Picky Eating
Julie Lumeng
I. Description of the problem. Picky eating occurs on a continuum and there is no clear cutoff for when it becomes problematic. Parental perception that their child’s unwillingness to eat familiar foods or sample new foods is outside the range of normal is probably the major reason for seeking medical advice. Therefore, the best definition of picky eating incorporates parental concern: an unwillingness to eat familiar foods or try new foods, severe enough to interfere with daily routines to an extent that is problematic to the parent, child, or parent-child relationship.
A. Epidemiology.
Although prevalence is hard to pin down because there is no strict definition, normative data tell us that about 36% of toddlers are described as “picky eaters.” In addition, 54% are not always hungry at mealtime, 33% do not seem to enjoy mealtimes, 34% have strong food preferences, 26% frequently refuse to eat, 21% request specific foods and then refuse them, and 42% try to end a meal after a few bites. Nearly two-thirds of parents report one or more problems in eating with their toddler.
Children who are picky eaters more often have negative temperamental traits and are more often behaviorally inhibited (shy) and anxious. Their parents report more difficulties in the parent-child relationship.
The most commonly rejected foods are vegetables, and picky eaters have lower dietary variety, but no significant difference in overall nutrient intake.
Picky eating in childhood has been associated with higher socioeconomic status, fewer children in the family, and being thinner. Having been breastfed and having a mother who eats more fruits and vegetables have been linked with being less picky. Being picky has not been associated with race, gender, having medical problems, food allergies, or maternal age. Picky eating is linked with more behavior problems in general but not eating disorders in particular.
The prevalence of picky eating increases over infancy and toddlerhood, from 19% at 4-6 months of age to 50% at 19-24 of age months. There is significant continuity in pickiness during this age range. Pickiness seems to continue to increase to 3 years of age, but thereafter seems to decline to about 20% by 8 years of age. If children are still described as picky after about 8-9 years of age, they are likely to be picky for the rest of their lives.
There seems to be a critical period during which children will expand the repertoire of liked foods in their diet that closes around 4 years of age. After 4 years of age, parents continue to introduce new foods, but the number of new foods children try that they learn to like does not continue to increase in the same way it did before 4 years of age.
B. Evolutionary framework. Picky eating seems to increase as children gain mobility. Some theorize that children are “wired” for pickiness to protect them from eating potentially poisonous substances in the environment. Children who are inherently reluctant to eat an unfamiliar food, or to eat a variety of foods, will not “wander into the bush and eat a poison berry.”
C. Etiology.
People reject foods because they (1) dislike the sensory characteristics (flavor and appearance); (2) have a fear of negative consequences (e.g., it causes stomach upset upon eating); or (3) are disgusted by the food (due to contamination or the thought of where it came from), which does not begin until 7-8 years of age.
Pickiness runs in families: about two-thirds of the variability in pickiness is explained by genetics. However, “nurture” (child caregiving practices) can modify “nature.”
II. Making the diagnosis.
A. History: key clinical questions.
1. “Tell me which foods she won’t eat.” A pattern of refusal, such as only refusing milk products or certain textures, raises the question of food allergies/intolerances or oral hypersensitivity.
2. “Tell me what she ate yesterday, starting with breakfast.” A diet history can give a flavor to how picky the child is and opens a discussion about what foods are presented to the child, how, and what is done when the child rejects them.
3. “What do you do when she rejects a food at dinner? What sort of rules do you have in your house around eating?” Obtaining a history that the child is required to remain at the table until his plate is clean, or that the child is coerced to eat a particular food, is important. Neither of these methods has been shown to result in a long-term improvement in picky eating, and both likely simply add stress and negativity to the family mealtime.
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