![Relationships between child characteristics and maternal perception of child as a fussy eater at 14 months, and use of feeding practices at 2 years (n = 279). For ease of reading figure, error terms associated with variables or measurement component of FPSQ-28 are not shown. WAZ: Weight-for-age z-score using WHO Standards [55]. How often does your child refuse food? Very often, often, sometimes, hardly ever. Does your child ever refuse food they usually eat? Hardly ever, yes. How willing is your child to eat unfamiliar foods? Very willing, willing, neutral, unwilling, very unwilling. Child decides amount of food eaten. Mother only, mostly mother, mother and child equally, mostly child, child only](https://www.researchgate.net/publication/319639695/figure/fig2/AS:963515351330839@1606731369244/Relationships-between-child-characteristics-and-maternal-perception-of-child-as-a-fussy_Q320.jpg)
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R E S E A R C H Open Access
Perceived fussy eating in Australian
children at 14 months of age and
subsequent use of maternal feeding
practices at 2 years
Rebecca Byrne
1*
, Elena Jansen
1
and Lynne Daniels
2
Abstract
Background: Concerns about fussy eating are common amongst parents of young children. However, studies of
the long-term impact of fussy eating show mixed results with regard to adequacy of dietary intake and child
growth. This may be in part because there is no accepted definition of fussy eating and studies measure the
construct in different ways, commonly relying on parent perception. This longitudinal analysis explores maternal
and child characteristics associated with maternal perception of her toddler as a fussy eater in early toddlerhood
and subsequent use of feeding practices at 2 years.
Methods: Mothers completed a self-administered questionnaire at child age 14 months, describing perception of
their child as fussy/not fussy and child behaviour. Intake was assessed using a single 24-h recall and weight was
measured by research staff. At child age 2 years mothers completed the validated 28-item Feeding Practices and
Structure Questionnaire (FPSQ-28).
Weight-for-age z-score (WAZ) was derived from WHO standards. Gram daily intake of fruit, vegetables and meat/
alternative and a dietary diversity score were determined. Maternal/child characteristics independently associated
(p≤0.05) with perception of child as a fussy eater were determined using logistic regression. Variables were
combined in a structural equation model assessing the longitudinal relationship between child/maternal
characteristics, perception of child as a fussy eater and eight FPSQ factors.
Results: Mothers’(n= 330) perception of her child as a fussy eater at age 14 months, was associated with higher
frequency of food refusal and lower WAZ (R
2
= 0.41) but not dietary intake. Maternal perception as fussy (age
14 months) was associated with four FPSQ factors at 2 years (n= 279) - Reward for Eating, Reward for Behaviour,
Persuasive Feeding and Overt Restriction, x
2
/df = 1.42, TLI = 0.95, CFI = 0.95, RMSEA = 0.04(0.03–0.05), PCLOSE = 0.99.
Conclusions: Lower relative child weight and food refusal prompted mothers to perceive their child as fussy. These
behaviours in healthy weight children most likely reflect self-regulation of energy intake and neophobia. This
perception was prospectively associated with use of non-responsive feeding practices, which may increase obesity risk.
Future interventions could directly address perceptions of growth and fussiness, supporting parents to understand
food refusal as developmentally appropriate behaviour in healthy young children.
Trial registration: ACTRN12608000056392. Registered 29 January 2008.
Keywords: Dietary intake, Food refusal, Fussy eating, Maternal feeding practices, Maternal perception, Obesity,
Overweight, Picky eating, Structural equation modelling, Toddlers
* Correspondence: ra.byrne@qut.edu.au
1
Centre for Children’s Health Research, School of Exercise and Nutrition
Sciences, Queensland University of Technology, 62 Graham St, South
Brisbane, QLD 4101, Australia
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Byrne et al. International Journal of Behavioral Nutrition and Physical Activity
(2017) 14:123
DOI 10.1186/s12966-017-0582-z
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Anecdotally, parents have a strong desire to raise a child
who is a ‘good eater’and children are routinely praised for
‘eating all the food on their plate’[1]. Concerns about
fussy eating and underweight are common amongst
parents in developed countries [2, 3] with fussy (or picky)
eating reported to occur in 25–40% of toddlers [3]. This is
in stark contrast to public health priorities which over-
whelmingly relate to consumption of too much food and
prevalence of childhood obesity [4]. The relationship be-
tween fussy eating and child outcomes, such as adequacy
of dietary intake and growth trajectory is unclear [5–10].
This is perhaps because the construct of fussy eating is
measured in a myriad of different ways [11].
From a theoretical perspective, fussy eating is defined
as the rejection of a substantial amount of familiar and
unfamiliar foods, potentially resulting in limited dietary
variety and food intake [12, 13] However, studies rarely
use objective measure of dietary intake (most likely be-
cause of the complexity and labour-intensive nature of
this type of data collection) and instead rely on parent
report/perception of fussiness [3, 10, 14, 15]. However, it
is important to explicitly examine the criteria that par-
ents use to label their child as a fussy eater. Parents,
health professionals and researchers may not necessarily
define fussy eating in the same way [16] and hence inter-
pret study-specific questions such as ‘is your child a
fussy/picky eater’[5, 7] quite differently. Perception may
also differ between mothers, fathers and non-parental
carers. Children could be labelled as fussy because they
do not consume the type and/or amount of food per-
ceived as appropriate [17] and parents may differ in the
type, frequency and extent of behaviours they consider
to be problematic. The Food Fussiness (FF) scale of the
Child Eating Behaviour Questionnaire (CEBQ) [18] is
frequently used to characterise fussiness according to
child behaviour, with five items related to food refusal,
tasting new foods and enjoying variety. In a cross-
sectional analysis of 3-year-old twin children (n= 1330
pairs) from the Gemini cohort in the United Kingdom,
FF was inversely correlated with liking of both fruit and
vegetables [19] but we are unaware of any examination
of the relationship with food intake amongst toddlers.
Our underlying premise is that a mother pieces together
information (consciously or not) about her child’sbehav-
iour, physical appearance and amount/type of dietary in-
take, which inform her perception and her subsequent
feeding practices. Non-responsive feeding practices are ac-
tions which a parent employs during feeding which may
interfere with a child’s ability to recognise and attend to in-
ternal hunger and satiety cues and increase obesity risk [20,
21]. Examples of these practices include pressuring a child
to eat more than they want to, and using food as a reward
to encourage eating or to encourage desired behaviour. In
another analysis of the Gemini cohort, this time of when
the twins were 16-month-old (n= 2026) [22], between-
family analyses indicated that ‘pressure to eat’and ‘instru-
mental feeding’i.e. using food to encourage healthy food
consumption/good behaviour were positively associated
with Food Fussiness on CEBQ [23]. An analysis of a subset
of 274 Gemini twin pairs that were most discordant on
food fussiness, found that mothers used more ‘pressure to
eat’and ‘instrumental feeding’with the twin perceived as
fussier. Similarly a cross-sectional survey of 413 parents of
Australian children aged 1–10 years found that ‘persuasive
feeding’and ‘reward for eating’(constructs which corres-
pond to ‘pressure to eat’and ‘instrumental feeding’respect-
ively) were both positively associated with Food Fussiness
on CEBQ [23]. Overall, there is evidence that parent per-
ception of fussiness is, at least cross-sectionally, associated
with non-responsive feeding practices which may in turn
be counterproductive in our obesogenic environment and
contribute to obesity risk.
The aims of this analysis were to 1. Identify what mater-
nal and child characteristics –demographics, behaviour,
measured dietary intake - were associated with maternal
perception of her child as a fussy eater in early toddlerhood
(12–16 months), and 2. Explore the prospective relation-
ship between child/maternal characteristics and maternal
perception of child as a fussy eater at 12–16 months, with
maternal feeding practices at age 2 years.
Methods
Design and participants
This is a secondary analysis of data from mother-child
dyads who participated in the control group of NOURISH,
a randomised controlled trial that evaluated an interven-
tion promoting positive feeding practices in very young
children [24], and an additional sample of mothers re-
cruited for the South Australian Infants Dietary Intake
(SAIDI) Study [25]. SAIDI participants were recruited
simultaneously and using the same protocol as NOUR-
ISH. Recruitment has been described in detail [24, 26].
Briefly, a consecutive sample of mothers (aged ≥18 years)
delivering healthy term infants (≥37 weeks gestation and
birthweight ≥2500 g) at maternity hospitals in Brisbane,
Queensland (n= 3) and metropolitan (n= 5) and regional
(n= 7) South Australia were approached within 72 h post-
delivery. Eligible mothers were asked to provide consent
to be contacted when infants were 4- to 7-months-of-age,
for full enrolment in the study. Approval was gained from
a total of 11 human research ethics committees including
Queensland University of Technology and Flinders
University (QUT HREC 00171 Protocol 0700000752).
Measurements
Maternal and child demographic data were collected
during initial recruitment in hospital including gender,
Byrne et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:123 Page 2 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
maternal age at birth of child (years), and maternal
university education.
Participants attended study-specific outcome assess-
ment clinics when children were 12–16 months of age
(June 2009 to June 2010). Child weight was measured by
trained staff using a standard protocol. Weight was mea-
sured twice, lying or sitting on electronic infant scales with
no nappy or clothes (except a singlet), to the nearest 10 g.
A third measurement was taken if the first two differed by
more than 50 g. In regional areas, participants were mea-
sured at their local child health or general practitioner
clinic. Mothers completed a self-administered question-
naire containing five questions regarding fussy eating and
child behaviour (Table 1).
Within two weeks of this assessment, child dietary intake
was assessed via telephone by a dietitian using a single
three-pass 24-h recall [27]. Recalls were collected on week
days and weekends. The mother was asked to recall every-
thing her child ate or drank in the previous 24 h, starting
from midnight on the previous day, with quantities esti-
matedusinghouseholdmeasures (metric cup, tablespoon
and teaspoon). A visual aide designed to improve estima-
tion, which showed actual size illustrations of these mea-
sures, was provided at assessment. Items from the recall
were entered into FoodWorks Professional version 9 using
the AUSNUT 2007 database from the 2007 Australian Na-
tional Children’s Nutrition and Physical Activity Survey
[28]. An additional database containing commercial infant
products was created by study staff. Mixed dishes prepared
at home were added to FoodWorks as a recipe or if there
were ≤three ingredients, entered into FoodWorks as separ-
ate items. A study-wide data checking protocol meant that
any children with very high or very low estimates of energy
intake - <3000kj or >6000kj had their FoodWorks file
checked against the original recall, to correct any possible
errors. Food recall data were exported from FoodWorks
into an Access database and merged with an eight digit
food group code which allows identification of each unique
food [29]. Study staff allocated additional eight digit codes
to infant foods and mixed dishes/recipes with codes
allocated based on the predominant ingredient. A compre-
hensive analysis of dietary intake data for this cohort has
been published elsewhere [27].
When the child was aged 2 years, mother-child dyads
attended a second assessment at which time mothers com-
pleted another questionnaire containing 28 items of the Feed-
ing Practices and Structure Questionnaire (FPSQ-28) [30]
and an item regarding Family Meal Setting (Additional file 1).
Derived variables
Weight-for-age z-scores were derived from measured
weight using WHO standards [30] and all data was
exported into SPSS 22.0 for analysis.
Maternal perception of child as a fussy eater at 12–16 months
and child behaviour
Responses to the question ‘Do you think your child is a
picky or fussy eater?’were dichotomised to form the variable
‘perception of child as a fussy eater’:fussy /not fussy as per
themethodologyofCarruthetal.[5](Table1).Table1also
shows the four questionnaire items chosen to characterise
child behaviour regarding refusal of familiar and unfamiliar
food.
Dietary intake
Intake (grams/day) of three food groups were derived based
on their unique eight digit food group code –i. fruit
(excluding 100% fruit juice), ii. vegetables (including beans
and lentils) and iii. Meat/alternatives (including fish,
poultry, and eggs). Australian and international studies in-
dicate that dairy and cereal groups contribute the highest
proportion of daily energy intake amongst young children
with these food groups tending to be consumed in excess
of dietary recommendations [27, 31, 32]. The most recent
representative study of Australian children aged 2–3 years
indicated 95% consumed dairy and 97% cereals, with each
Table 1 Items on self-administered questionnaire at child age 12–16 months used to characterise maternal perception of fussy
eating and child behaviour
Question Response Dichotomised variable used in regression model
Maternal perception of her child as a fussy eater:
Do you think your child
is a picky or fussy eater?
Very picky, Somewhat picky, Not picky, Not sure Fussy (very picky,somewhat picky combined),
Not fussy (not picky,not sure combined)
Child behaviour:
How often does your child
refuse food?
Very often, Often, Sometimes, Hardly ever Often (Very often, Often), Not often
(Sometimes, Hardly ever)
Does your child ever refuse
food they usually eat?
Hardly ever, Yes
How willing is your child to
eat unfamiliar foods?
Very willing, Willing, Neutral, Unwilling, Very unwilling Willing (Very willing, Willing), Not willing
(Neutral, Unwilling, Very unwilling)
Who decides how much food
your child eats –you or your child?
You only, Mostly you, You and your child equally,
Mostly your child, Your child only
Mother (You only, Mostly you, You and your child equally),
Child (Mostly your child, Your child only)
Byrne et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:123 Page 3 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
food group contributing 21% and 27% of daily estimated
energy intake, respectively [31]. Therefore they were not
considered an ‘at risk’food groups requiring further investi-
gation in this analysis.
A dietary diversity score was calculated for each child i.e.
number food groups consumed on 24-h recall with a poten-
tial score of 0–9 [33] (vitamin A-rich fruits and vegetables
[34], other fruit; other vegetables; legumes and nuts; meat,
poultry and fish; breads, cereals, roots and tubers; eggs;
dairy/alternatives; fats and oils). Australia’sseconddietary
guideline states that by 12 months of age children should
“enjoy a wide variety of nutritious foods…each day”[35].
Analyses
Bivariate analyses were conducted using independent t-
test or Mann-Whitney test for continuous variables and
Pearson’s chi-squared test for categorical variables to de-
termine differences between children perceived as fussy
or not fussy for thirteen independent variables that de-
scribed maternal and child demographics; child food re-
fusal and dietary intake. Variables with a significant
bivariate association (p≤0.05) with perceived fussiness
were entered into a logistic regression model to deter-
mine characteristics independently associated with per-
ception of child as a fussy eater (dependant variable),
with results expressed as odds ratios and 95% CI. Using
Mplus (v7.4), these variables were combined in a struc-
tural equation model with maternal perception of child
as a fussy eater and 28 items of the FPSQ-28 [30] and
the additional single item measuring family meal setting
(Additional file 1). The weighted least squares estimator
(WLSMV) was used to determine standardised regres-
sion weights for the pathways in the model since items
were treated as ordinal categorical variables [36]. Model
fit was determined using normed chi-square (x
2
/df),
Tucker-Lewis index (TLI), comparative fit index (CFI)
and root mean square error of approximation (RMSEA)
with 90% CI and probability (PCLOSE).
Results
Characteristics of mother-child dyads completing an as-
sessment at age 12–16 months (n= 330) are shown in
Table 2. Notably, no children were underweight [30].
Thirty-one percent of mothers defined their child as a
fussy eater - not fussy, n= 232; fussy, n=98(‘very picky’
n=10and‘somewhat picky’n= 88 combined). Bivariate
analyses comparing children perceived as ‘fussy’versus ‘not
fussy’revealed group differences for nine (highlighted by
italics) of the 13 variables considered: maternal age, mater-
nal education,child age,gender,WAZ, fruit intake, vegetable
intake, meat/alt intake; diversity; child decides amount of
food eaten; how willing is your child to eat unfamiliar foods?;
how often does your child refuse food?;anddoes your child
ever refuse food they usually eat? (additional file 2). However,
only five variables remained significantly associated with ma-
ternal perception in the adjusted cross sectional analysis
(Table 3): weight-for-age z-score and the four measures of
child behaviour. Mothers’perception of her child as a fussy
eater was associated with higher frequency of refusal of
familiar and unfamiliar food, the child choosing amount
eaten and lower WAZ; but not intake of fruit, vegetables,
meat or dietary diversity; x
2
(9) = 109.36, p<0.001,−2Log
likelihood = 287.56, R
2
=0.41(Nagelkerke).
Longitudinal data was available for 279 mother-child
dyads. The model showing the relationship between child
variables, maternal perception and the FPSQ-28 is shown in
Fig. 1 and was a good fit, x
2
/df = 1.42, TLI = 0.95, CFI = 0.95,
RMSEA = 0.04 (0.03–0.05), PLCOSE = 0.99. Maternal per-
ception of her child as a fussy eater at age 12–16 months
was directly associated with four factors of the FPSQ-28 at
2 years - Reward for Eating (β=0.34,p< 0.001), Reward for
Behaviour (β= 0.27, p< 0.01), Persuasive Feeding (β=0.37,
p< 0.001), and Overt Restriction (β=0.31,p< 0.001). The
relationships between WAZ, child decides amount of food
eaten, or does your child ever refuse food they usually eat
and maternal perception were no longer significant.
Discussion
In everyday lexicon young children tend to be categorised
as either a ‘good’eater or a ‘fussy’eater. Amongst this
sample of healthy children, a third were perceived as fussy
and this perception was associated with maternal feeding
practices that may be counterproductive in our obeso-
genic environment.
The finding that approximately 30% of mothers perceived
their child as a fussy eater is consistent with published
prevalence data [5, 37], and the analysis identified factors
that explain 40% of the variance in maternal perception.
However, instead of aligning with the theoretical definition
of fussy eating which is largely focussed on limited intake -
there was no difference in the amount of fruit, vegetables
or meat/alternatives eaten, or dietary diversity, between
thosechildrenperceivedasfussyandthosethatwerenot-
perception was related to child behaviour not food intake.
This supports previous qualitative analysis indicating “par-
ents believe that picky eating is not only defined by the food
the child eats, but also by the child's overall behaviours and
attitudes toward mealtimes”[38].
The relevant behaviours - child refused food often or un-
willing to eat unfamiliar foods –do support the definition
of fussy eating as the rejection of both novel and familiar
foods [12]. However, these behaviours could also be indica-
tive of normal toddler development i.e. self-regulation of
energy intake (refusal of familiar foods), neophobia (refusal
of unfamiliar foods) and emerging autonomy [39]. Rate of
growth in toddlers slows in comparison to infancy [40] with
a relative decline in energy requirements, which may result
in refusal of familiar foods in response to intrinsic cues of
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satiety. Food neophobia, the rejection of foods that are
novel or unfamiliar, also increases markedly at this age [12].
This heritable trait [41, 42] is thought to play a protective
function, discouraging children from ingesting toxic
substances as they become more mobile [43]. The age
group 12–16 months coincides with the development of
autonomy and independence [39] and meal times are
perhaps one of the few areas that toddlers can exert their
growing autonomy –by refusing to eat when they are not
hungry. It is unknown whether mothers distinguish be-
tween (and respond differently to) refusal of familiar versus
unfamiliar foods.
Kerzner et al. [44], in their ‘Pyramidal Representation of
Young Children’sFeedingBehaviors’identify four child
behaviour categories –normal, misperceived feeding prob-
lems, milder feeding difficulties and feeding disorders. Their
paper urges clinicians to take parent concerns seriously,
even if misperceived, given the potential for parents in re-
sponse to these concerns to “adopt inappropriate feeding
practices”.Thisisconsistentwithourfindings.Wepostu-
lated that a mother pieces together information about her
toddler which informs (consciously or unconsciously) her
perception and subsequent feeding responses/practices. In
our study, the child who refused familiar and unfamiliar
food more frequently was perceived as a fussy eater at age
12–16 months, which was associated with use of non-
responsive maternal feeding practices at 2 years. These in-
cluded specific practices such as using favourite foods in
Table 2 Characteristics of mothers and toddlers (N= 330)
Characteristic Mean (SD) n (%)
Child age (months) 13.8 (1.3)
Birthweight (kg) 3.5 (0.4)
Weight-for-age z-score
a
at 12–16 months of age 0.58 (0.86) Range: −1.6 to 2.9
Male gender 165 (49)
Maternal age at birth of child (years) 30.3 (5.0)
Maternal university education 193 (58)
Family income
b
≥70,001 $AUD 199 (60)
Child Dietary intake Median (IQR)
Fruit intake (g) on 24-h recall
c
118 (60–192)
Vegetable intake (g) on 24-h recall
c
80 (21–152)
Meat/alternatives intake (g) on 24-h recall
c
49 (15–108)
Dietary diversity score
d
6(5–7)
a
Weight-for-age z-score calculated using WHO Anthro (2008); 92% weight measured vs 8% self-reported based on measure with GP/nurse in rural areas
b
n = 321; Median Australian gross income, 2008 - all household types = 67,000 $AUD [56]
c
Intake on single 24-h recall of whole sample; Fruit: fresh, canned, dried, cooked, infant food or mixed dish where fruit is the predominant ingredient; Vegetables:
fresh, canned, cooked, beans and lentils, infant food or mixed dish where vegetable is the predominant ingredient; Meat/alternatives: fish, poultry, beef, lamb,
pork, game meats, egg, nuts and seeds, infant food or mixed dish where meat/alternative is the predominant ingredient
d
Diversity score from 0 to 9 representing number of different food groups (vitamin A-rich fruits and vegetables; other fruit; other vegetables; legumes and nuts;
meat, poultry and fish; breads, cereals, roots and tubers; eggs; dairy/alternatives; fats and oils) consumed on 24-h recall
Table 3 Variables independently associated with maternal perception of child as a fussy eater (N = 330)
Independent variables Dependant variable: perception of child as a fussy eater
(not fussy
a
, n = 232; fussy, n = 98); OR (95% CI)
Child weight-for-age z-score 0.69 (0.48–0.99)*
Child age (months) 1.17 (0.92–1.48)
Maternal university education; yes, n= 191 1.58 (0.85–2.96)
Fruit intake (g) on 24-h recall
b
0.99 (0.99–1.00)
Vegetable intake (g) on 24-h recall
b
0.99 (0.99–1.00)
Who decides amount of food eaten; child, n= 144 1.94 (1.07–3.51)*
How willing is your child to eat unfamiliar foods?; unwilling, n= 76 4.52 (2.33–8.75)***
How often does your child refuse food?; often, n= 47 6.12 (2.62–14.30)***
Does your child ever refuse food they usually eat?; yes, n= 158 2.31 (1.23–4.34)*
*p≤0.05; ***p≤0.001, x
2
(9) = 109.36, p< 0.001, −2 Log likelihood = 287.56, 0.41 (Nagelkerke)
Mean(sd) child age 13.8 (1.3) months; 49% male; WAZ using WHO standards [55]
a
Referent group
b
Intake on single 24-h recall of whole sample; Fruit: fresh, canned, dried, cooked, infant food or mixed dish where fruit is the predominant ingredient; Vegetables:
fresh, canned, cooked, beans and lentils, infant food or mixed dish where vegetable is the predominant ingredient
Byrne et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:123 Page 5 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
exchange for good behaviour or offering children food
when they are upset (Reward for behaviour), and insisting
children eat food despite not being hungry or showing dis-
approval when a child does not eat (Persuasive feeding). All
of these practices may prompt a child to eat for reasons
other than hunger and may interfere with self-regulatory
ability [43, 45, 46]. In a longitudinal study of 222 Australian
children, food fussiness at age two years (measured within a
‘food approach’constructusingitemsfromtheCEBQ)was
correlated with use of instrumental feeding practices i.e. use
of food as a reward, a year later [47]. Our findings also sup-
port the suggestion of Walton et al. that labelling a child as
fussymaycontributetosub-optimal feeding interactions
and endorse their call to reconceptualise fussy/picky eating
i.e. resistance during eating can be considered children’s
agency in communicating eating preferences instead of
deviant behaviour [48].
The finding that maternal perception of fussy eating was
not associated with objectively assessed dietary intake in
the NOURISH/SAIDI sample highlights the importance
of accurately assessing the child variables informing ma-
ternal perception. Perception of fussiness defined accord-
ing to actual inadequate dietary intake, might prompt use
of different feeding practices than those identified in this
analysis. This research could also be extended by consider-
ing whether particular feeding practices have differential
outcomes. For example is persuasive feeding associated
with adverse growth trajectory? Does offering preferred
foods effectively reduce exposure to a wide range of foods,
resulting in a narrow range of food preferences in later life
[49, 50]? Understanding different ‘types’of fussy eating,
differential feeding practices employed in response to
these, and subsequent effects on a range of child eating
behaviour, dietary intake and growth outcomes may facili-
tate the development of targeted interventions to address
the unique needs of parent-child dyads at each stage in
this continuum. Use of non-responsive practices could be
reduced by explicitly designing interventions to assist
mothers (and other carers) to understand developmentally
appropriate eating behaviour.
Limitations of the current analysis include not measur-
ing and adjusting for feeding practices used at 12–
16 months. When NOURISH and SAIDI were designed,
there were no tools validated to measure feeding practices
at both 12–16 months and 2 years. The FPSQ-28 is vali-
dated for use at 2 years, but not yet at younger ages. The
relationship between dietary variety and maternal percep-
tion was not assessed. While use of a single 24-h recall is
valid for group level estimates of food intake [51] and a
simple measure of diversity [33, 52], it is not suitable to
assess micronutrient intake. It is also not appropriate to
assess dietary variety, which may also inform a mother’s
0.09 0.06
0.31***
-0.15
0.37***
0.27**
0.34***
-0.07
0.18
-0.04
-0.38***
0.12
0.39***
Refuse food
usually eat?
Will... eat un-
familiar foods
Fit indices:
x2/df=1.42, TLI=0.95, CFI=0.95
RMSEA=0.04 (90% CI=0.03-0.05), PLCOSE=0.99
*pp p≤0.001
How often
refuse food?
WAZ
Maternal
perception of child
as a fussy eater at
14 months
Structured
meal
setting
Family meal setting
Reward for
eating
Covert
restriction
Structured
meal
timing
Overt
restriction
Persuasive
feeding
Reward for
behaviour
Child decides
amount eaten
Fig. 1 Relationships between child characteristics and maternal perception of child as a fussy eater at 14 months, and use of feeding practices at
2 years (n= 279). For ease of reading figure, error terms associated with variables or measurement component of FPSQ-28 are not shown. WAZ:
Weight-for-age z-score using WHO Standards [55]. How often does your child refuse food? Very often, often, sometimes, hardly ever. Does your
child ever refuse food they usually eat? Hardly ever, yes. How willing is your child to eat unfamiliar foods? Very willing, willing, neutral, unwilling,
very unwilling. Child decides amount of food eaten. Mother only, mostly mother, mother and child equally, mostly child, child only
Byrne et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:123 Page 6 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
perception of her child as fussy. Also, the premise that
child behaviour informs maternal perception is limited by
using maternal report of child behaviour. If a mother is
concerned or frustrated about a child refusing food, then
it is possible she could systematically overestimate the fre-
quency of this behaviour [53]. This bias would strengthen
the positive statistical relationship between frequency of
food refusal and perception of fussiness, but highlights
that a mother’s perception of her child may be more influ-
ential in determining what she does, than the child’sactual
intake or behaviour. The analysis may have been strength-
ened by comparing variables of interest across children
perceived as ‘very picky’versus ‘somewhat picky’versus
‘not picky’however given only 3% (n=10)ofthetotal
sample were characterised as ‘very picky’there is inad-
equate power to investigate differences between these
groups. The analyses reported here do not enable consid-
eration of important questions related to potential pro-
spective impact of maternal feeding practices on child
weight outcomes and hence the hypothesised role of feed-
ing practices as a mediator of reported associations be-
tween fussy eating and child weight. During an additional
analysis that added child WAZ at 2 years to the model, fit
became unacceptable (data not shown) and hence no con-
clusions could be drawn.
The sample comprised first-time mothers who were
slightly older with a higher level of education compared to
the Australian average [54] and hence generalisability is un-
clear. It is unknown whether the prevalence of perceived
fussy eating differs according to socioeconomic status (SES)
and it is feasible that the characteristics which mothers use
to inform their perception vary according to SES. The
contribution of fathers to feeding and family life generally is
acknowledged, but was outside the scope of this study.
Strength of this study lies in the use of SEM to simul-
taneously assess the relationship between child character-
istics, maternal perception and maternal feeding practices.
Many studies rely on parent report only, to investigate the
relationship between the ‘fussy child’and maternal prac-
tice. However, this analysis was able to take into account
multiple factors mothers used to inform their perception,
delineating between refusal of familiar and unfamiliar
foods and objective measures of dietary intake and weight.
Conclusion
Overall, there was no difference in food intake between
children perceived as fussy versus not. Mothers appear
to be interpreting developmentally appropriate feeding
behaviour as fussiness in the leaner but healthy weight
child. Importantly, this perception of typical child eating
behaviour as fussiness was prospectively associated with
use of non-responsive feeding practices, which may
teach children to eat in response to cues other than hun-
ger or satiety, disrupting self-regulation of energy intake
and increasing obesity risk. Interventions to modify feed-
ing practices should support parents and clinicians to in-
terpret food refusal as normal behaviour in healthy young
children and directly address perceptions of healthy child
growth and developmentally appropriate behaviour.
Additional files
Additional file 1: Factors and corresponding items of the Feeding
Practices and Structure Questionnaire (FPSQ-28) with an additional item
measuring family meal setting. (DOCX 16 kb)
Additional file 2: Results of bivariate analysis comparing children
perceived as ‘fussy’versus ‘not fussy’. (DOCX 15 kb)
Abbreviations
FPSQ: Feeding Practices and Structure Questionnaire,; SEM: Structural Equation
Modelling; WAZ: weight-for-age z-score; WHO: World Health Organisation
Acknowledgements
The authors thank the families participating in NOURISH and SAIDI and our
research team in Brisbane and Adelaide.
Funding
NOURISH was funded 2008–2010 by the Australian National Health and
Medical Research Council (grant 426,704). Additional funding was provided
by HJ Heinz, Meat & Livestock Australia (MLA), Food Standards Australia New
Zealand (FSANZ), and Queensland University of Technology.
Availability of data and materials
Daniels, Lynne; Byrne, Rebecca; Margarey, Anthea; Battistutta, Diana; Nicholson, Jan
M; Thorpe, Karen; Naughton, Geraldine; Bayer, Jordana; Farrell, Ann; Davidson,
Geoffrey; Cleghorn, Geoffrey. (2017): NOURISH dataset. [Queensland University of
Technology]. http://researchdatafinder.qut.edu.au/individual/n34249.
Authors’contributions
LD conceptualised and led the NOURISH study. RB and EJ participated in
data collection. RB conceptualised and conducted this data analysis and
drafted this manuscript, while EJ completed the analysis in Mplus. All authors
were involved in writing the paper and had final approval of the submitted
and published versions.
Ethics approval and consent to participate
Approval was gained from a total of 11 human research ethics committees
including Queensland University of Technology and Flinders University (QUT
HREC 00171 Protocol 0700000752).
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Centre for Children’s Health Research, School of Exercise and Nutrition
Sciences, Queensland University of Technology, 62 Graham St, South
Brisbane, QLD 4101, Australia.
2
School of Exercise and Nutrition Sciences,
Queensland University of Technology, Kelvin Grove, QLD 4069, Australia.
Byrne et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:123 Page 7 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Received: 22 February 2017 Accepted: 5 September 2017
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