Health providers, researchers, and parents do not yet have a handle on the management and messaging of picky eating in children. This is, in part, due to the lack of a precise and accepted definition of what constitutes picky eating. Moreover, the variation in those who persist in picky eating through developmental stages versus those who outgrow it has not been well studied. If picky eating is not a normative developmental event but rather an individual difference, recommendations for how to feed the picky eater may differ from those provided for typical eaters. One complicating factor is that what is common, as in a child’s position on a normative developmental curve, or adaptive and desirable, as in normative standards,1 is poorly operationalized in terms of what constitutes picky eating. This leaves pediatricians at a loss and parents disconsolate.
For example, the prevalence of picky eating can vary in the literature depending on how it is defined. When the definition is based on a “somewhat” response to the question “Is your child a picky eater?” the prevalence of picky eating can be as high as 50%.2 When more stringent and complex definitions are employed, the prevalence estimates are closer to 5%.3 The study by Fernandez et al4 in this issue of Pediatrics improves on this construct by using greater specificity to define picky eating. Via a person-centered approach, children were categorized into 3 groups (high, medium, and low) according to differences in their levels of food selectivity and its persistence over a 4-year period beginning at age 4. The findings in the current study confirm these previous differences in definition and the corresponding differences in prevalence that occur when these thresholds are altered. Taking a step back from these data reveals a crucial observation about picky eating: it is not normative, both in terms of frequency and adaptiveness. What does frequently occur is that children (and arguably adolescents and adults) are sometimes selective about the food they choose to eat. Also, this pattern is persistent and probably adaptive. Being cautious about food choices is probably wise given certain contexts and body states. However, when a parent describes a child as often or always selective, it is beyond normative, being neither common nor adaptive. Roughly only 14% were described this way, and its persistence across context and time may be associated with consequences, both psychosocial and otherwise. Future studies using this consistent definition are needed to confirm this hypothesis.
We Have Not Found the Optimal Period To Intervene
This raises the next question: What is to be done? Perhaps the most significant finding from Fernandez et al4 is that interventions need to begin at younger ages because of the stability of picky eating trajectories overtime. For example, Cashdan5 suggested there is a sensitive period of development in which children are more receptive to the exploration of new tastes, perhaps because they are directly under the safe guidance of adult caregivers (eg, ≤24 months). This is obviously not to say that change cannot be implemented beyond that period, but it is more to emphasize that this is a developmental stage on which to capitalize.
And/Or…We Have Not Found the Right Strategy
This study also provides important clues into what can be done during this developmental period and later developmental periods. Hughes et al6 argue that feeding styles explored in relation to picky eating are largely authoritarian rather than responsive. The authoritarian style is highly directive, lacks warmth, and tends to be punitive without consideration of the child’s individual needs or context. In contrast, the indulgent style is extremely sensitive to the child’s individual needs and context, but it lacks structure and authority. An authoritative feeding style combines attributes from both, having parent structure and guidance while being sensitive to the child’s needs without being punitive. Examining the impact of an authoritative feeding style on food exploration across levels of picky eating is a priority for future research. This is particularly true given the consistent finding in this study and others that children who are higher in picky eating are also higher in emotional lability and lower in emotion regulation. Although it is imperative that humans develop a sophisticated system of discerning which foods are safe and which substances should not be ingested,7 children who are high in emotional lability may also be more sensitive to threatening messages in the environment (eg, social cues of distaste, talk of healthy versus nonhealthy foods). Thus, well-intended guidance may have inadvertant consequences, creating a context that treats foods as potentially hazardous rather than pleasurable.
Findings from Fernandez et al,4 knowledge of fear learning,8 and curiosity about strategies to increase pleasure9 can be used to guide hypotheses about future directions for research and provide some immediate suggestions for parents. According to theories of inhibitory learning, memories of previous fearful events are not erased with new information,8 but rather, new memories that minimize threats compete with older memories to help individuals form new conclusions. In the context of feeding style, we can think of children with elevated picky eating as having thousands of negative memories about food (eg, conflict, unexpected tastes, discomfort). Thus, caregivers can work to create positive memories and experiences around food (eg, cooking, gardening) to help picky eaters expand their preferences. However, in doing so, it is critical that caregivers let go of their need for a child to taste something and instead focus on accumulating pleasant experiences. By minimizing the focus on outcomes (ie, child tries a food) in favor of building a pleasurable memory, children high in pickiness as well as emotional lability may begin to relax in the presence of food without worrying that their parents have an ulterior motive.10 Whether this approach eventually reduces pickiness is worth investigating; in the interim, it provides concrete objectives for parents, may reduce ineffective and resource-intensive feeding strategies, and overall, can ameliorate the shared eating experience.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: Dr Zucker received funding from the National Science Foundation and National Institute of Mental Health (grant R01-MH-122370). Dr Hughes received no external funding. Funded by the National Institutes of Health (NIH).
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-2018.
POTENTIAL CONFLICTS OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.