Image credit: Adobe Stock

Case

You are seeing 8-yo Caleb in your primary care practice. He is brought to you by his parents due to problems with his eating. “Every mealtime is a struggle. All he wants to eat is chicken nuggets! You have to do something!”

How Common is “Picky Eating”?

Prevalence: About 25-40% of parents report feeding problems in their infants and toddlers (Reauy, 1996.)  

What Causes Picky Eating?

There are various issues that can contribute such as 

Assessment / History  

Behavioural
 

Medical

Differential Diagnosis of Picky vs. Problem Eating

Investigations

• CBC, Hemoglobin, 
• Serum ferritin, iron
• Vitamin A  
• Vitamin D (25- OH) Note that although Vitamin D is recommended by certain guidelines, testing is may be discouraged by certain provincial Ministries of Health. 
• Folate 
• Vitamin B12. 
• Calcium, zinc 
• Thyroid function 
• Celiac testing

Management / Treatment of Children

Nutritional supplements and vitamins

Studies confirm that picky eaters generally still get enough macronutrients (e.g. protein, carbohydrates, fats), but that they may struggle to get enough micronutrients (e.g. vitamin, zinc, calcium) (Taylor, 2016). 

Supplements 

• Omega-3s 
• Pediatric nutritional supplements 
• Infant cereal (for increased iron intake) 
• Stage 2 formulas (6-18 months) 
• Fer-N-Sol (if low iron levels and prescribed by doctor) 
• Children’s complete multivitamin (with iron and without) 
• Boost Juice 

Multivitamins 

• Aim for a children’s complete multivitamin with iron, calcium, vitamin D 

Address underlying developmental, medical and/or behavioural contributors

In general, underlying issues need to be managed before a child can be expected to change their eating behaviour and accept new foods and beverages.

Address underlying developmental, medical and/or behavioural contributors

Parent Education about Picky / Problem Eating 

• Try to make changes gradually 
• Try to make only 1 change at a time. 

• Do have consistent mealtime routines
• Ensure family meals
  • Eat meals at a table as a family, in the kitchen or dining room if possible. 
  • Limit distractions to encourage your child to use all of his/her senses to experiment with new food. I.e. no watching TV, no electronics at the table. 
  • Thank your child for good mealtime behaviours, e.g. trying new foods, etc.
  • Be a good role model for your child by eating the same healthy foods. Human beings are wired to imitate each other. 
  • Ensure appropriate food portions for children, i.e. portion size for children is ¼ to ½ of an adult portion.
  • Remove unfinished food within 20 to 30 minutes of serving 
• Encourage fluid intake.
  • Age 2 years: 2% milk
  • Ideally 2 cups of milk at meals; (less than) ½ cup of juice (may be diluted with water); 2 to 3 cups of water per day. If milk is not a favorite beverage, consider adding it to fruit or yogurt smoothies. 
• Food chaining.

  • Place a non-preferred food next to the child’s preferred food to change the appearance of their meal. Having a favorite food on her plate will help attract his/her attention to her plate. Remember it can take up to 20 positive exposures to a food before a child accepts to eat it.

  • For more information (http://www.cheo.on.ca/en/Foodchaining) 

• Between meals

  • ​Limit meal and snack times. Offer 3 meals and 2 snacks per day. There should be two hours between each meal and snack with nothing in between (except water) to ensure that your child is hungry.

  • Food play. Allow your child to explore new foods, such as ‘food play activities’. Give your child a chance to see, touch and smell a variety of foods. There should be no expectation of eating during the times set aside for food play. It can take up to 15 or more positive food experiences for a child to accept a new food.

• Do try to stimulate the various senses:

• Help unpack vegetables/fruits and place them in a bowl or sort them by color, etc
• Bring your child grocery shopping and encourage them to feel the fresh produce
• Have your child help serve the food; build a rainbow of colours on the dinner plates
• Find books and games with pictures of food and introduce them to your child
• Describe the color, taste and shape of a food
• Encourage your child to participate in meal preparation, children love to stir!

• Have your child help arrange cut vegetables or fruits on a plate
• Have your child wash fruits and vegetables in the sink
• Ask your child to add fruit to a fruit smoothie
• Use raw or cooked foods during craft activities:
• Spaghetti can become a road for cars, or hair for a happy face
• Cucumber slices can become wheels for a car or eyes for a happy face
• Bread or carrot sticks can be used to make a fence
• An orange slice can become a sun
• Finger paint with pudding or pureed food, and make Jell-O gigglers
• Use peas, cherry tomatoes, orange slices, crackers or other food for a counting or stacking activities
• A potato or other firm fruit can be used to make a stencil
• Dried fruits can be used to make a walking path
• A cucumber can be used as a rolling pin
• Rub foods on hands, arms and progress to cheeks and mouth area. As child builds acceptance to touch, you can rub tastes along the lips and encourage your child to lick the food.

• Expose your child to a variety of scents (vanilla, lemon, spices) and discuss whether they like/do not like that smell. Make a graph with pictures of “Nice Smells” vs. “Not-so-Nice Smells”.

Hear

• Game: What noise does this food make?
• Exaggerate the sounds of biting, chewing, and swallowing.

• Don’t reward eating foods, e.g. don’t reward with screen time, don’t reward with dessert, etc. You might say that “After we finish eating, then it will be time for ____”. As opposed to saying, “If you eat ___, then you will get ___.” 
• Don’t allow other food unless it’s a planned mealtime or snacktime, i.e. don’t graze constantly throughout the day. 

Advice for Parents of Teens

• I will plan and prepare meals.
• I will include a food or two at each meal that you generally eat. This way, you can decide whether and how much you will eat of the foods I have included in the meal. 
• I will expect you to show up for dinner on time and hungry. Comments? Criticisms?” 

Prevention of Picky Eating

• Cruciferous vegetables (cauliflower, cabbage, garden cress, bok choy, broccoli, Brussels sprouts)
• Spicy cuisine
• Fermented foods (e.g. kimchi)


• At  4-6-months, when starting to introduce solid foods to the baby, include pureed vegetables, iron-fortified cereals and meats first  and then offer fruits. 

• At age 8-mos. to 10-mos., most babies can handle small portions of finely chopped finger foods, such as soft fruits, vegetables, pasta, cheese, well-cooked meat, baby crackers and dry cereal. Include foods that are bitter, spiced or have interesting flavors; eventually, introduce different texturess

When and Where to Refer 

• Picky/problem eating at any time

If YES then  → Dietitian.