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Manuscript_ec5e2678a275efbb8a3b71c860eff05b

Picky Eating, Pressuring Feeding, and Growth in Toddlers

Julie C. Lumeng, MD, Alison L. Miller, PhD, Danielle Appugliese, MPH, Katherine Rosenblum,

PhD, Niko Kaciroti, PhD,

Author Affiliations: Center for Human Growth and Development, University of Michigan, Ann

Arbor, MI (JCL, NK, KR, AM); Department of Pediatrics and Communicable Diseases,

University of Michigan Medical School, Ann Arbor, MI (JCL); Department of Nutritional

Sciences, University of Michigan School of Public Health, Ann Arbor, MI (JCL); Department of

Health Behavior and Health Education, University of Michigan School of Public Health, Ann

Arbor, MI (ALM); Department of Psychiatry, University of Michigan Medical School, Ann

Arbor, MI (KR); Department of Biostatistics, University of Michigan School of Public Health,

Ann Arbor, MI (NK)

Corresponding and Reprint Request Author: Julie C. Lumeng, MD; Center for Human

Growth and Development; 300 North Ingalls Street, 10th Floor; University of Michigan; Ann

Arbor, MI 48109-5406; Tele: (734) 647-1102; Fax: (734) 936-9288; E-mail:

jlumeng@umich.edu

Short Running Head: picky eating, pressuring feeding, and growth

Keywords: feeding, infant, child, growth

Abbreviations: WLZ, weight-for-length z-score

© 2018 published by Elsevier. This manuscript is made available under the Elsevier user license
https://www.elsevier.com/open-access/userlicense/1.0/
 INTRODUCTION

Picky eating is common in early childhood (Dovey, Staples, Gibson, & Halford, 2008)

and is often raised as a concern by parents. Parents can respond to picky eating with pressuring

feeding practices, with the goal of helping the child to overcome picky eating and ultimately

attain more rapid growth. Although some degree of encouragement of picky eaters is likely

adaptive and could be viewed as responsive parenting that is sensitive to the child’s needs, other

types of pressure may be maladaptive. Specifically, pressure that is intrusive or not responsive

to the child is theorized to cause increases in picky eating. In addition, some have theorized that

pressure can overwhelm a child’s healthy internal hunger and satiety cues, leading to excessively

rapid growth (Dovey et al., 2008; Farrow, Galloway, & Fraser, 2009; Finistrella et al., 2012;

Gibson et al., 2012; Hayes et al., 2016).

Clarifying the temporality and bidirectionality of associations between picky eating,

pressuring feeding, and growth, particularly in toddlerhood, would provide valuable practical and

theoretical information. Toddlerhood is a developmental period during which picky eating

begins to emerge (Dovey et al., 2008), and therefore during which pressuring feeding and

conflict in the parent-child interaction around food often develops. Pediatric practice guidelines

include a focus on reducing picky eating (Hassink, 2006) as well as limiting pressure or

excessive control (Barlow & The Expert Committee, 2007). If pressuring feeding that occurs in

response to a child’s picky eating leads in turn to healthy growth or reductions in picky eating,

this would suggest that encouraging parents to implement responsive pressure (i.e., pressure that

is not intrusive or excessive) may be a valuable intervention strategy for the child who is a picky

eater and/or has poor growth. If in contrast, pressuring feeding leads to increases in picky eating
and further slowing of growth, this would suggest that pressuring feeding may not be a

worthwhile strategy for changing the trajectory of children’s picky eating and growth.

Prior studies examining these temporal relationships have mixed results. Specifically,

prior studies have found either no association between pressuring feeding and future markers of

adiposity (Faith et al., 2004; Gregory, Paxton, & Brozovic, 2010; Lumeng et al., 2012; Webber,

Cooke, Hill, & Wardle, 2010) or have found an inverse association (Afonso et al., 2016; M. S.

Faith et al., 2004; Jansen et al., 2014; Rodgers et al., 2013; Thompson, Adair, & Bentley, 2013;

Tschann et al., 2015; Ventura & Birch, 2008). Thinner child weight status has been found in

several studies to predict increases in pressure (Afonso et al., 2016; Jansen et al., 2014;

Thompson et al., 2013; Tschann et al., 2015; Webber et al., 2010). Several prior studies have

linked pressuring feeding with picky or restrained eating concurrently (Carper, Orlet Fisher, &

Birch, 2000; Carruth et al., 1998; Farrow et al., 2009; Ventura & Birch, 2008; Wardle, Carnell, &

Cooke, 2005). We identified only two studies that tested the association between pressuring

feeding and future picky eating, with conflicting results (Galloway, Fiorito, Lee, & Birch, 2005;

Gregory et al., 2010) Picky eating has been associated with controlling or pressuring feeding in

in several cross-sectional studies (Clark, Goyder, Bissell, Blank, & Peters, 2007; Faith et al.,

2004; Galloway et al, 2005; Nowicka, Sorjonen, Pietrobelli, Flodmark, & Faith, 2014; Ventura

& Birch, 2008), but to our knowledge this association has not been tested longitudinally.

Examining these pathways in low-income populations is especially relevant given that

picky eating (Cardona Cano et al., 2015; Dubois, Farmer, Girard, Peterson, & Tatone-Tokuda,

2007; Hafstad, Abebe, Torgersen, & von Soest, 2013; Tharner et al., 2014), pressuring feeding

(Shloim, Edelson, Martin, & Hetherington, 2015), and both over- and under-weight (Ogden,

Lamb, Carroll, & Flegal, 2010) have all been reported to be more common in this demographic.
Therefore, within a diverse cohort of low-income toddlers followed longitudinally at ages 21, 27,

and 33 months, we sought to test the hypotheses that: (1) pressuring feeding predicts increases

in weight-for-length z-score (WLZ); (2) lower WLZ predicts increases in pressuring feeding; (3)

pressuring feeding predicts increases in picky eating; (4) picky eating predicts increases in

pressuring feeding; and (5) picky eating predicts decreases in WLZ. To our knowledge, this is

the first test of these associations including all constructs simultaneously in a longitudinal design.

SUBJECTS AND METHODS

Participants

Participants were recruited between 2011 and 2014 via flyers posted in community

agencies serving low-income families. The study was described as examining whether children

with different levels of stress eat differently. Inclusion criteria were: the biological mother was

the legal guardian, had an education level less than a 4-year college degree, and was > 18 years

old; the family was English-speaking and was eligible for Head Start, Women, Infants and

Children (WIC) Program, or Medicaid; and the child was born at a gestational age > 36 weeks,

had no food allergies or significant health problems, perinatal or neonatal complications, or

developmental delays, and was between 21 and 27 months old. Mothers provided written

informed consent. The University of Michigan Institutional Review Board approved the study.

Mother-child dyads were invited to participate in three waves of data collection at child

ages 21, 27, and 33 months. A total of 244 dyads participated, with 186 dyads entering the study

at age 21 months and 58 entering at 27 months to maximize recruitment. This analysis was

limited to those participants with complete data for all measures at a given time point, with 222

participants contributing data at at least one time point. There were 150, 166 and 136 dyads who

participated at the 21, 27, and 33 months, respectively, with 76 dyads participating at all three
time points. There were 101, 116 and 91 dyads that participated at only two time points (21 and

27, 27 and 33, and 21 and 33 months, respectively). There were no differences between those

who completed the study versus those who did not with regard to child sex, or maternal

depressive symptoms or education. However, those who did not complete the study were more

likely to be Hispanic or not white than those who remained in the study (94% versus 42%,

p=0.0002).

Measures

Mothers reported child sex, age, and race and ethnicity, and maternal education, and

family structure. Child weight and length were measured by trained research staff. Weight-for-

length was calculated and z-scored based on United States Centers for Disease Control Growth

Charts. Mothers’ weight and height were measured and body mass index (BMI) calculated.

Pressuring feeding was measured with the Pressuring to Finish subscale of the Infant

Feeding Styles Questionnaire (IFSQ) (Thompson et al., 2009). Items (Appendix 1) are answered

on a 1 to 5 scale, with higher scores indicating more pressuring feeding and reverse scoring

applied as appropriate. Responses to the 8 items are averaged to create a summary score (α =

.67-.70 across age points).

There is debate in the field regarding the definition of picky eating (Dovey et al., 2008),

and the construct was therefore measured using two approaches. The Children’s Eating

Behavior Questionnaire-Toddler (CEBQ-T)(Carnell & Wardle, 2007) Food Fussiness subscale

consists of 6 items (Appendix 1), to which mothers respond on a scale of 1=never to 5=always.

Responses are averaged (α = .87-.90 across age points). The Brief Autism Mealtime Behavior

Inventory (BAMBI) was designed to measure mealtime behavior problems observed in children

with autism, but has strong face validity for the assessment of picky eating behaviors among
toddlers (Lukens & Linscheid, 2008). Mothers responded on a scale of 1=never to 5=at almost

every meal. We averaged items (Appendix 1) contributing to the original Limited Variety and

Food Refusal subscales to create a Picky Eating Subscale (13 items; α = .75-.78 across age

points).

Statistical Analysis

Descriptive analyses were conducted using SAS 9.4 (SAS Institute Inc., Cary, NC).

Univariate statistics were used to describe the sample. One-way repeated measures ANOVAs

and Chi square were used to test whether WLZ, pressuring feeding, or picky eating differed

across 21, 27, and 33 months.

Path models were conducted (using MPLUS version 7.3; Muthen & Muthen, Los

Angeles, CA) to test the concurrent, longitudinal, and cross-lagged associations between WLZ,

pressuring feeding, and picky eating at ages 21, 27, and 33 months (Figure 1). This model was

run twice, once using the CEBQ-T Food Fussiness subscale to measure picky eating, and once

using the BAMBI Picky Eating subscale to measure picky eating. This approach estimates

tracking of each construct at the individual level measured by the auto-correlation or longitudinal

correlation. Bayesian estimation technique in MPLUS was used to fit models, and Bayesian

posterior predictive checks (PPC) using Chi-square statistics and the corresponding posterior

predictive p-values (ppp) were used to assess the goodness of fit in each model. A p value within

0.05 to 0.95 range indicate acceptable fit for the model.(Gelman, 2004)
Figure 1. Conceptual model for longitudinal associations between WLZ, pressuring feeding,
and picky eating in toddlerhood

RESULTS

Characteristics of the sample by age point are shown in Table 1. At age 21 months, the

sample was 50.7% male, 48.0% non-Hispanic white, and 40.0% of mothers had a high school

education or less. Demographic composition of the cohort did not change significantly across

age points. WLZ, IFSQ Pressuring to Finish, and BAMBI Picky Eating did not change across

age points. CEBQ Food Fussiness increased across toddlerhood.

 Table 1. Characteristics of the sample (n=222)
21 months 27 months 33 months Test statistic p-value
(F)/chi-sq
n=150 n=166 n=136
Child Sex 0.78 .68
Female 74 (49.3) 74 (44.6) 62 (45.6)
Male 76 (50.7) 92 (55.4) 74 (54.4)
Child 2.74 .84
Race/Ethnicity
Non-Hispanic 72 (48.0) 78 (47.3) 70 (51.5)
white
Non-Hispanic 34 (22.8) 43 (26.1) 34 (25.0)
black
Hispanic (any 15 (10.1) 19 (11.5) 14 (10.3)
race)
Other 28 (18.8) 25 (15.2) 18 (13.2)
Maternal Education 0.24 .89
<= high school 60 (40.0) 62 (37.4) 53 (39.0)
>High school or 90 (60.0) 104 (62.7) 83 (61.0)
GED
WLZ 0.52 (1.06) 0.41 (1.08) 0.38 (1.00) 0.87 .42
IFSQ Pressuring to
1.57 (0.56) 1.51 (0.51) 1.56 (0.60) 0.52 .59
Finish
CEBQ-T Food
2.30 (0.87) 2.46 (0.97) 2.68 (0.96) 6.44 .002
Fussiness
BAMBI Picky
1.88 (0.55) 1.98 (0.60) 1.98 (0.59) 1.62 .20
Eating

Cross-lagged analysis results for the conceptual model depicted in Figure 1 are presented

in Table 2. The fit of both cross-lagged models was good with the ppp value for each model well

within the recommended 0.05 to 0.95 range. Weight-for-length z-score, maternal pressuring

feeding, and picky eating (by either measure) tracked strongly across all 3 age points. There

were several concurrent associations between pressuring feeding and picky eating at 21 and 33

months, using both measures of picky eating. There were no prospective associations between

pressuring feeding and future WLZ; WLZ and future pressuring feeding; pressuring feeding

andfuture picky eating; picky eating and future pressuring feeding; or picky eating and future

WLZ.
Table 2. Path coefficients for model shown in Figure 1 in total sample (n=222)
CEBQ-T Food BAMBI Picky
Path Fussiness Eating
ppp=0.42 ppp=0.22
WLZ 21m →WLZ 27m b1 0.847* 0.846*
WLZ 27m→ WLZ 33m b2 0.861* 0.856*
Pressuring feeding 21m→ b3 0.677* 0.674*
Pressuring feeding 27m
Pressuring feeding 27m→ b4 0.547* 0.565*
Pressuring feeding 33m
Picky eating 21m→ Picky eating 27m b5 0.614* 0.569*
Picky eating 27m→ Picky eating 33m b6 0.743* 0.627*
WLZ 21m→Picky eating 21m b7 -0.124 -0.042
WLZ 27m→ Picky eating 27m b8 0.043 0.064
WLZ 33 m→ Picky eating 33m b9 -0.048 -0.199
WLZ 21m→Pressuring feeding 21m b10 0.003 0.011
WLZ 27m→ Pressuring feeding 27m b11 -0.019 -0.032
WLZ 33 mos→ Pressuring feeding 33m b12 -0.082 -0.081
Picky eating 21m→Pressuring feeding 21m b13 0.230* 0.326*
Picky eating 27m→ Pressuring feeding 27m b14 0.009 0.181
Picky eating 33 m→ Pressuring feeding 33m b15 0.139 0.218*
Pressuring feeding 21m→WLZ 27m b16 -0.037 0.003
Pressuring feeding 27m→ WLZ 33m b17 0.037 0.028
WLZ 21 m→ Pressuring feeding 27m b18 0.016 -0.018
WLZ 27m→ Pressuring feeding 33m b19 -0.025 -0.030
Pressuring feeding 21m→Picky eating 27m b20 0.089 0.040
Pressuring feeding 27m→ Picky eating 33m b21 0.094 0.089
Picky eating 21m→Pressuring feeding 27m b22 0.030 0.003
Picky eating 27m→ Pressuring feeding 33m b23 0.055 -0.016
WLZ 21m→Picky eating 27m b24 0.033 -0.027
WLZ 27m→ Picky eating 33m b25 0.029 0.023
Picky eating 21m→ WLZ 27m b26 0.016 -0.066
Picky eating 27m→ WLZ 33m b27 -0.080 -0.055
* p<.05; ppp= posterior predictive p-values, m=months
 DISCUSSION

There were several main findings. First, child weight-for-length z-score, maternal self-

report of pressuring her child to eat, and mother-reported child picky eating tracked across

toddlerhood. Although there was evidence for concurrent associations between maternal report

of pressuring feeding and maternal report of child picky eating, there was no evidence to support

prospective associations between pressuring feeding and future WLZ; WLZ and future

pressuring feeding; pressuring feeding and future picky eating; picky eating and future

pressuring feeding; or picky eating and future WLZ.

Consistent with prior reports, pressuring feeding (Afonso et al., 2016; Faith et al., 2004;

Gregory et al., 2010; Webber et al., 2010), picky eating (Gregory et al., 2010; Marchi & Cohen,

1990; Mascola, Bryson, & Agras, 2010), and WLZ (Nader et al., 2006) tracked within

individuals across childhood. We found that mothers who self-reported using pressuring feeding

practices also rated their children concurrently as pickier eaters, consistent with prior literature

examining these associations concurrently (Carper et al., 2000; Carruth et al., 1998; Farrow et

al., 2009; Ventura & Birch, 2008; Wardle et al., 2005). These studies used a range of measures

of pressuring feeding and picky eating, with just one using CEBQ and IFSQ as we did (Farrow et

al., 2009). The cohorts in prior studies were primarily white and middle income and all from the

US or UK (Carper et al., 2000; Carruth et al., 1998; Farrow et al., 2009; Wardle et al., 2005), in

contrast to our cohort which was entirely low-income and with greater racial/ethnic diversity.

Prior cohorts had sample sizes similar to ours, ranging from fewer than 200 (Carper et al., 2000;

Carruth et al., 1998; Farrow et al., 2009), to one study with 564 participants (Wardle et al., 2005).

The ages of children in the prior studies were entirely between 2-6 years (Carper et al., 2000;
Carruth et al., 1998; Farrow et al., 2009), and our cohort was therefore slightly younger. In

summary, among cohorts from the US and UK, who are primarily white and middle-income in

the preschool age range, mothers (and in one case the children themselves (Carper et al., 2000))

report across a range of measures the co-occurrence of maternal pressuring feeding and child

picky eating. Our findings confirm and extend this observation to a slightly younger age range

and slightly more racially and ethnically diverse cohort. Future research might consider

examining this association in more diverse populations and at older ages.

We did not find concurrent associations between pressuring feeding and WLZ. These

findings differ from the primarily inverse associations found in 11 of 13 cross-sectional studies

among children ages 4 to 12 years in one recent review (Shloim et al., 2015). Our findings may

have differed from those in this review given that the children in our cohort were younger. In

other studies of toddlers, there have also been null concurrent associations between pressuring

feeding and child WLZ (Blissett & Farrow, 2007; Lumeng et al., 2012). In addition, as described

elsewhere (Lumeng et al., 2012), associations between pressuring feeding and WLZ are more

likely to be null when the measures of pressuring feeding are less controlling or intrusive, as may

have been the case in our study. A different measure of pressuring feeding that captured more

assertive feeding practices may have found different associations with WLZ.

We found no evidence for a prospective relationship between pressuring feeding and

future growth, consistent with all prior studies that have examined this question (Faith et al.,

2004; Gregory et al., 2010; Lumeng et al., 2012; Webber et al., 2010). Specifically, a prior study

in a relatively large US cohort that was primarily white and middle-income also found no

prospective association between pressuring feeding at age 15 months and weight gain to 36

months (Lumeng et al., 2012). Among a primarily white cohort of 57 children, there was no
cross-lagged correlation between pressuring feeding at age 5 years and body mass index at age 7

years (Myles S. Faith et al., 2004). Similarly, among a primarily white cohort of 2- to 4- year old

children in Australia, there was no prospective association between pressuring feeding and body

mass index one year later (Gregory et al., 2010). Likewise, among 7- to 9- year old children in

the UK, there was no prospective association between pressuring feeding and child body mass

index 3 years later (Webber et al., 2010). Our study replicates these null prospective findings in

a relatively diverse cohort of low-income US toddlers. Overall, the pattern of results in our study

as well as prior work suggests that pressuring feeding is unlikely to be a pathway to altering a

child’s growth, particularly for low-income toddlers. Specifically, altering the growth trajectory

of low-income toddlers (whether to reduce or increase that trajectory) may require other

strategies besides addressing maternal pressuring feeding.

We also did not find concurrent associations between picky eating and WLZ, consistent

with the primarily null associations in cross-sectional studies described in a recent review

(Brown, Schaaf, Cohen, Irby, & Skelton, 2016). We also found no evidence to support the

hypothesis that picky eating causes either increased or decreased rates of growth, using two

different measures of picky eating, which is also consistent with the primarily null findings of

longitudinal studies in a recent review (Brown et al., 2016).

Although parents are often cautioned against pressuring their children to eat on the

premise that pressuring the child could further increase pickiness, we found no evidence to

support a prospective relationship. This aligns with findings in a primarily white cohort of 156

2- to 4- year old children in Australia; pressuring feeding was not associated with greater food

fussiness one year later when baseline food fussiness was controlled (Gregory et al., 2010). A

prior study among 7 to 9 year old girls found a prospective association between pressuring and
picky eating 2 years later (Galloway et al., 2005); however, this study did not control for baseline

picky eating, which could explain the discrepancy with other studies. In addition, it is possible

that pressuring feeding prospectively predicts increases in pickiness in school age, but not

toddler and preschool-aged children. Overall, the research to date suggests that pressuring

feeding in toddler- and preschool-aged children has little impact on changing picky eating, at

least over a period of one year. Future studies in other age groups and over longer follow up

periods may further clarify any potential association between pressuring feeding and picky

eating.

Limitations

There are several limitations to this study. The longitudinal design is a strength, but due

to the high-risk nature of the study cohort, attrition was high and there were missing data. Results

may not be generalizable to other study populations outside low-income toddlers in the United

States. There is debate in the field regarding how to best measure the construct of picky eating

(Brown et al., 2016), and our measures included some variety of reluctance to eat both new foods

(food neophobia) and familiar foods (picky eating). Despite these limitations, the study was able

to test pathways in common theoretical frameworks in a very young age group longitudinally in

a diverse population at a low socioeconomic level.

Conclusion

We found that maternal pressuring feeding, child picky eating, and weight-for-length z-

score tracked over a year during early childhood. Although pressuring feeding and picky eating

were concurrently associated, we found no prospective associations between pressuring feeding,

child picky eating, and weight-for-length z-score.

 There are several areas for future work. First, our measure of pressuring feeding has

substantial overlap with how pressuring feeding is measured in a range of questionnaire

measures, but compared to some other measures, did not focus as strongly on more intrusive

pressuring feeding strategies (i.e., age inappropriate spoon feeding, bribery, punishment, etc). It

is possible that findings may differ with alternative definitions of pressuring feeding, and this

possibility should be explored. Secondly, the findings may differ among different subgroups,

such as children with different weight status at baseline, or from different racial/ethnic or

socioeconomic groups. Future work should test these associations in different subgroups. Third,

future work should consider examining these associations in even younger age groups, during

bottle feeding and the transition to solid foods, using longitudinal designs. Finally, additional

studies that examine pressuring feeding, picky eating, and child growth longitudinally and

employ cross-lagged analyses in large sample sizes with power to detect small but clinically

significant effects will be important.

In summary, our results call into question the value of attempts to alter maternal

pressuring feeding as a strategy to alter children’s picky eating or growth. Although parents are

interested in how to reduce picky eating, and providers are enthusiastic about reducing parental

pressure to eat, there is little evidence that intervening upon these behaviors impacts growth

trajectories. Additional work is needed to identify effective strategies that target salient

behaviors.
APPENDIX.

Pressure to Finish Subscale Items, IFSQ

2. It’s important that an infant finish all of the milk in his or her bottle
12. It’s very important that a toddler finish all the food that is on his or her plate
37. I try to get (name of child) to eat even if s/he seems not hungry
38. If (name of child) will not try a new food that I give him/her, I will work hard to have
him/her try it during that meal
43. I praise (name of child) after each bite to encourage him/her to finish his/her food
45. I try to get (name of child) to finish his/her food
47. If (name of child) seems full, I encourage him/her to finish his/her food anyway
51. I try to get (name of child) to finish his/her milk

Food Fussiness Subscale Items from CEBQ-T

8. My child refuses new foods at first.
15. My child enjoys a wide variety of foods REVERSED.
20. My child enjoys tasting new food REVERSED.
24. My child is difficult to please with meals.
25. My child decides that s/he doesn’t like food even without tasting it.
29. My child is interested in tasting food s/he hasn’t tasted before REVERSED.

Food Refusal and Limited Variety Items from BAMBI

1. My child cries or screams during mealtimes
2. My child turns his/her face or body away from food
4. My child expels (spits out) food that he/she has eaten
7. My child is disruptive during mealtimes (pushing/throwing utensils, food)
8. My child closes his/her mouth tightly when food is presented
10. My child is willing to try new foods- REVERSED
11. My child dislikes certain foods and won’t eat them
13. My child prefers the same foods at each meal
14. My child prefers crunchy foods (e.g. snacks, crackers)
15. My child accepts or prefers a variety of foods- REVERSED
16. My child prefers to have food served in a particular way
17. My child prefers only sweet foods (e.g. candy, sugary cereals)
18. My child prefers food prepared in a particular way (e.g. fried foods, cold cereals, raw
vegetables)
 ACKNOWLEDGEMENTS

Author Contributions: JCL, KR, and ALM designed research; JCL, KR and ALM conducted

research; DA and NK analyzed data; JCL wrote the paper; JCL had primary responsibility for

final content. All authors read and approved the final manuscript.

Conflicts of Interest: The authors have no conflicts of interest to disclose.

Sources of Support: R01HD069179

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