What Picky Eaters Really Don’t Eat?

Patient Presentation
A 2-year-old female came to clinic for her health supervision visit.
Her mother was concerned that over the past 2 months, she had started to refuse to eat many of the regular table foods that were eaten by the family. Specifically she was now refusing to eat anything that had a sauce or dressing on it including pasta, tacos, mashed potatoes with gravy, and even jelly on toast. She sometimes would eat it if it was presented “on the side” of the plate separate from the other foods. Her mother said that more often now she seemed to have one favorite food for a few days and then abruptly refused to eat it when served. Her mother said she was concerned about her not eating very much and so she would make her other preferred foods and would let her eat whenever she wanted to during the day. Her mother asked about any vitamins she could give her to help her appetite. The mother denied any emesis, diarrhea, loose stools, or obvious weight loss. “She’s never been very big, but she looks skinnier to me,” her mother said. Developmentally she was saying 1-3 word sentences, would scribble on the chalkboard in the room, would use a spoon and cup, and could run and jump. She got along well with her 3.5 year old brother and other children in her daycare class. The past medical history was non-contributory. The family history was negative for any gastrointestinal diseases. There was some generalized anxiety in the mother and other maternal relatives. The review of systems was otherwise negative.

The pertinent physical exam revealed a well-appearing female. Her weight was 10.6 kg (10% for age) which was only 200 grams up from her 18 month visit (= 10.4 kg, 25%). Her length was 82.5 cm (25%) and her head circumference was 47 cm (25-50%). The rest of her physical examination was normal.

The diagnosis of a healthy child with picky eating habits and declining weight percentiles was made. The pediatrician recommended that the child be offered 3 meals and 2-3 snacks during the day. Each meal should have at least 2 hours between the meals. The meals were to be served with the child sitting down to eat with appropriate plates, cups and utensils for the meal, trying to keep the meal a quiet and pleasant social time between the child and other family members. “Even if you are out and about, you can all sit down and enjoy a snack for a short time together,” he noted. He recommended that the child be offered the meal and then 1/2 way through the meal offer any beverage so the child wouldn’t fill up on only the liquid. “A serving should be the size of her palm or fist. She doesn’t need a lot, so don’t try to give her too much because then she might be overwhelmed with too much food on her plate,” he mentioned. “I also recommend using a big plate because then the food amount looks small. Just like anyone wants some choices in their foods, she can have them too but there are limits. Generally I recommend 2 choices for a snack. She can be offered the same meal that the rest of the family is having. If after 10-15 minutes she hasn’t eaten her meal, then you can just put it away. The food doesn’t come out again until the next meal or snacktime. Then you can re-serve the previous meal’s food if it is appropriate,” he also recommended. “I want to see her back in about a month to recheck on her weight and see how you all are doing”

The patient’s clinical course at one month showed her weight to be 10.95 kg (10-25%). Her mother reported that they had stopped letting her eat between her meals but weren’t always good about not offering her several choices of food when she refused to eat. They also weren’t as good about sitting down to eat a meal and her mother would feed her while in the car or stroller many times too. The pediatrician praised the mother for starting to make some changes and having appropriate weight gain over the month. He reiterated that she would learn healthy eating practices from the mother, and re-recommended taking a break to sit down for a meal and fewer food choices. During a sick visit ~10 weeks later, the child’s weight was now 11.5 kg (10-25%) and tracking. The mother said that they still didn’t sit down for all the meals but did for more than before, plus the child only got two choices for a snack. “Sometimes I still let her have a sandwich at dinner instead of what we are having,” she confided.

Picky eating does not have one definition and is a broad term. In general, picky eaters are described as limiting the amount and types of food, and a refusal to eat novel foods.

Normal healthy children often will reject different types of food they have accepted before in their second year of life. They tend to place more value on food properties such as the color or texture. Feeding problems occur in 25-45% of normally developing children and in up to 80% of developmentally delayed children. Most of the problems are acute issues and resolve within a short time with reasonable guidance and interventions. Most children have resolution of picky eating behaviors by 6 years of age.

Parents and other caregivers can become quite stressed about the picky eating. They worry about the child’s health, as potentially picky eating can cause poor nutrition or the child to become underweight. They also are worried about behavioral or emotional problems such as tantrums, aggression, being oppositional, depression, anxiety and social withdrawal. Studies have been mixed regarding being a picky eater as a child and correlation with eating disorders as an adolescent or adult. Risk factors such as having unpleasant meals or conflicts around meals/eating, food avoidance, and eating slowly which do occur for some picky eaters, are the same risk factors for eating disorders.

Though most picky eaters will have resolution quite quickly, others will last longer but resolve within 1-2 years. Still others will be persistently picky with > 3 years duration of picky eating behaviors. One study was able to identify children who were more likely to be persistently picky eaters (>3 year duration) using a questionnaire with 3 key questions: “Is your child a picky eater? (Yes), does s/he have strong likes with regard to food? (Yes), and does your child accept new foods readily? (No)”

Learning Point
Using data from the 2008 Feeding Infants and Toddler’s Study of children up to 48 months, researchers in 2016 reported that picky eaters ate:

  • Lower amount of meats/protein including eggs
  • Lower amount of vegetables especially raw vegetables
  • Lower calories when eating mixed dishes (i.e. casserole, burrito, etc.)
  • Less of certain food textures such as mushy or slimy or highly textured requiring more chewing. Texture resistance was highly correlated with picky eating.

Fruit, grain, milk or other beverages, and sweet intake was not different for picky or non-picky eaters. Bitter taste also was not different between the groups. Other studies have also shown picky eaters tend to consume less fat.

Questions for Further Discussion
1. What recommendations do you offer to caretakers of picky eating toddlers?
2. What are your criteria for further medical or psychological evaluation or treatment for picky eaters?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Toddler Nutrition and Child Nutrition.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Toyama H, Agras WS. A test to identify persistent picky eaters. Eat Behav. 2016 Jul 15;23:66-69.

Machado BC, Dias P, Lima VS, Campos J, Gonçalves S. Prevalence and correlates of picky eating in preschool-aged children: A population-based study. Eat Behav. 2016 Aug;22:16-21.

van der Horst K, Deming DM, Lesniauskas R, Carr BT, Reidy KC. Picky eating: Associations with child eating characteristics and food intake. Appetite. 2016 Aug 1;103:286-93.

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital