Parents of selective eaters will tell you there’s more going on at their table than just developmentally typical “picky eating.” Looking forward to mealtimes is as foreign to these parents as enjoying a paper cut dipped in rubbing alcohol. Mealtimes are emotionally painful, full of anxiety and distress that is not helped by rewards, bribes, or other means of coercion. There’s none of this “hiding the veggies in the spaghetti sauce” going on here – if spaghetti sauce is even on the menu – and if it is, attempting to sneak another food under the cover of marinara is a sure fire way to add yet another food to the list of things that won’t be eaten. Parents know they need help, and many approach their primary healthcare provider for guidance and support, only to be sent on their way with a dismissive, “don’t worry.” Lack of medical support is somewhat of an axiom among parents in the selective eating community.
This axiom inspired a questionnaire that asked parents to describe their experience when discussing their concerns about their child’s eating with their primary healthcare provider. 481 surveys were returned, and 22% (n=106) indicated the parent did not seek support from their primary healthcare provider. The questionnaire did not ask any more questions of participants who didn’t seek support from a doctor because the survey sought to gather information from parents who did. We might speculate that parents who didn’t seek support from their family physician were already receiving adequate support from another source. There may be other reasons; another survey may offer more insight.
Responses that indicated the parent did discuss concerns about their child’s eating with their family doctor (78%, n=375) were asked more questions about this interaction. Forty-nine surveys were returned incomplete and twenty-six surveys answered questions with “N/A”. Another ten responses created a very small and unique subgroup of parents who did not observe signs of food refusal until age 6-11 years. The remaining 290 surveys reported parent observed onset of feeding difficulty between birth and 5 years of age.
Responses indicated a variety of physical and neurological diagnoses that are not uncommon among children who struggle with food acceptance. Responses were categorized into four groups: sensory, executive functioning, medical, and no diagnosis. The sensory group (n=61) captured responses that may be consistent with the diagnostic criteria for ARFID, insofar that “the eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder.” (DSM-5, 2013) This group included responses that indicated a diagnosis of ARFID, behavioural feeding disorder, developmental feeding disorder, specific food phobia, selective eating disorder, and picky eating where the same respondent did not indicate a concurrent medical condition or mental disorder that may better explain the eating disturbance.
The executive function group (n=71) included responses which indicated a diagnosis of ADHD, autism spectrum disorder, and sensory processing disorder. The medical group (n=75) included responses which indicated a physical or medical barrier to eating, ranging in severity from mild to life-threatening, including allergy, anaphylaxis, oral motor delay, swallowing disorder, and various disorders of the esophagus, stomach and intestinal tract.
The no-diagnosis group (n=83) had not received any medical or psychological explanation for the eating disturbance.
As a purposive sample, the following results have limitations. Because those who completed the survey are assumed to have an interest in expressing an opinion on this subject, this sample may over or under represent subgroups in this population. Still, the responses from this observational pilot study offer a parent perspective of pediatric feeding difficulties that is not currently available in the literature, and offers insight for primary care providers to better understand the needs of the families who approach them for support with children who struggle with eating.
The mean (average) age of the child at parent observed onset of the feeding difficulty for all groups was 1.392 years (s = 1.075). Parents of children with medical diagnoses (1.129; s=1.014) and the sensory group (1.229; s=1.016) tended to notice problems with eating earlier than the mean for all groups, and children in the executive functioning (1.531; s=1.115) and no diagnosis group (1.629; s=1.048) tended to be older.
At the first discussion between the parent and the primary healthcare provider to discuss eating concerns, the mean age of the child for all groups was 2.156 (s=1.643). Again the mean age was lower than all groups combined for the medical and sensory groups (1.629; s=1.445 and 2.033; s=1.507 respectively) and higher for the EF and no diagnosis groups (2.24; s=1.441 and 2.653; s=1.916 respectively).
The difference between the mean age of parent observed onset and the mean age at the first discussion with the primary healthcare suggests parents who perceive their child is struggling with physical eating barriers wait the least amount of time to seek medical support (0.5 years), while children who struggle with food acceptance due to its sensory characteristics struggle with eating for longer periods of time (0.804 years for the sensory group and 1.024 years for the no diagnosis group). Results suggest the executive function group struggled for 0.709 years before seeking healthcare provider support.
The medical group was least likely to be told the child “will grow out of it” or “will eat when s/he gets hungry” (49.33%). The sensory (81.97%), executive function (77.46%), and no diagnosis (80.72%) groups heard their primary care physician utter this phrase most often. The sensory (26.23%), executive function (28.17%) and no diagnosis (27.71%) groups reported the parent perceived that the doctor took their concern about the child’s eating seriously, compared to the medical group (48%).
The most common parental concern in all groups with the child’s eating was not trying new food (67.59%, n=196). Compared to the percentages reported from all groups, not trying new foods was reported more frequently in the sensory (70.49%, n=43) and no diagnosis groups (75.9%, n=63). The sensory group also showed more parental concern with progressing with more challenging textures (45.9%, n=28), gagging (44.26%, n=27), choking (9.84%, n=6), brand specificity (27.87%, n=17), and a diet limited to less than 10 foods (57.38%, n=35). Concerns in the medical group showed more parental concern with not eating enough food (38.67%, n=29), difficulty progressing with textures (49.33%, n=37), vomiting after most meals (16%, n=12), choking (17.33%, n=13), and pain after eating (16%, n=12). Responses in the executive function group indicated more concern with brand specificity (21.13%, n=15) and a diet limited to less than 10 foods (46.48%, n=33). In addition to not trying new foods, responses from the no diagnosis group had more concerns with not eating enough food (38.55%, n=32), and a diet limited to more than 10 but less than 20 foods (34.94%, n=29).
The medical group was more likely to be very confident (9.33%, n=7) and somewhat confident (28.0%, n=21) in their family doctor’s knowledge of pediatric feeding struggles compared to all groups (4.83%, n=14; and 22.41%, n=65 respectively). The executive function group reported feeling not very confident (54.93%, n=39 ), and the sensory group reported feeling disappointed (42.62%, n=26) with their family doctor’s knowledge of pediatric feeding difficulties compared to all groups (40%, n=116; 32.07%, n=93).
Using the percentages of all groups as a baseline reference, the executive function and no diagnosis group were more likely to report nothing had been helpful for their child (16.9% vs 25.35%, n=18; 19.28%, n=16 respectively). The sensory group was more likely to turn to the Internet for support (8.28% vs 9.84%, n=6), while the no diagnosis group was more likely to seek support from other parents in online forums (11.03% vs 19.28%, n=16). The medical group indicated the most helpful support for the child was a feeding therapist (RD, OT, SLP) (41.33%, n=31) or a medical specialist (17.33%, n=13) compared to all groups (26.9% and 10% respectively). No pressure, family meals based on a division of responsibility was indicated as the most helpful support for the child in the sensory (36.07%, n=22), executive function (28.17%, n=20), and no diagnosis groups (28.92%, n=24) compared to all groups (26.9%).
Parents in the no diagnosis group were more likely to indicate they had found nothing (10.69% vs. 14.46%, n=12) or turned to the Internet (12.07% vs. 18.07%, n=15) for self support. Parents in the executive function and medical group were more likely to feel supported by a medical specialist (8.45%, n=6; 12.0%, n=9) and feeding therapist (16.9%, n=12; 28.0%, n=21) more than all groups (7.24% and 16.55% respectively). The sensory and medical groups were most likely to find self support from other parents online (29.51%, n=18; 28.0%, n=21 respectively). The executive function and no diagnosis groups indicated the support parents found most helpful support for themselves was no pressure family meals (33.8%, n=24 and 31.33%, n=26) compared to all groups (27.93%).
A chi-square test for association was performed to examine the relation between the parent’s confidence in the physician’s knowledge of feeding difficulties and the parent’s perception of their concerns being taken seriously. The relation between these variables was significant, (X2 (3, N = 288) = 102.718, p<0.001). Parents who felt their their concerns had been taken seriously were more likely to be somewhat confident in their physician’s knowledge of feeding difficulties.
A Fisher’s exact test showed parents who felt their primary healthcare provider had taken their concerns seriously were more likely to feel well supported to cope with the challenges faced with feeding. (X2 (1, n = 290) = 9.894, p = 0.002)
Childhood feeding struggles are common, and impacted by a variety of genetic, medical, environmental, behavioural, and parental factors. (Phalen, 2013 Dec) (Budd, et al., 1992). In the years between infancy and toddlerhood, children learn a great deal about food and eating (Aldridge, Dovey, Martin, & Meyer, 2010 Sep) (Rommel, et al., 2003). When feeding doesn’t appear to be going well, many parents turn to their child’s physician for advice on how to treat childhood food refusal behaviours (Linscheid, Budd, & Rasnake, 2003).
Responses from this sample indicated parents attempt to remedy feeding difficulties on their own, struggling without support for six months to a year or longer before seeking medical advice. Parents of children with non-organic food refusal tend to wait longer than those experiencing organic feeding issues before approaching their family physician for advice. The results of this paper are consistent with other research that shows parents who struggle with mealtimes are frequently not provided with the necessary support to foster effective feeding practices. (Gallagher & Vietze, 1986). Lack of support combined with stressful mealtimes promotes dysfunctional feeding patterns that can include forced feeding, excessively prolonged feeding at mealtimes, conditional distraction, and feeding persecution. (Levy, et al., 2009)(Manikam & Perman, 2000) (Mascola, Bryson, & Agras, 2010)
Often, parents who approach their family physician with concerns about their child’s picky eating are experiencing food refusal “beyond what is considered typical” (Kerzner, 2009). Dismissing parental concerns exacerbates the existing worry parents are already experiencing that makes approaching their primary healthcare provider necessary, and denies the child access to available systems of support. Feeding struggles strain the parent-child relationship; lack of support may contribute to high levels of parental anxiety, and put the child’s physical and psychological health at risk. (Davies, et al., 2006) It may help general practitioners to provide better support to the parents they counsel around feeding to understand that medical advice in this area is often sought out of desperation, and not as a mild parenting concern.
Concern about children’s lack of willingness to try new foods was most frequently reported by parents in all groups. Parents believe that their feeding practices can exert a major influence on children’s food preferences (Burroughs & Terry, 1992), although research indicates this influence “is not necessarily in the ways that parents intend.” (Johnson & Birch, 1994) Problems with emotional regulation, and sensory processing, combined with excessive parental anxiety, and authoritarian feeding practices can contribute to the development of feeding problems in early childhood (Arts-Rodas & Benoit, 1998) (Lyons-Ruth, Zeanah, & Benoit, 1996). Consistent with these data, other research has observed parents of younger children (6 months to 4 years) are often most concerned with limited dietary intake, and not trying new foods, and may be overly concerned about nutrition, weight, or psychosocial development (Benjasuwantep, Chaithirayanon, & Eiamudomkan, 2013).
The pervasive messages promoting nutrition as a means to improve health and appearance can contribute to a tendentious eating environment. The emphasis on promoting healthy eating in early childhood puts added focus on the consumption and avoidance of certain foods, and undermines the instinctive preferences and aversions that influence food acceptance in children (Birch & Fisher, 1998)(Beesdo, Knappe, & Pine, 2009)(Dovey, Staples, Gibson, & Halford, 2008). As a result, parents are encouraged to manipulate their child’s food selection to achieve “nutritionally desirable dietary outcomes,” (Birch & Fisher, 1998) and children are expected to unconditionally comply. This expectation in response to difficult eating behaviour is strongly associated with lowering the child’s enjoyment of eating (Thaner, et al., 2014 ) and contributes to decreased food acceptance in children (Mascola, Bryson, & Agras, 2010). The evidence base on childhood eating behaviour consistently cautions against stressing nutritional excellence over the development of eating skill (Birch & Fisher, 1998) (Scaglioni, Salvioni, & Galimberti, 2008) (Brown & Ogden, 2004) Emphasis on nutritional excellence may contribute to an unhealthy psychosocial dynamic within the home feeding environment, and has great potential to influence a long-lasting, unhealthy relationship with food and eating in children. (Sadeh-Sharvit, 2015)
While picky eating in young children is considered a developmentally normal trait, some children persist with strong likes and dislikes for food into adolescence and adulthood. (Wildes, Zucker, & Marcus, 2012) Children expressing extreme food refusal (neophobic, selective, fussy) tend to eat small meals, eat slowly, be less interested in food, have limited dietary variety, strong food preferences, require food to be prepared in a specific way, have an unwillingness to try new foods, have a limited intake of vegetables, and are more likely to have tantrums when parents limit food. (Dubois, et al., 2007)(Mascola, Bryson, & Agras, 2010).
Previous literature has cautioned the medical community to examine more than the child’s responsibility in feeding issues “so as not to create iatrogenic feeding disorders”(Manikam & Perman, 2000). Kerzner provided a guide for pediatricians to evaluate feeding difficulties in young children. He suggested taking the child’s history and utilizing anthropometric measurements and physical examination in order to identify red flags or markers for underlying pathology of feeding difficulties. Kerzner also recommended obtaining additional details of feeding practices, problematic behaviors, and parent-child feeding interaction as necessary (Kerzner, 2009).
Attempts to convince parents that their child will “grow out of” a feeding difficulty may only serve to reduce parent confidence in the physician who makes no effort to understand how the child “grew into” a fierce distrust of novel foods. Parents who felt their family doctor had taken their concerns seriously tended to have a more favourable view of the physician’s knowledge of feeding difficulties, and improved the parent’s sense of feeling supported with their child’s feeding difficulties. Responses from this sample described family meals based on Satter’s division of responsibility (Satter, 2007) as the support that was most helpful for both the child and the parent for non-organic food refusal. Family meals have been shown to improve nutritional intake, psychosocial development, and improve enjoyment of eating (Neumark-Sztainer, et al., 2003). Eating enjoyment has been shown to decrease problems associated with picky eating. (Mustonen, Oerlemans, & Tuorila, 2012). The family physician, without the burden of learning another discipline in addition to medicine, is already ideally situated to reduce parental stress by providing existing resources for evidence-based feeding support and guidance, while determining the most appropriate response to any underlying pathology that may impede eating ability in children.
This study was completed without financial compensation, and was conducted entirely for the reason that I had a question and the answer required that I “do my research.” Mealtime Hostage is grateful for the participation of parents who responded to the survey, and to K. Rowell, J. McGlothlin, I. Anchondo, and C. Lutter who patiently tolerated my many questions.
Aldridge, V., Dovey, T., Martin, C., & Meyer, C. (2010 Sep). Identifying clinically relevant feeding problems and disorders. J Child Health Care. , 14(3):261-70.
Arts-Rodas, D., & Benoit, D. (1998 Jan-Feb). Feeding problems in infancy and early childhood: Identification and management. Paediatr Child Health. , 3(1): 21–27. PMC2851259.
Benjasuwantep, B., Chaithirayanon, S., & Eiamudomkan, M. (2013 Jun ). Feeding Problems in Healthy Young Children: Prevalence, Related Factors and Feeding Practices. Pediatr Rep. , 5(2): 38–42. doi: 10.4081/pr.2013.e10.
Beesdo, K., Knappe, S., & Pine, D. (2009 Sep). Anxiety and Anxiety Disorders in Children and Adolescents: Developmental Issues and Implications for DSM-V. Psychiatr Clin North Am , 32(3): 483–524.
Birch, L., & Fisher, J. (1998). Development of Eating Behaviours Among Children and Adolescents. American Academy of Pediatrics , pp. 539-547.
Brown, R., & Ogden, J. (2004). Children’s eating attitudes and behaviour: a study of the modelling and control theories of parental influence. Health education research, 19(3), 261-271.
Budd, K., McGraw, T., Farbisz, R., Murphy, T., Hawkins, D., & Heilman, N. e. (1992). Psychosocial concomitants of children’s feeding disorders. Journal of Pediatric Psychology , 17:81-94.
Burroughs, M., & Terry, R. (1992). Parents’ perspectives toward their children’s eating behavior. Top Clin Nutr. , 8:45–52.
Davies, W. H., Satter, E., Berlin, K. S., Sato, A. F., Silverman, A. H., Fischer, E. A., … & Rudolph, C. D. (2006). Reconceptualizing feeding and feeding disorders in interpersonal context: the case for a relational disorder. Journal of Family Psychology, 20(3), 409-41
Dovey, T., Staples, P., Gibson, E., & Halford, J. (2008). Food neophobia and ‘picky/fussy’ eating in children: a review. Appetite , 50(2-3):181-93. Epub 2007 Sep 29.
DSM-5. (2013). American Psychiatric Association. Diagnostic and statistical manual of mental disorders. DSM-5, 5th-ed. , American Psychiatric Association, Arlington, VA.
Dubois, L., Farmer, A., Girard, M., Peterson, K., & Tatone-Tokuda, F. (2007 Apr). Problem eating behaviours related to social factors and body weight in preschool children: A longitudinal study. International Journal of Behavioural Nutrition and Physical Activity.
Gallagher, J., & Vietze, P. (. (1986). Families of handicapped persons: Current research, programs, and policy issues. In P. Brookes. Baltimore.
Johnson, S., & Birch, L. (1994). Parents’ and children’s adiposity and eating style. Pediatrics , 94:653–661.
Kerzner, B. (2009 Nov). Clinical investigation of feeding difficulties in young children: a practical approach. Clin Pediatr (Phila). , 48(9):960-5. doi: 10.1177/0009922809336074.
Levy, Y., Levy, A., Zangen, T., Kornfeld, L., Dalal, I., Samuel, E., et al. (2009). Diagnostic Clues for Identification of Nonorganic vs Organic Causes of Food Refusal and Poor Feeding. Journal of Pediatric Gastroenterology & Nutrition , v48, i3:355-362.
Linscheid, T. R., Budd, K. S., & Rasnake, L. K. (2003). Pediatric Feeding Problems.
Lyons-Ruth, K., Zeanah, C., & Benoit, D. (1996). Disorder and risk for disorder during infancy and toddlerhood. In B. R. In Mash EJ, Child Psychopathology (pp. 457-91). New York: Guilford Press.
Manikam, R., & Perman, J. (2000 Jan). Pediatric Feeding Disorders. Journal of Clinical Gastroenterology: , Volume 30 – Issue 1 – pp 34-46.
Mascola, A. J., Bryson, S. W., & Agras, S. (2010 Dec). Picky eating during childhood: A longitudinal study to age 11 years. Eating Behaviour , Vol 11, Issue 4: pp 253-257.
Mustonen, S., Oerlemans, P., & Tuorila, H. (2012 Jun). Familiarity with and affective responses to foods in 8-11-year-old children. The role of food neophobia and parental education. Appetite , 58(3):777-80. doi: 10.1016/j.appet.2012.01.027. Epub 2012 Feb 2.
Neumark-Sztainer, D., Hannan, P. J., Story, M., Croll, J., & Perry, C. (2003). Family meal patterns: associations with sociodemographic characteristics and improved dietary intake among adolescents. Journal of the american dietetic association, 103(3), 317-322.
Phalen, J. (2013 Dec). Managing Feeding Problems and Feeding Disorders. Pediatrics in Review , Vol 34, No 12;.
Rommel, N., De Meyer, A., Feenstra, L., & Veereman‐Wauters, G. (2003 July). The Complexity of Feeding Problems in 700 Infants and Young Children Presenting to a Tertiary Care Institution. Jornal of Pediatric Gastroenterology & Nutrition , Vol 37, Iss 1:p 75-84.
Satter, E. (2007). Eating Competence: Definition and Evidence for the. J Nutr Educ Behav. , pp. 39:S142-S153.
Sadeh-Sharvit, S., Levy-Shiff, R., Feldman, T., Ram, A., Gur, E., Zubery, E., … & Lock, J. D. (2015). Child feeding perceptions among mothers with eating disorders. Appetite, 95, 67-73.
Thaner, A., Jansen, P., Kiefte-de Jong, J., Moll, H., van der Ende, J., Jaddoe, V., et al. (2014 ). Toward an operative diagnosis of fussy/picky eating: a latent profile approach in a population-based cohort. International Journal of Behavioural Nutrition and Physical Activity , 11:14.
Scaglioni, S., Salvioni, M., & Galimberti, C. (2008). Influence of parental attitudes in the development of children eating behaviour. British Journal of Nutrition, 99(S1), S22-S25.
Wildes, J., Zucker, N., & Marcus, M. (2012). Picky Eating in Adults: Results of a Web-Based Survey. Int J Eat Disord , 45:575–582.
@Mealtime Hostage, 2017. All Rights Reserved.