be something causing this inconsistency. As mentioned
earlier, the largest variable factor in each experiment is how picky eaters are chosen from the
non-picky eaters. Putting in place a standard definition with more specific requirements for picky
eating categorization could possibly be what removes the disparity between findings.

Classification and Treatment:

Due to picky eatings high prevalence in young children, physicians and caregivers
appropriate response to resolution sets the path of the childs future health, both physically and
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emotionally. Although a call to standardize classification has been made, treatment plans should
have a general outline based upon which category the child falls under, but should also allow
some room for individualized alterations. Though the treatments outlined are a great basis to start
from, parents and guardians should work with their physician to create a plan that best fits the
child.
An article by Benny Kernzer and his peers goes through a more detailed way of
categorizing childrens feeding difficulties [3]. They break down three distinct groups of
children: those with limited appetite, selective intake, and fear of feeding. Following this
breakdown, each category is broken down into sub-categories to help standardize the correct
identification and classification of children with feeding difficulties. The sub-categories for
children with limited appetite include energetic and active children with limited appetites and
those who are inactive and disinterested. Interest levels not only regard their attitudes towards
foods, but towards their environments as well. The key suggestion for treating the former (active)
group is to engage in practices that help the child understand the difference between feeling
hungry and feeling full (including how to respond to each in an appropriate way), and also
helping parents to understand and respect that this differentiation is ultimately up to the
individual childs interpretation. picky eaters are in a sub-category of selective intake. The latter
(inactive) group of children simply need to have supportive interactions and provision of
adequate nutrition. Three sub-categories comprise the larger Children with Selectivity: Mild
Selectivity, Highly Selective, and Organic. Picky eaters, in this classification system, are
considered to only have mild selectivity. Educating caregivers to continue to offer new foods to
the child at least 15 times without any pressure is suggested. In addition, small tricks to ensure
the child is consuming enough from each food group are discussed: add pureed vegetables, use

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dips to improve the flavor of foods that the child does not like, demonstrate eating the problem
foods, give the foods fun nick names, include the child in work to prepare the meals, and finally,
get creative to enhance the appearance of the food offered.
Chart 1. Breaking down the classification of picky eaters
Concern of Guardian, Improper Feeding Behavior,
or Inappropriate Feeding

History, Systems Review, Anthropometrics, Physical Examination

Investigations as Needed

Limited Appetite

Selective Intake

Fear of Eating

Energetic, Apathetic, Organic

Neophobia, Mildly Selective,

Misperceived Pain, Infant

(Structural, Gastrointestinal,

Highly Selective, Organic

Pattern, Older Child

Cardiorespiratory, Neural,

(Delayed Development,

(Chocking), Organic (Causes

Metablolic)

Dysphagia)

of Pain: Esophagitis,
Disordered Motility, Visceral
Hyperalgesia; Tube Feeding)

A study from Maastricht University supports one of these recommendations, finding that
visual appeal is a better promotor of fruit consumption than use of restriction. The experiment
consisted of two phases: prohibition and free reign. During the first phase, children were
individually categorized into one of three groups. One group a child may have been placed in

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was labeled as the regular fruit prohibition group, another was visually appealing fruit
prohibition group, and the last possibility was no prohibition group. All children involved in
the study were placed in a room alone without any distractors. Soon after, an experimenter
entered, introduced his/herself, and proceeded to obtain levels of tastiness and desire towards the
two previously-weighed fruit platters that were placed in front of child. One fruit platter had
plainly sliced fruit with skewer in each piece. The other platter had diced fruit in a watermelon
that each had a skewer with a flag on it. The childs satiety was measured, and then the
experimenter left the room. If a child was in the regular fruit prohibition group, they were not
allowed to eat the fruit on the regular tray throughout the first phase, a child from the visually
appealing fruit prohibition group was not allowed to eat the fruit from the visually appealing
platter, and a child in the no prohibition group was unrestricted. After the first round, the
platters were weighed again to measure the level of desire each child had for the fruit. During the
free-reign phase, all children were individually unrestricted while left alone for another 5
minutes. The platters were weighed once again. The experiment showed significant effects of
visual appeal on intake, with a p value of 0.001. More visually appealing fruit were consumed
than regular fruit, with a mean of 135.37 g and 73.34 g, respectively. Therefore, advice to
enhance the appearance of the foods offered to picky eaters can, based on scientific data, truly
increase their intakes of their respective problem foods [9].
Returning to Kerzners classification system, highly selective eaters only eat 10-15 foods
and have sensory food aversions (related to food taste, texture, smell, temperature, and/or
appearance). Treatment is a bit more challenging with this group, but only offering the food that
the child would like to eat if he/she progressively accepts the less desired foods and replacing
one food with a similar food may work. The caregiver(s) and child are encouraged to see a

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therapist for more guided treatment. The third sub-category is organic composed of children
who have medical conditions that make them selective eaters. These feeding problems should be
managed by specialists. Another category is composed of children with a fear of eating in
infants, older children, and in children with a fear induced by feeding problems from medical
complications. The most important part of treating this group of children is to reassure them and
help resolve the source of their fear.
This classification system is quite detailed, providing ranges and examples for clear and
simple categorization. The use of this system would help pediatric physicians to treat children
with feeding problems more accurately. From the chart, both parents and physicians would be
quite clear about which typed of children need to be referred to a specialist and which simply
need their guardians to be better educated. This could save both families and the health care
system a large amount of money.
In short, picky eating is oftentimes used as an umbrella term to cover a multitude of
symptoms. More specific determinants for picky eating should be developed, and the term
should be broken down to include progressive eating behavior problems (i.e. mild and severe
selectivity).
To help encourage childrens interest in meals, parents should involve their child in the
food preparation process as much as possible [12]. A study by Esther Jansen about improving
fruit consumption proved that presenting more appealing and creative food options increases
childrens intake of foods that are commonly disliked. Another study by Klazine van der Horst
mentions that even gardening can be a useful tool to get kids excited about their meals [5].
Parents can be as creative as they want, but should remember that restricting food intake and

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applying pressure on children to eat certain foods have been found to have adverse effects on
childrens eating habits.

CONCLUSION:
Without specifically defined categories, guidelines, many children are grouped into the
vague umbrella term of picky eaters. The use of only the picky eater may lead to
inappropriate parental actions, incorrect treatment plans, and unnecessary referrals to specialists.
After a standard classification system has been widely approved by research, more studies should
once again be pursued to correctly identify whether or not picky eating should be of a higher
concern to guardians and pediatric physicians. After accurate identification of picky eaters,
parents should be educated not to force their child to eat. Additionally, parents should patiently
continue to introduce the child to a new food repeatedly, as it may take several tries for the child
to become accustomed to eating differently. If persistence fails guardians should try to puree
foods high in nutrients that the child lacks and add it into the foods he or she does like. When all
else fails, be creative and take it one bite at a time.

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REFERENCES:
1. Xue Y et al. Growth and development in Chinese pre-schoolers with picky eating
behavior: A cross-sectional study. PLOS One. 2015; 10(4): e0123664.
2. Garg P. A pilot study to assess the utility and perceived effectiveness of a tool for
diagnosing feeding difficulties in children. BioMed Central. 2015; 14(7): 1-8.
3. Kerzner B et al. A practical approach to classifying and managing feeding difficulties.
PEDIATRICS. 2015; 135(2): 344-353.
4. Goh DY. Perception of picky eating among children in Singapore and its impact on
caregivers: a questionnaire survey. BioMed Central. 2012; 11(5): 1-9.
5. Van der Horst K. Overcoming picky eating. Eating enjoyment as a central aspect of
childrens eating behaviors. Appetite. 2012; 58(1): 567-574.
6. Nasir A. Counseling on early childhood concerns: sleep issues, thumb-sucking, picky
eating, school readiness, and oral health. The American Family Physician. 2015.
7. Mascola AJ et al. Picky eating during childhood: A longitudinal study to age 11-years.
Eat Behavior. 2010; 11(4): 253-257.
8. Rydell AM et al. Characteristics of school children who are choosy eaters. The Journal of

Genetic Psychology. 1995; 156(2) 217-229.

9. Cano, SC et al. Trajectories of picky eating during childhood: A general population
study. International Journal of Eating Disorders. 2015; 48(6): 570-579.
10. Castell-Gonzlez M et al. Can toddlers diets influence cognitive development?
Archives of Disease in Childhood. 2015; 99: 154-157.
11. Ekstein S et al. Does picky eating affect weight-for-length measurements in young
children? Clinical Pediatrics. 2010; 49(3): 217-220.

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12. Jansen E, et al. How to promote fruit consumption in children. Visual appeal versus
restriction. Appetite. 2010; 54(1): 599-602.
13. Kim K. Effects of multiple herb formula SEC-22 supplementation on dietary intake,
picky eating behaviors, and growth indices in thin preschool children. Nutrition Research
and Practice. 2015; 9(4): 393-399.
14. Northstone K and Emmett P. The associations between feeding difficulties and behaviors
and dietary patterns at 2 years of age: The ALSPAC cohort. Maternal & Child Nutrition.
2013; 9: 533-542.
15. Persaud N. Association between serum cholesterol and eating behaviors during early
childhood: a cross-sectional study. Canadian Medical Association. 2013; 185(11): E531.
16. Quick V et al. Relationships of neophobia and pickiness with dietary variety, dietary
quality and diabetes management adherence in youth with type 1 diabetes. European
Journal of Clinical Nutrition. 2014; 68(1): 131-136.
17. Shim JE et al. Association between picky eating behaviors and growth in preschool
children. Journal of Nutrition and Health. 2013; 46(5): 418-426.
18. Taylor CM et al. Picky/fussy eating in children: Review of definitions, assessment,
prevalence and dietary intakes. Appetite. 2015; 95(1): 349-359.
19. Shim J. Associations of infant feeding practices and picky eating behaviors of preschool
children. American Dietetic Association. 2011; 111(9).
20. HealthyChildren.org. American Academy of Pediatrics. healthychildren.org

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