Time to reconsider feeding difficulties in healthy children: a narrative synthesis of definitions and associated factors

Abstract

Despite the lack of a “gold-standard” definition and identification of influential factors for identifying feeding difficulties in children, many international studies have been published in recent years on the subject. Thus, the aim was to examine studies on children with feeding difficulties and their associated factors that impact on their difficulties. Feeding difficulties were identified as limit the variety of food intake, and/or avoiding food due to sensory stimulus, i.e., food appearance, aroma, and flavor. A literature search in three databases was performed up to April 2021. English language articles were included if they investigated preschool and school age children using an observational or experimental design evaluating feeding difficulties and their factors. Findings indicate that almost 60% of the studies evaluated picky/fussy eaters, followed by 20% evaluating food neophobia. Parental influence, mainly mothers, were seemed to be the most reported influence. Studies have shown a lower consumption of fruit and vegetables and higher intake of discretionary foods among picky and food neophobic children. Most of the studies showed that children were on normal weight to overweight status. Few studies identified socio-demographics (i.e., age, sex, race/ethnicity, and birth age), emotional distress and other lifestyle behaviors (screen-time use during meals). Studies were mixed in terms of positive effects on breastfeeding and introduction to foods. Improved feeding difficulties in this population group are dependent from these factors, whereas they should be used to inform policies, strategies, and use in clinical practices.

Full text

Vol.:(0123456789)
1 3
https://doi.org/10.1186/s41110-021-00151-7
REVIEW
Time toreconsider feeding difficulties inhealthy children: anarrative
synthesis ofdefinitions andassociated factors
PriscilaMaximino1· AnaCarolinaB.Leme1· GabrielaMalzyner1· RaquelRicci1· NatháliaGioia1· CamilaFussi1·
MauroFisberg1,2
Received: 30 June 2021 / Accepted: 19 November 2021
© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2021
Abstract
Objective Despite the lack of a “gold-standard” definition and identification of influential factors for identifying feeding
difficulties in children, many international studies have been published in recent years on the subject. Thus, the aim was to
examine studies on children with feeding difficulties and their associated factors that impact on their difficulties.
Methods Feeding difficulties were identified as limit the variety of food intake, and/or avoiding food due to sensory stimu-
lus, i.e., food appearance, aroma, and flavor. A literature search in three databases was performed up to April 2021. English
language articles were included if they investigated preschool and school age children using an observational or experimental
design evaluating feeding difficulties and their factors.
Results Findings indicate that almost 60% of the studies evaluated picky/fussy eaters, followed by 20% evaluating food
neophobia. Parental influence, mainly mothers, were seemed to be the most reported influence. Studies have shown a lower
consumption of fruit and vegetables and higher intake of discretionary foods among picky and food neophobic children. Most
of the studies showed that children were on normal weight to overweight status. Few studies identified socio-demographics
(i.e., age, sex, race/ethnicity, and birth age), emotional distress and other lifestyle behaviors (screen-time use during meals).
Studies were mixed in terms of positive effects on breastfeeding and introduction to foods.
Conclusion Improved feeding difficulties in this population group are dependent from these factors, whereas they should be
used to inform policies, strategies, and use in clinical practices.
Keywords Feeding difficulties· Children· Behavioral factors· Narrative review
Introduction
Pediatric feeding difficulties can be defined as a pattern of
oral consumption of nutrients that differs from accepted
standards [1]. Although definitions and measures vary,
estimates of feeding difficulties are quite high in preschool
and school age children, with 25 to 35% on healthy chil-
dren and up to 80% with children with intellectual dis-
abilities (such as autism disorders and down syndrome) [2].
This highlights the need to identify effective methods of
* Ana Carolina B. Leme
acarol.leme@gmail.com
Priscila Maximino
primaximino@gmail.com
Gabriela Malzyner
gamalzyner@gmail.com
Raquel Ricci
raquelnutrociencia@gmail.com
Nathália Gioia
nathaliagioiang@gmail.com
Camila Fussi
fussicamila@gmail.com
Mauro Fisberg
mauro.fisberg@gmail.com
1 Center forExcellence inNutrition andFeeding Difficulties,
PENSI Institute, Sabará Children’s Hospital, José Luis
Egydio Setúbal Foundation, Av. Angélica 2071, SãoPaulo,
SP01228-200, Brazil
2 Department ofPediatrics, Federal University ofSão Paulo,
SãoPaulo, SP, Brazil
/ Published online: 6 December 2021
Nutrire (2021) 46: 20

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assessment and intervention. Given that the act of feeding
is complex, several issues can disrupt its execution, needing
broad definitions to cover a wide spectrum of problems. As
consequence, there are many cases of children with feeding
difficulties that require interdisciplinary care, and complex
aspects of feeding should be addressed in an integrated way,
but might not be needed for all cases [3].
The preschool and school (2 to 10) age years are char-
acterized as a time for rapid growth and development, with
the peak for weight gain by age 2, and slowing between
2 to 5years old [4, 5]. As a consequence, to the decrease
rate of growth, this might impair on children appetite [6].
Thus, children’s appetite can be quite irregular, presenting it
into different spectrums of feeding difficulties, such as food
neophobia (rejection or avoidance for new foods) and picky/
fussy eating (unwillingness to eat familiar foods or try new
foods) [7]. Alternatively, from an evolutionary perspective,
its supposed that children show initial rejection of new foods
to certify that they are not poisonous [8]. Evidence suggests
that time and repetition to neutral exposures might change
children acceptance for new foods [6].
There is a large body of evidence that many of these feed-
ing difficulties are led by a combination of biological, medi-
cal, and environmental aspects [1–3, 9, 10]. Therefore, influ-
ence on children’s food choices demands an understanding
of the developmental factors that hinders their acceptance
and consumption of certain food sources, such as fruit and
vegetables, and whole grains sources [7, 11]. Essential to
developmental influences are behaviors, such as fussy eat-
ing, picky eating, and food neophobia children. The nature
of these feeding difficulties needs to be understood. Finally,
consideration about what factors sustain these feeding dif-
ficulties through the different stages of childhood (from
infancy to school age years) should also be understood to
acknowledge before the development of successful policies
and behavioral-change strategies.
Despite the lack of a guideline “gold-standard” defini-
tion and identification of influential factors for identifying
feeding difficulties in typically developing children, many
international studies have been published in recent years
on the subject. For instance, studies have been consistently
associating differences in food intake and other aspects that
impact children eating behaviors. The purpose of this narra-
tive review was to examine studies on children with feeding
difficulties and their associated factors that impact on their
difficulties. Feeding difficulties were self-reported by their
parents/caregivers. This was presented to better understand
the nutritional and clinical consequences of feeding difficul-
ties among preschool and school age children.
Methods
This narrative review was conducted in accordance with
guidance from Green etal. [12] stating the minimum
acceptable criteria for narrative reviews of the literature.
For reporting, the PRISMA 2020 (Preferred Reporting
Items for Systematic Reviews and Meta-Analysis) guide-
lines were followed to certify that all steps for a literature
search, screening, and inclusion were done [13].
Identification ofthestudies
A literature search of three electronic databases (i.e., Pub-
Med, PsycINFO, and Web of Science) was performed up
to April 2021. Search results were indexed within each
database from the date of inception to the search date and
were screened by two authors (AL and PM). The following
structured search strings were used: Children OR Pediat-
ric OR School Age OR preschoolers AND Feeding Dif-
ficulties OR Feeding Disorders OR Eating Disorders OR
Feeding Behavior OR Eating Issue OR Eating Problem OR
Picky Eating OR Eating Behavior OR Food Neophobia OR
Food Preferences OR Food Intake. Relevant truncations
and adjacencies were used to enhance results by allow-
ing variations of the search terms. Manual review of the
reference list was conducted to identify studies that may
have been missed. Records were downloaded to EndNote
X9.2 and duplicates removed. Records were first assessed
by title and abstract and then full text. All records were
assessed for inclusion based on the defined criteria. Any
uncertainties regarding the inclusion of a study were
resolved through discussion among A.L and P.M or G.M.
Eligibility criteria
This review was limited to studies published in English
and with no limitation on studies date of publication. All
studies were assessed according to the following inclusion
and exclusion criteria summarized according to the PICO
(Participants, Intervention/Exposure, Comparison, and,
Outcome) framework:
Participants: Studies were eligible if they included free-
living preschoolers and school age children from 2 to
10years old. The age range was selected due to most
of feeding difficulties cases are reported on these ages
[1, 3]. Studies that included atypical developing chil-
dren, i.e., any organic or genetic condition that could
affect diet, were excluded (e.g., autism disorder, down
syndrome, and, cleft lip).
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Intervention/exposure: Studies were included if parents/
caregivers and/or other health professional reported a
feeding difficulty to the child. Feeding difficulties were
defined based on the criteria that eating behaviors, in
particular food selectivity, poor appetite, and fear of
feeding/eating while diminishing the role that medical
or psychological comorbidities play in feeding prob-
lems. Further, it was emphasized on specific types of
eating behaviors, pertaining to the pediatric field [14].
Comparison: Different study designs, i.e., case-studies,
cohort, cross-sectional, and, intervention (randomized
and non-randomized trials), were included in this review.
If intervention design was used, no exclusion criteria
were placed on duration, length of follow-up, or date.
Outcome: The key outcome of this review was to assess
the behavioral and environmental aspects associated to
feeding difficulties on typically developing child. Studies
were excluded if they focused on medical and biological
aspects of feeding difficulties, i.e., genetic and other bio-
logical markers, and organic causes.
A secondary outcome of this review was to identify all
the types of feeding difficulties reported in the studies.
Data extraction
Data were independently extracted from eligible studies
by one reviewer (A.L) and cross-checked for accuracy by a
second reviewer (P.M). The extracted data included sample
characteristics (sample size, sex, and, age), country, type of
feeding difficulties, definition, and, behavioral factors associ-
ated to the feeding difficulties.
Data synthesis
Due to the broad topic approached in this study (feeding
difficulties in children and its behavioral aspects), it was not
possible to perform a systematic review. A narrative sum-
mary of the finding was conducted [12].
Quality assessment andrisk ofbias
Study quality was assessed using a designed appraised tool
developed by the Effective Public Health Practice Project
(EPHPP) [15] for observational, cross-sectional, before and
after studies, and randomized controlled trials. Individual
component and overall quality ratings were scored as 1 for
strong, 2 for moderate, and 3 for weak.
Results
Literature search andscreening
Studies included in this review are summarized in Fig.1. A
total of eligible articles 16,892 were identified: 9,247 from
Fig. 1 Flowchart of the included
articles for the narrative review Records identified from:
Databases (n = 16,892)
9,247 PubMed, 4,447 PsycInfo, and,
3,198 Web of Science
Records removed before screening:
Duplicate recordsremoved (n =3,203)
Records screened
(n = 13,689)
Reports sought for retrieval
(n =4342)
Reports assessed for eligibility
(n = 203)
Reports excluded:
Health condition that might impair on the FD (n=21)
No full-texts/editorial/commentaries/debate (n=14)
Not in the age range (2-10yo) (n=17)
No full texts found (n=44)
Participants with eating disorders and other psychiatric
disorders (n=14)
Other outcomes that have feeding difficulties as a
secondary outcome (n=21)
Systematic reviews/narrative reviews (n=18)
Studies included in review
(n =54)
noitacifitnedI
Screening
Included
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PubMed, 4,447 from PsycInfo, and 3,198 from Web of Sci-
ence. After excluding duplicates and reading titles, 4,342
were sought for retrieval. Finally, 203 full-text articles met
the inclusion criteria, and 54 were considered for the qualita-
tive synthesis.
Studies design characteristics ofthechildren
withfeeding difficulties
From the 54 articles included, 34 (62.9%) articles were
cross-sectional [16–49], 13 (24.1%) were longitudinal/cohort
studies [50–61], only two (3.7%) were case–control studies
[62, 63], and five (9.3%) were interventions studies; from
these, three (5.6%) were quasi-experimental [64–66], and
two (3.7%) were randomized controlled trial [67, 68]. From
these studies, only two used representative samples [55, 56]
from a cohort conducted in the UK with over 13,000 parents/
caregivers and children. Other studies were derived from
convenience sample. Table1 shows details of the studies,
which included the type of feeding difficulties in children
and definitions. The majority of the studies (n = 32, 59.3%)
[17, 20, 21, 23, 26, 27, 29, 32–36, 38–40, 47, 49–58, 60, 61,
63, 67–69] was evaluating picky/fussy eating behaviors, 11
(20.4%) were evaluating food neophobia [18, 44, 46, 64, 65],
7 (12.9%) evaluated feeding difficulties as a broad concept
(not specifying types) [16, 19, 37, 45, 62, 66], three (5.6%)
were evaluating two types of feeding difficulties (food neo-
phobia and picky/fussy eating) [22, 31, 67], and only one
(1.9%) evaluated food avoidance [48] (Table2).
Factors associated withfeeding difficulties
indeveloping children
The factors associated with feeding difficulties are reported
based on the social-ecological model [70] and presented on
Fig.2. The majority of the studies reported that parents influ-
ence their children for having a feeding difficulty (n = 25,
43.10%) [18–23, 25–29, 31, 38, 39, 41–43, 47, 48, 50, 51,
53, 54, 66, 67] and mothers played a major role on their
kids being picky eater and being neophobic to certain foods.
For example, parents being concern of their child not eating
enough foods, and thus, providing a variety of strategies to
feed them, which includes physically promoting the child
to eat or even forcing food on them. Studies analyzed also
evaluated dietary intake among children (n = 13, 22.41%)
[17, 24, 30, 31, 35, 39, 46, 55, 56, 59, 62, 63, 68] and from
these studies’ lower consumption of fruit and vegetables, and
higher intake of discretionary foods were observed in picky
eaters and food neophobic children.
Weight status and other anthropometric measurements
were identified as factors related to feeding difficulties
(n = 9, 15.5%) [16, 23, 29, 34, 52, 58, 60, 64, 68]. Most of
these studies showed that children with feeding difficulties
were varying from normal weight to overweight status. Six
(10.34%) of the studies observed differences between socio-
demographic characteristics and feeding difficulties [19, 33,
35, 45, 49, 57]. Age, sex, race/ethnicity, and birth age being
the associated factors. Emotional distress and other lifestyle
behaviors (such as screen time use during meals) (n = 7,
12.1%) [22, 27, 42, 44, 52, 54, 65] were associated with
being picky/fussy and/or food neophobic. Behaviors such
as feeding strategies (e.g., forcing children to eat), restric-
tion to certain foods, and negative affect were viewed as an
influence for feeding difficulties in children. Only two stud-
ies (3.5%) [37, 61] were mixed in relation to positive effects
on breastfeeding and/or introduction to foods in relation to
feeding difficulties and/or being picky eaters.
Risk ofbias
From all the included studies, withdrawals and dropouts
(M = 2.06 ± 0.95) were the most reported bias, while analysis
(M
=
1.26
±
0.49) was the less reported bias. Overall score
was 1.59 ± 0.37, i.e., strong to moderate studies included in
this review. Figure3 shows the risk of bias of each compo-
nent rating for the included studies.
Discussion
This review synthesized the evidence from observational,
case–control, and, intervention studies reporting the types of
feeding difficulties and risk factors children. The 54 studies
included in this review were conducted across 21 countries,
thus representing a broad perspective on this study objective.
This review found that picky/fussy eating and food neopho-
bia were the most common feeding difficulties reported on
the studies. Factors related to these difficulties were identi-
fied based on the socio-ecological model [70] as individual,
environmental, and societal influences. Family, mainly par-
ents, play a major role on their child eating behaviors and
the developing of feeding difficulties. A review provided
an approach for resolving a variety of feeding difficulties,
advocating for a progressive approach of managing feeding
problems in all clinical settings. Identifying for example,
that a responsive feeding style is the ideal feeding approach
for parents and is characterized by appropriate reactions to
children’s feeding cues [3].
Positive parental influences, in special maternal model-
ling, is commonly indicated as utmost importance in reduc-
ing the risk for picky/fussy eating or food neophobia in pre-
school and school age children. For example, in a study of
Lebanese parents of 2 to 10years old, parents; higher instru-
mental feeding scores (i.e., use food as reward instead of
encouraging words) were associated with children refusal for
eating fruit and vegetables, fish, and eggs [18]. Therefore,
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Table 1 Key characteristics of the identified studies
Reference Study design, country Sample size, sex, age Classification of feeding dif-
ficulties
Characteristics of feeding
difficulties
Main results
Schmidt etal. [62] Case control, Germany 29, 45% female,
7.5 ± 3.3years (20 from the
ARFID and 9 control group)
Avoidant/Restrictive Feeding
Intake Disorder (ARFID)
Semi-structure interview
based on the Eating Disor-
der Examination
Limit variety of food intake
Diet with limit amount
Lower total energy intake,
carbohydrate intake, but no
reduced in micronutrient
intake
Prasetyo etal. [16] Cross-sectional, Indonesia 245, 55.1% female, 3–5years
old
ARFID Based on the diagnos-
tic of DSM-5
Avoiding food due to sensory
stimulus (food appearance,
aroma, and flavor)
Majority of children (76.7%)
were normal weight followed
by 11% obese
Pickard etal. [65] Pre-posttest, France 83, 57.8% female,
58.5 ± 10.7months
Food Neophobia and Picki-
ness Parents report by Child
Food Rejection Scale
Food rejection tendencies Increased levels of food
rejection predict poor food
identification
Maiz etal. [64] Quasi-experimental, Spain 196, 43.4% female, 8–9years:
nutrition education and
hands on group
Food neophobia Spanish Food
Neophobia Scale
Reluctance to eat new foods,
hinder willingness to try
fruit and vegetables
No differences in weight
status and diet quality scores
between two groups Nutrition
education slighted higher
diet quality score Hand on
slighted higher BMI
Iwinski etal. [50] Longitudinal, USA 110, 51.8% female,
21 ± 2.7months
Picky eating behaviors
Self-reported questionnaire
(Oregon Research Institute
Child Eating Behavior
Inventory—ORI-CEBI)
Video-taped family meal-
times
Physical food refusals, physi-
cal food avoidances, verbal
food avoidances, and verbal
food refusals
Caregiver-child interactions
may impact degree to which
food responsiveness is effec-
tive in reducing picky eating
Fraser etal. [17] Qualitative study, Australia,
Canada, German, UK, USA
Forum posts with over
105,000 parents of
12–36months
Fussy eating Definition from
previous research
Fussy or picky are used to
describe a spectrum of food
refusal behaviors: refusal of
both familiar and unfamiliar
foods (neophobia), limited
dietary variety and inad-
equate intake
Fussy eating poses a barrier to
children’s dietary variety and
establishing healthy eating
habits
El Mouallem etal. [18] Cross-sectional, Lebanon 656, 50.8% female,
2–10years
Food neophobia Rejection for new or unfamil-
iar foods
Parents’ instrumental feeding
score: refused to eat veg-
etables, fish, fruits, or eggs
Parents’ encouragement lower
neophobia
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Table 1 (continued)
Reference Study design, country Sample size, sex, age Classification of feeding dif-
ficulties
Characteristics of feeding
difficulties
Main results
Zohar etal., [51] Longitudinal, Israel 215, 52.,6% female,
3.3 ± 1.0years
Picky eating Self-reported Child refuse to foods Picking eating is a passing
phase. Maternal feeding prac-
tices limit long-term influ-
ences on children’s PE Unless
picking eating is persistent
and severe, parents would
best be advised to relax their
feeding efforts
Simione etal. [19] Qualitative study, USA 30, 43.3% female,
43.0 ± 13.4months
Feeding difficulties: broad
spectrum Parents’ perspec-
tive
Broad range of difficulties
resulting in oral intakes
impairment
Feeding disorders impact daily
lives of children and families
Treatment incorporates
principles of family-centered
care focus on meaningful
outcomes to improve health
quality of life and address
modifiable socio-contextual
determinants
Shimsoni etal. [66] Pre-post treatment, USA 15, 13.3% female,
9.14 ± 2.63years
Avoidant/restrictive food
intake
Selective of foods based on
sensory properties (picky
eating or food neophobia);
limited interest in eating
or poor appetite; fear of
aversive consequences from
eating, such as chocking,
vomiting, or gastrointestinal
pain
93% picky eating; 6% poor
appetite; and 26% fear of eat-
ing Family has an important
role on the accommodation of
the severity of the ARFID
Searle etal. [20] Cross-sectional, Australia 205, 49% female,
3.6 ± 1.0years
Fussy eating Rejection of both familiar and
unfamiliar foods is thought
to be developmental expres-
sion of autonomy
Mothers’ perception of child
food fussiness mediated the
relationship between difficult
temperament and increased
provision of alternative meals
to the child from the rest
of the family Mothers’ and
fathers’ perception of child
food fussiness mediated the
relationship between difficult
child temperament and lower
frequency of sitting at a table
together for family meals
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Table 1 (continued)
Reference Study design, country Sample size, sex, age Classification of feeding dif-
ficulties
Characteristics of feeding
difficulties
Main results
Rendall etal. [21] Validation study, UK 67, 58.2% female,
3 ± 1.0years
Fussy eating Rejection of familiar and
novel foods resulting in diet
that is insufficient and/or
inadequately varied
Maternal reports of food fussi-
ness were positively related
to food rejection behaviors
and negatively related to
food acceptance behaviors.
Maternal reports of food
fussiness were also found
to be negatively related to
the proportion of familiar/
appealing of familiar foods
consumed by the child
Kutbi [22] Cross-sectional, Saudi Arabia 195, 48.2% female, ≤ 2 to
7years old (55.4–2 to
4years)
Food neophobia and picky
eating
Reluctance of eating novel
foods and the rejection
of substantial amounts of
familiar and unfamiliar
foods
Positive associations with pres-
sure-to-eat feeding strategy
and food neophobia and picky
eating Negative associations
with healthy home food envi-
ronment and food neophobia/
picky eating Maternal prac-
tices of teaching and monitor-
ing were associated with food
neophobia/picky eating
Fernandez etal. [52] Longitudinal, USA 269, 48.1% female, and
4–9years measured at five
different times
Picky eating Eating a limited a number of
foods, rejection of novel
foods, and strong food
preferences
Three trajectories of picky eat-
ers: persistently low, medium,
and high High picky eating
was associated with higher
emotional lability and lower
emotional regulation Picky
eating was associated with
restrictions and demanding-
ness—low picky eating with
low restriction and high picky
eating with high demanding-
ness Medium and high-picky
eating associated with low
BMIz
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Table 1 (continued)
Reference Study design, country Sample size, sex, age Classification of feeding dif-
ficulties
Characteristics of feeding
difficulties
Main results
Brown & Perrin [23] Cross-sectional, USA 286, 47.8% female,
4.9 ± 2.3years
Picky eating Wide range of what is
considered “decreased
variety” is why picky eating
is described on a spectrum.
Picky eating is generally
considered a developmen-
tally normal behavior in
young children that usually
resolves by school age and
does not affect growth
Three distinct picky eating
factors: try new foods, eating
sufficient quantity, and desire
for specific food preparation
No factors were associated
with weight perceptions.
Parents’ who were more con-
cerned with their child did not
eat enough were more likely
to pressure-to-eat and these
children had lower BMIz
Anjos etal. [24] Cross-sectional, Brazil 214, 50.47% female,
3–6years (62.6% from
5–6years)
Food neophobia Reluctance to eat or the avoid-
ance of new or unfamiliar
foods
85.9% low-median and 11.2%
high food neophobia Children
with high neophobia con-
sumed more ultra-processed
foods and protein-rich foods
Children with level of neo-
phobia had lower adherence
to traditional dietary patterns
An etal. [25] Cross-sectional, Ireland 205, 43.9% female,
2.4 ± 0.7years
Food neophobia Reluctance to eat or avoidance
of new foods
Higher score of food neophobia
was associated with maternal
practice of coaxing the chil-
dren to eat at refusal, unpleas-
ant emotions at mealtime,
and mother’s own degree of
food neophobia Mothers not
worried when confronted
with child’s food refusal were
negatively associated with
kids neophobia
Wolstenholme etal. [26] Qualitative, Ireland 24 children, 56.5% female,
6–10years
Fussy eating Consumption of inadequate
variety or quantity of foods
through the rejection of both
new and familiar foods
Three family process themes
were identified, explaining
how families respond to fussy
eating behaviors: dynamic
and evolving feeding goals,
managing negative emo-
tions, and parenting practices
Changes of parent responses
change over time: resistance-
to-acceptance, fluctuating
response, and consistent
response
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Table 1 (continued)
Reference Study design, country Sample size, sex, age Classification of feeding dif-
ficulties
Characteristics of feeding
difficulties
Main results
Whelan & Penrod [63] Case-study, USA Two brothers, 6 and 3years
old
Picky eating Consumption of restrictive
number of foods (i.e., < than
3) in at least one food group
and resistance to trying new
foods when presented
Presenting non-preferred
foods as an appetizer was
not successful in increasing
consumption Consumption
only increased after high-
preferred foods were made
contingent on consumption of
non-preferred foods
Sandvik etal. [68] Randomized controlled trial,
Sweden
130, 54% female,
5.2 ± 0.7years
Picky/fussy eating Child’s unwillingness to eat
familiar foods or try new
foods, with negative impacts
on children and parents in
their daily activities
Intervention was unable to
reduce the degree of picky
eating using two instruments
(CBEQ and LBC) Inter-
vention = evidenced-based
parenting styles Picky eating
was associated with lower
BMIz and lower intake of
vegetables
Rahill etal. [27] Cross-sectional, Ireland 296, 51.0% female, 5–8years Fussy eating Rejection of a large propor-
tion of both familiar and
novel foods
Child preferences and food
advertising are barriers
to provide healthy eating
as higher score for fussy
eating Parental neophobia
and child’s preference were
positively associated with
higher score for child being
fussy, and advertising was
negatively associated with
higher scores for fussy eating
Kutbi etal. [28] Cross-sectional, Saudi Arabia 216, 50% female,
5.09 ± 1.06years
Food Neophobia Picky eating Food neophobia: refusal of
new foods Picky eating: lim-
ited variety of foods through
the rejection of either famil-
iar or unfamiliar food
98.6% food neophobia and
89.9% pickiness eating
Peer modeling and parental
strategies were negatively
associated with neophobia
and picky eating
Katzow etal. [67] Randomized controlled trial,
USA
187, 53% female, newborn to
2years
Picky eating Food neophobia: refusal to
accept new foods Picky eat-
ing: response to new foods
and limitations in the variety
of foods accepted
Maternal concerns about picky
eating may reflect deeper
depressive symptoms and
negative perceptions of her
child’s behavior
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Table 1 (continued)
Reference Study design, country Sample size, sex, age Classification of feeding dif-
ficulties
Characteristics of feeding
difficulties
Main results
Sandvik etal., [29] Cross-sectional, Sweden 1272, 51% female,
4.9 ± 0.8years
Picky eating Unwillingness to eat familiar
foods or try new foods, with
negative impacts on chil-
dren/parents’ daily activities
Half of the children was pick
eating 30% severe picky
eating Food responsiveness
was lower for picky eaters
with differences only in obese
children Slowness in eating
was not pronounced in obese
children High pressure to
eat was more pronounced
in thinness/normal weight
children Parents of picky eat-
ers were more likely to report
more time spent on screens,
complaining about PA, and
negative affect toward food
Picky eating was less com-
mon, but still prevalent with
obese children
Koziol-Kozakowska etal. [30] Cross-sectional, Poland 325, 48.6% females, 2–7years Food neophobia Tendency to reject novel or
unknown foods
12.3% low and 10.8% high
food neophobia High level
of neophobia consumed less
eggs, raw and cooked veg-
etables, and legumes. Tend
to consume more frequently
sweets and snacks and often
consumed in-between meals
Low consumption of vegeta-
bles impact on meeting far
below the recommendations
for vitamins
Harris etal. (a) [31] Qualitative, Australia 12, N/E gender, 9–48months
age
Fussy eating/food neophobia Reject new or familiar foods Feeding concerns: learning
challenges in the process of
transition from a milk-based
to a solid-based diet; Emo-
tional accounts of feeding as
interactable problem Child’s
eating behavior battle, over
limited intake and variety of
foods constructed as bad or
wrong Parent anxiety evoked
parent non-responsive feed-
ing practices or provision of
foods the child preferred
20 Page 10 of 19 Nutrire (2021) 46: 20

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Table 1 (continued)
Reference Study design, country Sample size, sex, age Classification of feeding dif-
ficulties
Characteristics of feeding
difficulties
Main results
Harris etal. (b) [32] Cross-sectional, Australia 208, 50.0% females,
3.6 ± 1.0years
Fussy eating/picky eating Reject foods, whether novel or
familiar
Parents’ rewards for behaviors
were associated with child
fussy eating
Galloway etal. [33] Cross-sectional, New Zealand 193, 47% females, 1–5years Picky eating/fussy eating Rejection of number of foods
that results in low dietary
variety and low food intake
in general
Socio-economic status and
picky eating predict infant
growth over the time
Cole etal. [53] Longitudinal, USA 326,48.5% female,
52.4 ± 8.4months
Picky eating Avoidance of food and inad-
equate dietary variety
Child control over feeding
and watching TV during
mealtimes with picky eating
Higher sense of positive cli-
mate during family meals less
the change of picky eating
Chao [34] Cross-sectional, China 300, 48% female,
2.95 ± 0.59years
Picky eating Strong preferences, consum-
ing an inadequate variety of
foods, restricting the intake
of some food groups, eating
a limit amount of food, or
being unwilling to try new
foods
54% picky eaters Anthropo-
metric measurements were
lower in picky eaters Fear of
unfamiliar places, poor physi-
cal activity, constipation, and
high frequency of medical
illness was associated with
being picky eater
Brown etal. [35] Cross-sectional, USA 506, 51.38% female,
49.31 ± 6.35months
Picky eating Eating a limit variety of foods Sex, age, and difficult tempera-
ment were associated with
picky eating. Overall diet
quality score was negatively
associated with picky eating,
as well as for total and whole
fruits, vegetables, greens/
beans, and total proteins
Steinsbekk etal. [36] Cross-sectional, Norway 752, 50% female,
6.7 ± 0.18years
Picky eating Unwillingness to eat specific
foods or try new foods, thus
limiting dietary variety
20.7% moderate picky eaters
0.5% severe picky eaters
Steinsbekk etal. [54] Cohort, Norway 1250, N/E gender, 4 and
6years in the two cohorts
Picky eating Unwillingness to eat specific
foods or try new foods, thus
limiting dietary variety
26% picky eaters Parental
structuring was found to
reduce the risk of children’s
picky eating, whereas paren-
tal sensitivity increased Sen-
sory sensitivity predicts picky
eating at age 4 Temperamen-
tal surgency, and negative
affectivity not
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Table 1 (continued)
Reference Study design, country Sample size, sex, age Classification of feeding dif-
ficulties
Characteristics of feeding
difficulties
Main results
Ramos etal. [37] Cross-sectional, Brazil 70, 32.9% female,
3.0 ± 2.1years
Feeding difficulties Broad concept: agitated,
limited appetite, phobia,
misinterpretation, organic,
picky eating
No differences in presenting
any type of feeding difficul-
ties as compared to picky eat-
ing Age at texture transition
both from breastfeeding to
complementary feeding and
from complementary feeding
to solid foods did not vary
according to feeding difficul-
ties diagnostic
Luchini etal. [38] Cross-sectional, USA 50, 52.0% female, 3–5years Picky eating –- Parents perceived 1.4 × t heir
child as being picky eating
as providers from child care
Perceived pickiness from
parents has greater influence
on mealtime strategies
Kwon etal., [39] Cross-sectional, South Korea 184, N/E gender, 1–5years Picky eating Limit variety Children eating small amounts
consumed less energy and
nutrients Picky eaters’ differ-
ences in energy density and
micronutrients content
Byrne etal. [40] Cross-sectional, Australia 336, 51% female,
13.8 ± 1.3months
Fussy eating Rejection of a substantial
amount of familiar and
unfamiliar foods, potentially
resulting in limited dietary
variety and food intake
Reward for eating, reward for
behavior, persuasive feeding,
and over-restriction with
mothers’ perceptions of child
being fussy
Taylor etal. [55] Longitudinal, UK 13,998, N/E gender,
2–5.5years
Picky eating Reduction in dietary variety
and consequently an
unhealthy or possibility
inadequate diet
Picky eaters aged 3 lower
mean for carotene, iron,
and, zinc Free sugars were
consumed as more than the
recommendations Nutrients
differences were explained by
lower intakes of meat, fish,
vegetables, and fruits Sugary
foods and drinks were higher
in older picky eaters
Taylor etal. [56] Longitudinal, UK 13,998, N/E gender,
2–5.5years
Picky eating Reduction in dietary variety
and consequently an
unhealthy or possibility
inadequate diet
Dietary fiber was lower in
picky eaters due to low con-
sumption of vegetables
20 Page 12 of 19 Nutrire (2021) 46: 20

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Table 1 (continued)
Reference Study design, country Sample size, sex, age Classification of feeding dif-
ficulties
Characteristics of feeding
difficulties
Main results
Moding and Stifter (a) [41] Cross-sectional, USA 115, 45.2% female,
6–12months
Food neophobia Tendency to reject novel or
unknown foods
Maternal neophobia has been
associated with children
rejection of novel foods
Moding and Stifter (b) [42] Cross-sectional, USA 115, 45.2% female,
6–12months
Food neophobia Tendency to reject novel or
unknown foods
Maternal pressure predicts
child food neophobia Toddler
negative affect was associated
with food neophobia
Cano etal. [57] Cohort study, the Netherlands 3,748, 49.4% female, 1.5, 3,
and 6years
Picky eating Food refusal, eating a limited
variety of food, an unwill-
ingness to try new food
(food neophobia)
Persisting PE predict pervasive
developmental problems at
age 7. Not associated with
behavioral or emotional
problems
Antoniou etal. [58] Cohort study, the Netherlands 1024, 60.9% female, 5years Picky eating –- 39.4% picky eaters Picky eat-
ers have higher changes to
become overweight
Perry etal. [59] Longitudinal, Australia 194, 54.2% female, 5, 14, and,
24months
Food neophobia Rejection of novel or
unknown foods, is minimal
at infancy and peaks some-
time between two and six
Neophobic children have lower
variety of fruits and vegeta-
bles, and greater proportion
of daily discretionary foods
Harvey etal. [43] Cross-sectional, UK 61, 44.3% female,
4.23 ± 1.83years
Feeding difficulties—in
general
Not defined Parents’ anxiety and reports of
child feeding difficulties
Barse etal. [60] Longitudinal, the Netherlands 4191, 50.3% female, 4 to
6years
Fussy eating/picky/selective/
choosy eating
Often reject new food items
(food neophobia), but they
are particularly character-
ized by their consistent
rejection of specific familiar
foods, especially vegetables
Fussy eaters are at risk for
lower BMI z scores and fat-
free mass
Cano etal. [69] Longitudinal, the Netherlands 4191, 50.3% female, 4 to
6years
Picky eating Consuming a limited variety
of foods, unwillingness to
try new foods (food neo-
phobia) and aberrant eating
behaviors
26.5% of picky eaters at
1.5years and 27.6% at
3years, declined to 13.2% at
6years Male sex, lower birth
weight, non-Western maternal
ethnicity, and low- parental
income predicted persistent
picky eating
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1 3
Table 1 (continued)
Reference Study design, country Sample size, sex, age Classification of feeding dif-
ficulties
Characteristics of feeding
difficulties
Main results
Faith etal. [44] Cross-sectional, USA 66 (twins), 53% female,
4–7years
Food neophobia Tendency to avoid eating
unfamiliar foods
Food neophobia was related
to reduced child compliance
of prompted foods; compli-
ance with initially refused
foods—overall sample, boys
and girls. Girls only food
neophobia was also related to
food type demandingness
Benjasuwantep etal. [45] Cross-sectional, Thailand 402, 46.8% female,
22.93 ± 9.62months
Feeding difficulties—general Persistence feeding distur-
bance and either a failure to
gain weight or significant
weight for at least one
month without significant
medical conditions or lack
of available food
26.9% feeding difficulties
(15.43% highly selective
intake) Birth order was asso-
ciated with feeding difficul-
ties Less frequency of meals,
prolonged meal durations,
fed at child’s table/table with
other family members
Howard etal. [46] Cross-sectional, Australia 277, 51.0% female,
24 ± 1.0years
Food neophobia Reduced preferences for all
food groups, in particular
vegetables, with liking fewer
food types, a higher number
of untried food preferences
and less healthful food
preferences overall
Food neophobia was associated
with liking fewer vegetables
and fruits, and trying vegeta-
bles Repeated exposure to
new food was not associated
with food liking
Goh and Jacob etal. [47] Cross-sectional, Singapore 46.2% female, 1–10years Picky eating Inadequate variety of foods One year most prevalent year
of present first episode 45%
parents/caregivers were very
much concern Pressure to eat
was significant associated
with picky eating Caregiver’s
stress was associated with
picky eating, and picky eating
impact negatively on family
relationships
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Table 1 (continued)
Reference Study design, country Sample size, sex, age Classification of feeding dif-
ficulties
Characteristics of feeding
difficulties
Main results
Shim etal. [70] Cohort, USA 129, 57.4 female,
2.97 ± 0.7years
Picky eating Unwilling to try new foods or
having strong opinions on
food preferences, prepara-
tion methods, and choice of
food groups
Exclusive breastfeeding at
3m was associated with
preference for specific food
preparation method Exclusive
breastfeeding at 6m was
associated with preference
for specific food preparation
method, food rejection, and
food neophobia Introduction
with complementary foods
before 4m was associated
with limited variety of foods
Introduction with comple-
mentary foods before 6m
was associated with food
neophobia and limited variety
of foods
Powel etal. [48] Cross-sectional, UK 95,44.2% female,
5.20 ± 1.13years
Food avoidance Display of such behaviors:
food refusal, selective,
picky or fussy eating, eating
slowly, being less inter-
est in food and having less
appetite
Food avoidance were associ-
ated with an emotional child
temperament, high levels of
maternal feeding control,
using food for behavior
regulation, and low encour-
agement of a balanced and
varied food intake. Maternal
pressure to eat predict food
avoidance in child
Evans etal. [49] Cross-sectional, USA 659, N/E gender,
3.26 ± 1.35years
Picky eating Not defined Spanish and black parents were
more used to use food to calm
their kids (than English-
speaking Spanish parents)
Notes: BMI body mass index, PA physical activity, PE physical education
Page 15 of 19 20Nutrire (2021) 46: 20

1 3
parents should be aware of the adequate methods to use to
help their child get familiarized with food. Encouraging
words and attitudes might be an opportunity to reduce levels
of food avoidance in children. Alternatively, offering food as
reward in a tentative to eat certain food showed more signs
of avoidance [71]. Feeding difficulties are common during
the early years [8, 71]. Thus, results associating picky or
neophobic children with lower consumption for certain food
sources can explain the urgency of dealing with inadequate
eating behaviors to help diversify the diet of children. Also,
poor diet quality might be risk factors for the development
of broaden concept of the feeding difficulties [72].
Studies have been mixed in terms of total energy intake,
but were unanimously in terms of eating less fruit and veg-
etables, and more discretionary foods (e.g., sugar-sweetened
beverages, and other sweets and sugary items). Alterna-
tively, few studies have found evidence for nutrient-specific
deficiencies, with one study reporting lower vitamins and
minerals intake in a sample of 20 children and adolescents,
as determined by three-day food records [62]. This might
explain the increased prevalence of overweight in this popu-
lation, while in the past years, children with feeding dif-
ficulties were associated with underweight or malnutrition
[4, 8, 73, 74]. This is consistent with evidence that parents
Table 2 Types of feeding difficulties in typically developing children and their definition according to the included studies
Feeding difficulties Definition
Feeding difficulties broad definition [16, 19, 37, 43, 45, 62, 66]• Limit variety of food intake
• Avoiding food due to sensory stimulus (appearance, aroma, and flavor)
• Persistence feeding disturbance and either a failure to gain weight or signifi-
cant weight for at least 1month without significant medical conditions or lack
of available food
Picky/fussy eating [20, 21, 23, 26, 27, 29, 32–36, 38–40, 47,
49–58, 60, 61, 63, 64, 67–69]
• Physical food refusals, physical food avoidances, verbal food avoidances, and
verbal food refusals
• Spectrum of food refusal behaviors: refusal of both familiar and unfamiliar
foods (neophobia), limited dietary variety and inadequate intake
• Eating a limited number of foods, rejection of novel foods, and strong food
preferences
• Child’s unwillingness to eat familiar foods or try new foods, with negative
impacts on children and parents in their daily activities
Food neophobia [30, 41, 42, 46, 59, 64, 65]• Reluctance to eat or the avoidance of new or unfamiliar foods
• Tendency to reject novel or unknown foods
Food avoidance [48]Display of such behaviors: food refusal, selective picky or fussy eating, eating
slowly, being less interest in food and having less appetite
Fig. 2 Social ecological model adapted to the feeding difficulties in
developing children
00.511.5 2 2.5 3
Selection Bias
Study Design
Confounders
Blinding
Data Collection Methods
Withdrawals and dropouts
Intervention integretiy
Analysis
Total Score
Fig. 3 Risk of bias of the included studies based on the Effective
Public Health Practice Project: ratings for each component and over-
all score
20 Page 16 of 19 Nutrire (2021) 46: 20

1 3
of picky/fussy eaters and neophobic children apply greater
pressure to eat [74]. Children tend to gain less weight if their
parents/caregivers responded to refuse food with more pres-
sure to eat; this might simply be caregivers responding to
slow infant growth, although it is possible that the pressure
could actually suppress the young infants’ appetite for some
foods [75]. However, there is somewhat conflicting evidence
that suggests that feeding difficulties in children may reduce
the risk of obesity and may not be a serious health concern
unless the diet restriction is extreme.
The strengths of this narrative review include the exami-
nation of a topic that filled a gap in the existing literature.
This study aimed to identify types of feeding difficulties
in typically developing children and the associated factors
regarding to these difficulties. This study corroborates with
the argument of Walton etal. [8] that labelling children as
a picky/fussy or neophobic to foods might lead to difficult
feeding interactions. This is due to such labels pathologize
what may be normal variations in child food preferences and
reinforce parent and child stress. This study was not without
limitations. Only studies including children between 2 to
10years old. Prevalence for feeding difficulties in older chil-
dren (pre-adolescents) may be lower and the difficulties to
identify feeding difficulties in infants (≤ 2years old). Infants
have different nutritional requirements, and most of them are
breastfeed. Only studies that evaluate feeding difficulties in
developing children were included; no other children with a
health condition (e.g., autism disorder and Down syndrome)
that might impair on their dietary intake were included. This
may have caused confirmation bias, when interpreting the
studies [76]. Further, despite the authors’ extensive efforts,
including searching of databases and manual searching of
literature reference lists, it is possible that studies meeting
the inclusion criteria may have been missed. Only one author
performed title, abstract, and full-text screenings. However,
any uncertainties regarding study inclusion were resolved
through discussion among three authors. This review was
also limited by the heterogeneity of the included studies,
whereby reporting measures and outcomes were often not
consistent. Finally, uncertainties on risk of bias information
may be considered a limitation. Some studies did not provide
relevant information on certain sources of bias, such as allo-
cation, concealment and blinding of participants, personnel
and outcome assessment, an underpowered study, and an
analysis not accounting for clustering.
Conclusion
In sum, this narrative review showed that children are natu-
rally prone to be picky/fussy eater and/or food neophobic,
and this dependents on different factors. These factors can be
classified according to the socio-ecological model proposed
by Bronfenbrenner in 1974 [70], and they were linked to
individual (i.e., child weight status and dietary intake),
environment (socio-demographics and being breastfed),
and societal (peer/family modelling and food advertising).
Improved feeding difficulties in this population group are
dependent from these factors, whereas they should be used
to inform public health policies, behavioral-change strate-
gies, and their use on clinical practices. Moreover, most of
the studies have showed the opposite that instead of feeding
difficulties being a common problem among underweight
children; this has been also a problem in those in an over-
weight status. This may be impact on their different food
choices. However, more research is needed to examine
how these factors may be impacting on children that can be
addressed in different types of feeding difficulties, as well
as to identify whether additional support is needed for over-
weight preschoolers and school age children.
Author contribution ACBL, GM, MF, and, PM made the conception
and design of the study and revised critically for important intellectual
content. ACBL, MF, and, PM coordinated the study and made final
approval of the version to be submitted. ACBL conducted data search
and synthesis, and wrote the first draft. CF, GM, RR, and NG con-
tributed with important intellectual content. All authors revised and
discussed the manuscript.
Availability of data and material The dataset and/or files used dur-
ing the current study are available from the corresponding author on
reasonable request.
Code availability Not applicable.
Declarations
Ethics approval Not applicable.
Consent to participate Not applicable.
Consent to publication Not applicable.
Conflict of interest The authors declare no competing interests.
References
1. Bąbik, K., etal., Infant feeding practices and later parent-reported
feeding difficulties: a systematic review. Nutr Rev, 2021.
2. Saini V, etal. A systematic review of functional analysis in pedi-
atric feeding disorders. J Appl Behav Anal. 2019;52(4):1161–75.
3. Milano K, Chatoor I, Kerzner B. A functional approach to feeding
difficulties in children. Curr Gastroenterol Rep. 2019;21(10):51.
4. Sun J, etal. Infant BMI peak as a predictor of overweight and
obesity at age 2 years in a Chinese community-based cohort. BMJ
Open. 2017;7(10):e015122.
5. Roy SM, etal. Body mass index (BMI) trajectories in infancy differ
by population ancestry and may presage disparities in early child-
hood obesity. J Clin Endocrinol Metab. 2015;100(4):1551–60.
6. Haines J, etal. Nurturing children’s healthy eating: position state-
ment. Appetite. 2019;137:124–33.
Page 17 of 19 20Nutrire (2021) 46: 20

1 3
7. Dovey TM, etal. Food neophobia and ‘picky/fussy’ eating in chil-
dren: a review. Appetite. 2008;50(2):181–93.
8. Walton, K., etal., Time to re-think picky eating?: A relational
approach to understanding picky eating. The International Journal
of Behavioral Nutrition and Physical Activity, 2017. 14.
9. Rubio EK, McMahon MXH, Volkert VM. A systematic review
of physical guidance procedures as an open-mouth prompt to
increase acceptance for children with pediatric feeding disorders.
J Appl Behav Anal. 2021;54(1):144–67.
10. Kininmonth, A., etal., The association between childhood adipos-
ity and appetite assessed using the Child Eating Behavior Ques-
tionnaire and Baby Eating Behavior Questionnaire: a systematic
review and meta-analysis. Obesity Reviews, 2021.
11. Leme, A.C., etal., Diet quality of Canadian preschool children:
associations with socio-demographic characteristics. Canadian
Journal of Dietetic Practice and Research, 2021: p. 1–5.
12. Green BN, Johnson CD, Adams A. Writing narrative literature
reviews for peer-reviewed journals: secrets of the trade. J Chiropr
Med. 2006;5(3):101–17.
13. Page, M.J., etal., The PRISMA 2020 statement: an updated guide-
line for reporting systematic reviews. BMJ, 2021. 372: p. n71.
14. Goday, P.S., etal., Pediatric feeding disorder: consensus definition
and conceptual framework. Journal of Pediatric Gastroenterology
and Nutrition, 2019. 68(1).
15. Effective Public Health Practice Project, in Quality Assessment
tool for quantitative studies 2021: Canada.
16. Prasetyo YB, etal. A belief-based parenting behavior model
for promoting family’s ability to care for children with avoidant
restrictive food intake disorder (ARFID) in Indonesia. J Public
Health Res. 2021;10(1):1964.
17. Fraser, K., etal., Fussy eating in toddlers: a content analysis
of parents' online support seeking. Matern Child Nutr, 2021: p.
e13171.
18. El Mouallem, R., etal., Food neophobia in Lebanese children:
scale validation and correlates. Public Health Nutr, 2021: p. 1–9.
19. Simione M, etal. Family-centered outcomes that matter most to
parents: a pediatric feeding disorders qualitative study. J Pediatr
Gastroenterol Nutr. 2020;71(2):270–5.
20 Searle BE, etal. What children bring to the table: the association
of temperament and child fussy eating with maternal and paternal
mealtime structure. Appetite. 2020;151:104680.
21. Rendall S, Dodd H, Harvey K. Behavioural validation of
a parent-report measure of child food fussiness. Appetite.
2020;154:104796.
22. Kutbi, H.A., The relationships between maternal feeding practices
and food neophobia and picky eating. Int J Environ Res Public
Health, 2020. 17(11).
23. Brown CL, Perrin EM. Defining picky eating and its relation-
ship to feeding behaviors and weight status. J Behav Med.
2020;43(4):587–95.
24. Anjos, L.A.D., etal., Low adherence to traditional dietary pattern
and food preferences of low-income preschool children with food
neophobia. Public Health Nutr, 2020: p. 1–8.
25. An, M., etal., Are maternal feeding practices and mealtime emo-
tions associated with toddlers' food neophobia? A Follow-Up to
the DIT-Coombe Hospital Birth Cohort in Ireland. Int J Environ
Res Public Health, 2020. 17(22).
26. Wolstenholme H, Heary C, Kelly C. Fussy eating behaviours:
response patterns in families of school-aged children. Appetite.
2019;136:93–102.
27. Rahill S, etal. The factors associated with food fussiness in Irish
school-aged children. Public Health Nutr. 2019;22(1):164–74.
28. Kutbi, H.A., etal., Food neophobia and pickiness among children
and associations with socioenvironmental and cognitive factors.
Appetite, 2019. 142.
29. Sandvik, P., etal., Picky eating in Swedish preschoolers of dif-
ferent weight status: application of two new screening cut-offs.
The International Journal of Behavioral Nutrition and Physical
Activity, 2018. 15.
30. Kozioł-Kozakowska A, Piórecka B, Schlegel-Zawadzka M. Prev-
alence of food neophobia in pre-school children from southern
Poland and its association with eating habits, dietary intake and
anthropometric parameters: a cross-sectional study. Public Health
Nutr. 2018;21(6):1106–14.
31. Harris HA, etal. What’s the fuss about? Parent presentations of
fussy eating to a parenting support helpline. Public Health Nutr.
2018;21(8):1520–8.
32. Harris HA, et al. Do dads make a difference? Family feeding
dynamics and child fussy eating. Lippincott Williams & Wilkins.
2018. https:// doi. org/ 10. 1097/ DBP. 00000 00000 000566.
33. Galloway AT, etal. Socioeconomic position and picky eating
behavior predict disparate weight trajectories in infancy. Front
Endocrinol (Lausanne). 2018;9:528.
34. Chao HC. Association of picky eating with growth, nutritional
status, development, physical activity, and health in preschool
children. Front Pediatr. 2018;6:22.
35. Brown CL, etal. Association of picky eating with weight status
and dietary quality among low-income preschoolers. Acad Pediatr.
2018;18(3):334–41.
36. Steinsbekk, S., etal., Screening for pickiness—a validation study.
The International Journal of Behavioral Nutrition and Physical
Activity, 2017. 14.
37. Ramos CC, etal. Delayed development of feeding skills in chil-
dren with feeding difficulties-cross-sectional study in a Brazilian
reference center. Front Pediatr. 2017;5:229.
38. Luchini V, etal. Differences and agreement in perception of child
picky eating among center- and home-based childcare providers
and parents and its impact on utilized mealtime strategies. Nutr
Metab Insights. 2017;10:1178638816684830.
39. Kwon, K.M., etal., Association between picky eating behaviors
and nutritional status in early childhood: performance of a picky
eating behaviorq. Nutrients, 2017. 9(5).
40. Byrne, R., E. Jansen, and L. Daniels, Perceived fussy eating in
Australian children at 14 months of age and subsequent use of
maternal feeding practices at 2 years. The International Journal
of Behavioral Nutrition and Physical Activity, 2017. 14.
41. Moding KJ, Stifter CA. Stability of food neophobia from infancy
through early childhood. Appetite. 2016;97:72–8.
42. Moding KJ, Stifter CA. Temperamental approach/withdrawal and
food neophobia in early childhood: concurrent and longitudinal
associations. Appetite. 2016;107:654–62.
43. Harvey L, etal. Parental perceptions of childhood feeding prob-
lems. J Child Health Care. 2015;19(3):392–401.
44. Faith MS, etal. Child food neophobia is heritable, associated
with less compliant eating, and moderates familial resemblance
for BMI. Obesity. 2013;21(8):1650–5.
45. Benjasuwantep B, Chaithirayanon S, Eiamudomkan M. Feeding
problems in healthy young children: prevalence, related factors
and feeding practices. Pediatr Rep. 2013;5(2):38–42.
46. Howard, A.J., etal., Toddlers’ food preferences. The impact of
novel food exposure, maternal preferences and food neophobia.
Appetite, 2012. 59(3): p. 818–825.
47. Goh DY, Jacob A. Perception of picky eating among children in
Singapore and its impact on caregivers: a questionnaire survey.
Asia Pac Fam Med. 2012;11(1):5.
48. Powell, F.C., C.V. Farrow, and C. Meyer, Food avoidance in chil-
dren. The influence of maternal feeding practices and behaviours.
Appetite, 2011. 57(3): p. 683–692.
49. Evans A, etal. Parental feeding practices and concerns related
to child underweight, picky eating, and using food to calm differ
20 Page 18 of 19 Nutrire (2021) 46: 20

1 3
according to ethnicity/race, acculturation, and income. Matern
Child Health J. 2011;15(7):899–909.
50. Iwinski S, etal. Child attachment behavior as a moderator of the
relation between feeding responsiveness and picky eating behav-
ior. Eat Behav. 2021;40:101465.
51. Zohar, A.H., etal., A longitudinal study of maternal feeding and
children's picky eating. Appetite, 2020. 154.
52. Fernandez, C., etal., Trajectories of picky eating in low-income
US children. Pediatrics, 2020. 145(6).
53. Cole NC, etal. Home feeding environment and picky eating
behavior in preschool-aged children: A prospective analysis. Eat
Behav. 2018;30:76–82.
54. Steinsbekk, S., etal., Child and parent predictors of picky eating
from preschool to school age. The International Journal of Behav-
ioral Nutrition and Physical Activity, 2017. 14.
55. Taylor CM, etal. Macro- and micronutrient intakes in picky eat-
ers: a cause for concern? Am J Clin Nutr. 2016;104(6):1647–56.
56. Taylor CM, etal. Picky eating in preschool children: associa-
tions with dietary fibre intakes and stool hardness. Appetite.
2016;100:263–71.
57. Cano SC, etal. Behavioral outcomes of picky eating in childhood:
a prospective study in the general population. J Child Psychol
Psychiatry. 2016;57(11):1239–46.
58. Antoniou EE, etal. Picky eating and child weight status develop-
ment: a longitudinal study. J Hum Nutr Diet. 2016;29(3):298–307.
59. Perry, R.A., etal., Food neophobia and its association with diet
quality and weight in children aged 24 months: a cross sectional
study. The International Journal of Behavioral Nutrition and Phys-
ical Activity, 2015. 12.
60. de Barse LM, etal. Longitudinal association between preschool
fussy eating and body composition at 6 years of age: The Genera-
tion R Study. Int J Behav Nutr Phys Act. 2015;12:153.
61. Shim JE, etal. Associations of infant feeding practices and
picky eating behaviors of preschool children. J Am Diet Assoc.
2011;111(9):1363–8.
62. Schmidt, R., etal., Macro- and micronutrient intake in children
with avoidant/restrictive food intake disorder. Nutrients, 2021.
13(2).
63. Whelan CM, Penrod B. An evaluation of sequential meal presenta-
tion with picky eaters. Behav Anal Pract. 2019;12(2):301–9.
64. Maiz, E., etal., Child involvement in choosing a recipe, purchas-
ing ingredients, and cooking at school increases willingness to try
new foods and reduces food neophobia. J Nutr Educ Behav, 2021.
65. Pickard A, Thibaut JP, Lafraire J. Strawberries and cream: the
relationship between food rejection and thematic knowledge of
food in young children. Front Psychol. 2021;12:626701.
66. Shimshoni Y, Silverman WK, Lebowitz ER. SPACE-ARFID: A
pilot trial of a novel parent-based treatment for avoidant/restrictive
food intake disorder. Int J Eat Disord. 2020;53(10):1623–35.
67. Katzow, M., etal., Maternal depressive symptoms and perceived
picky eating in a low-income, primarily Hispanic sample. 2019,
Lippincott Williams & Wilkins: US. p. 706–715.
68. Sandvik P, etal. Picky eating in an obesity intervention for
preschool-aged children - what role does it play, and does the
measurement instrument matter? Int J Behav Nutr Phys Act.
2019;16(1):76.
69. Cano SC, etal. Trajectories of picky eating during childhood: a
general population study. Int J Eat Disord. 2015;48(6):570–9.
70. Bronfenbrenner, U., Child development. Developmental Research,
Public Policy, and the Ecology of Childhood. Vol. 45. 1974. 5.
71. Fries LR, van der Horst K. Parental feeding practices and asso-
ciations with children’s food acceptance and picky eating. Nestle
Nutr Inst Workshop Ser. 2019;91:31–9.
72. Diagnostic and statistical manual of mental disorders (DSM-5®).
2013, American Psychiatric Association: Washington, DC.
73. Babik, K., etal., Infant feeding practices and later parent-reported
feeding difficulties: a systematic review. Nutr Rev, 2021.
74. Gibson EL, Cooke L. Understanding food fussiness and its impli-
cations for food choice, health, weight and interventions in young
children: the impact of professor Jane Wardle. Curr Obes Rep.
2017;6(1):46–56.
75. Wright CM, Parkinson KN, Drewett RF. How does maternal
and child feeding behavior relate to weight gain and failure
to thrive? Data From a Prospective Birth Cohort. Pediatrics.
2006;117(4):1262.
76. Riebl SK, etal. A systematic literature review and meta-analy-
sis: the theory of planned behavior’s application to understand
and predict nutrition-related behaviors in youth. Eat Behav.
2015;18:160–78.
Page 19 of 19 20Nutrire (2021) 46: 20