Abstract
Background: The aim of this study is to assess the prevalence of picky eating among preschoolers and to address the clinical link between eating behavior and growth, physical activity, development, and health status.
Methods: In this study, a structured questionnaire was used to perform a crosssectional descriptive study of 800 parents of preschoolers aged 2-4 years in Kurdistan/ Iraq. Data collected included: demographics, food preferences, eating behavior, body weight, BMI, height, development, physical activity, and records of medical illness. Data from children defined as picky or non-picky eaters responses were analyzed and compared using standard statistical tests according to questionnaire records obtained from participating parents.
Results: The mean age of the children was 2.85 years; among eight hundreds participants, 620 (77%) were picky eaters. Compared with non-picky eaters 180 (23%), z-score of weight-for-age, height-for-age, and body mass index (BMI)-for-age in picky eaters was 0.90, 0.71, and 0.42 SD lower, respectively. There were significant variations of rates in the weight-for-age, height-for-age, and BMI-for-age percentiles <15, between picky and non-picky eaters (P = 0.04, 0.023, and 0.005, respectively). Certain findings were higher in picky as compared to non-picky preschoolers including negative social communication such as afraid of unfamiliar places 65% vs 13.3%, afraid of being lonely 14.6% vs 12.1%, poor physical activity 36.8% vs 17.7%, learning disability 16.2% vs 7%, attention deficit 11.8% vs 4.3%, speech delay 4.6% vs 3.3%, respectively).
Conclusion: The prevalence of picky eaters in preschool children was high, resulting in significant negative impacts on growth, nutritional status, development, physical activity, and health status.
Keywords: Picky Eating; Preschoolers; Growth and Development; Physical Activity; Health Status
Introduction
\Picky or selective eating often refers to those children with strong food preferences, consuming an insufficient variety of foods, restricting the intake of certain food groups, consuming a limited amount of food, or being reluctant to try new foods. Picky-eating behaviors are common during infancy and childhood [1]; though, till now the term picky eater is not well understood [2-4]. The prevalence of selective eating among children varies in different countries. In a study conducted in USA, almost fifty percent of young children were reported by their parents not to be eating optimally [5]. Another study of 120 children aged 2-11 years identified thirty nine percent as picky eaters [6], and picky eating prevalence as high as fifty percent was reported in children aged 19-24 months in a study carried out in North America [7]. Among children aged three to seven years old in China, fifty four percent was reported by parents to be picky eaters [8]. A recent study reported that thirty six percent of young Chinese preschoolers aged 2-3 years old had selective-eating behaviors [9].
Moreover, contradictory outcomes of prevalence of childhood
picky eaters were reported studies, probably due to variations
in definitions, methods of assessment, and diverse age ranges of
children studied (Goh, Jacob, 2012, Jacobi et al, 2008, Mascola et al,
2010, Micali et al, 2011) [1,6,10,11]. Preschoolers often use their
body language or non-linguistic verbalizations to express their
meal favors, while older children independently make their food
preferences at school, therefore the parent understand the refusal
of food as being stronger as the child grows. However, picky eating
behaviour is quite frequent in school children with the prevalence
ranging from thirteen percent-forty seven percent in developed
countries (Goh. Jacob, 2012, Jacobi et al, 2008, Mascola et al, 2010)
[1,6,10]. Picky eaters usually have a limited dietary variety and
consume few fruits, vegetables and meat rich in micronutrients
[12]. In addition, their intake of fats, fiber, protein and sweets is
lower than that of non-picky eaters [2]. It is still unclear whether
the impact of picky eating on height and weight depends on the
types of food rejected by the picky eaters.
Picky eaters might have normal development besides to those
with medical or developmental disorders [5], and selective eating
in early childhood might extend and proceed to eating disorders in
adolescence and early adulthood [13]. Also, there might be a link
between behavioral feeding disorders and delayed development
in children, and few picky eaters’ children might have low weight
[3,8,14,15]. In addition, fussy eaters have certain distinguished
characteristics reluctance to try new foods, a dislike of certain
varieties of foods, and a very good opinions about food preparation
[1,2,12], which result in eating small quantities and a limited types
of food, potentially impacting a child’s growth (Goncalves 2013)
[9,16]. Consequently, this can result in long-term eating disorders
in adolescence and early adulthood. Hence, childhood picky eating
have reported conflicting results, possibly due to inconsistencies
in definitions and methods of assessment, as well as different
age ranges of children studied. (Needham 2007) [17]. Prevalence,
studies [1,6,10,11].
Some picky eating behavior in very young children, from
parents’ subjective perceptions, may be due to Neophobia, which is
different from pickiness in older children. Neophobia is the phobia
or fear of trying anything new in particular continuous and unusual
fear. In its milder form, the child dislike to try unusual things that
seem to him to be new or unfamiliar. In the context of children the
term is generally used to indicate a tendency to reject strange foods.
High nutrient requirement is needed for school-aged children as
they undergo rapid growing ; therefore, their eating habits are
essential for optimal development. However, picky eating behavior
is relatively common during childhood while at school, with the
prevalence ranging from thirteen percent to forty seven percent
in developed countries [1,6,10]. Moreover, selective eating in early
childhood has been shown to continue into mid-adolescence, which
is associated with eating disorders, lasting fussy eating, and limited
dietary variety in adolescence and adulthood [18-20].
However, the clinical impact of picky eating on the growth of
children is still controversy. One longitudinal study of 1498 children
aged 2.5, 3.5, and 4.5 years in Québec found that picky eaters were
twice as likely to be underweight at 4.5 years old than children who
were never picky eaters [21], whereas, Contradictory findings from
another longitudinal study with 120 children in the San Francisco
Bay area followed from 2 to 11 years of age suggested no significant
effects of picky eating behavior on growth [6]. These opposite
results might be due to certain reasons: 1st, the differences in perceptions
and assessments of picky eating, 2nd, failure to adjust various
confounding factors including age, gender, birth weight of the
child, and socio-demographics. Cognition and intellectual status of
school children is very relevant and is often concerning for parents.
Certain studies indicated that nutrition during early childhood had
long-lasting impacts on the intelligence of children [22,23].
As the brain grows and develops faster than the rest of the body,
nutrient deficiency, especially protein, iodine, iron, zinc, folic acid,
and vitamin B 12, at a critical stage of development may result in
everlasting changes in brain structure and cognition status [22].
In comparison to non-picky eaters, selective eaters usually have
a restricted dietary variety and limited consumption of few fruits,
vegetables, and meat rich in micronutrients [15]. Moreover, their
intake of fats, fibre, protein and sweets is lower than that of nonpicky
eaters [2]. It is unclear whether the impact of picky eating on
height and weight depends on the variety of food rejected by the
picky eaters. However, in one study a lower intake of vitamin E and
C, and fibre was found in picky nine-year-old girls [2].
Subjects and Methods
This is a cross-sectional descriptive study used a structured questionnaire to obtain information from parents in Iraq/Kurdistan region who were parents to children aged 2-4 years. Participants were randomly selected from Zakho General Hospital-Department of Pediatrics, Nutrition Rehabilitation Center(NRC) as well as private clinic for general pediatrics, child’s nutrition and growth in Zakho-Duhok city in Iraq to meet pre-specified allocations for race, age, and gender, representative of the national population. A total of 800 participants (400 from each place) who met the eligibility criteria were enrolled and included in this study. Consent forms were obtained from each preschoolers’ parents or caregivers to address their participation in this research study.
Interview Process
The interviews were scheduled, managed and enrolled by the authors themselves. Children aged 2-4 years old who had history of chronic illnesses, that might negatively impact their food behavior, were excluded including prematurity, low birth weight (<2,500 g), dental diseases, organic diseases, mental disorders such as cerebral palsy, genetic diseases, psychiatric illness, anorexia, gastro-esophageal reflux disease, food allergies, and lactose intolerance. As well as those preschoolers with acute illness such as flu or diarrhea were all excluded. Data for this study were collected between September 2018 and July 2019. All participants gave their written and informed consent signed by their parents. Using a multi-stage stratified cluster sampling method, 800 children aged 2-4 years were recruited. Data collection were obtained in this study through face-toface interviews with the children’s parents. The participants were all eligible to share in this study. Also, parents with limited economic means to support their children’s nutrition, had inadequate idea or knowledge for children’s diets, development, and physical activities, or were unable to provide sufficient healthy diet for other reasons, were not included in this study.
Socio-Demographics and Anthropometric Measurements
The authors, after confirming eligibility, contacted families and
arranged a meeting with parents for a face-to-face interview. The
socio-demographic information was collected from the parents
with a structured questionnaire survey (mothers: 99% of parents)
and was administered by trained interviewers. Demographic data
included child’s date of birth, gender, ethnicity, and birth weight.
As well as Data including any medical history of child’s food allergy
history and parents’ body weight and height were also considered
from the interview. During interview process we asked parents
what they do children prefer to eat, how do the children act when
they eat, their growth and development, physical activity, general
health questionnaire. The interviews took approximately half an
hour to complete.
Special forms for parents were used to collect information about
the family size and the education level to get socio-demographic
data using questionnaires. Closed-ended categorical questions
including lists of options for parents to choose, to get information
about the nutrition and general medical health status of the included
participants. The main questions included diets preferences, eating
behaviour, parent/child communication during mealtimes, speech
ability, developmental behaviors, day activities, and records of
chronic diseases in the last 12 months. A quantitative study with no
detailed discussions were conducted in this research. The author
carried out the interviews between the 1st of April and the 31of
June 2019. All parents of children introduced their agreement and
signed a consent form for their children to participate in this study.
Growth and Nutritional Assessment of Preschoolers
Children’s weight and height were measured in Zakho General Hospital-Nutrition Rehabilitation Center-Department of pediatrics on an individual and solicited basis, before the interview associated with the food frequency questionnaire. Children were weighed without shoes and wore napkins only for accuracy purposes to get body mass index (BMI) [weight (kg)/height (m2)]. The percentile and z-score of weight-for-age, height-for-age, and BMI-for-age were considered to assess the impact of picky eating behavior on children’s growth and nutrition status. Weight-for-age, weightfor- height, and height-for-age were expressed as sex and age agespecific percentiles, and the growth standards for height, weight, and BMI based on a general WHO population were used to obtain z-scores for each measurement according to age and sex [24]. The used parameters to assess growth status were height-for-age and weight-for-age z-scores, and those used to evaluate nutritional status were weight-for-age and BMI-for-age z-scores. Weightfor- age, height-for-age, and BMI-for-age percentiles <15 were considered to indicate that the child was underweight, of short stature, or suffering from malnutrition, correspondingly.
Assessment of Picky Eating
To evaluate picky eating behavior through organized questionnaire tow categories were addressed in this study. 1st is the food preferences and 2nd is the eating behavior.
Food Preferences: In an organized questionnaire, all parents were questioned about their child’s food preferences. Questions about preferences for food and food variety included a modified version of a questionnaire based on the United Kingdom Department of Health Survey of the Diets of British School Children [24] and dietary assessment among school-aged children [18]. Also, changes were made to the questionnaire used and based on Iraqi-Kurdistan dietary culture and food habits.
The questionnaire included 2 main items:
Child’s Meals and their Preferences in more than Ten Food Categories
(i) Grains (rice, bread, cereals, potato, noodles, pasta, etc.),
(ii) Protein foods (eggs, red or white meat, fresh fish, seafood,
beans, potato, etc.)
(iii) Vegetables,
(iv) Fruits,
(v) Dairy products (milk, cheese, yogurt, etc.),
(vi) Fats and oils (vegetable oil, butter, cream, salad, etc.), and
(vii) Snacks and sweets (chips, candy, cookie, cake, etc.) in past
15 days.
Preferences in Common Foods (list of Fifty Foods for Regular Meals): The responses were had and did not have ” in each food and responding to preferences of the tried foods. Items were scored on a five-point scale as “love and enjoy it very much,” “love it moderately,” “Dislike it moderately,” and “Dislike it very much.”
Feeding and Eating Behaviors
On the other hand, another questionnaire arranged for parents to find out about their feeding behaviors (10 items: six appropriate behaviors, four inappropriate behaviors) and their child’s eating behaviors (ten items: 4 healthy eating behaviors, six picky eating behaviors). The eating behavior questionnaires were inspired from the Children’s Eating Behavior Questionnaire developed by Wardle et al. the classification of feeding disorders of infancy and early childhood by Chatoor and Ammaniti [13] and a study about the trends of eating behaviors in preschool children [25,26].
The four questions for picky eating behaviors included
(i) Eats limited foods
(ii) Reluctance to eat usual meals,
(iii) Refusal to try new meals, and
(iv) Refusal of one or multiple food groups in six major food
groups (grains, protein foods, vegetables, fruits, dairy foods,
and fats and oil).
Items were scored on a five-point scale as “not at all,” “seldom,”
“on occasion,” “frequently,” or “always.” Mean scores were calculated
for each subscale (range 1-5) with higher scores indicating higher
values of each trait.
Accordingly, a defined picky eating behavior was derived in
case of positive response of “always” to at least one item of the
picky eating behaviors on questionnaire of eating behaviors in this
research study.
Assessment of Development
The questionnaire for assessment of development was modified based on the Denver Developmental Screening Test II. The test assesses children from 2 to 4 years old who are apparently asymptomatic . The DDST-II consists of 125 items grouped into four areas: personal-social, fine motor, gross motor and language. Additionally, each recording sheet includes a behavioral test in which several items are recorded, such as the child’s interests or capacity to pay attention, among other items. Upon completion of the test, three scores or classifications are possible: normal, suspect and not testable. The DDST-II has been adapted and emphasized in Singapore, Iran and Sri Lanka. The Sensitivity and specificity values in Spanish version of the test were 89 and 92 %, respectively; and more reliable in Hallioglu et al. study found sensitivity values of 100 % and specificity of 95 percent. DDST II for early identification of the infants who will develop major deficit as a sequel of hypoxicischemic encephalopathy.
Assessment of Physical Activity
A modified questionnaire for assessment of physical activity was used based on a study of objective measurement of physical activity and sedentary behavior [23]. Statements relating to physical activity requested respondents to rate their degree of agreement on a five-point scale (unacceptable, improvement expected, acceptable, exceeding expected, outstanding). Mean scores were calculated for each subscale (range 1-5) with higher scores indicating higher values of each trait. The questionnaire assessing physical activity consisted of four items: normal-pace walking; sport activities; stair-climbing; and running. The answers of “unacceptable” or “improvement expected” of the item assessed were considered as having low level physical activity. Those with two or more low-level physical activities were defined as having a poor general physical activity level.
Results and Findings
Data and Characteristics
In this cross-sectional study, eight hundred preschoolers aged 2-4 years were screened, of whom 740 met eligibility criteria were enrolled. Sixty participants were excluded, 30 preschoolers had chronic illnesses affecting eating habits and growth status, 15 caregivers had limited economic means to support their children’s diets, and caregivers did not have enough concept for children’s nutrition support, development, and physical activities or were unable to provide adequate nutrition for other reasons. Table 1 illustrates the demographic variations between picky and nonpicky eaters. Based on the food and dietary questionnaire survey, 620 preschoolers (77%) were found to have picky-eating behavior. The mean age of these children was 2.97 ± 0.59 years. Certain factors such as gender, age, primary caregiver, education levels of caregiver, or family size between the participants have no statistical variations in this study (Table 1). In this study, {always} responders among picky preschoolers cohort were commonly as follows: Eating sweets or snacks instead of meals(52.6%), Refusing food, particularly fruits and vegetables (37.8%), Reluctant to eat regular meals (27.6%), Do not like to try new food (Neophobia, 23.3%), Ingestion of specific kinds of food (16%), Excessive drinking of milk (14.2%). Seventy-eight cases among preschoolers disliked meat (9.7%), vegetables(180 cases, 22.8%), fruit(62 cases, 7.7%), and certain types of fruit or vegetables (52%, 220 cases).
Anthropometric Data
As shown in Table 2 below, in this study in Iraq/Kurdistan region, for preschoolers, the standard weight, height, and BMI(Body Mass Index) were 12.4 kg, 91.66 cm, and 14.93, correspondingly. In comparison to non-picky eaters, such results for picky eaters were interestingly low. As well as picky eaters had significantly lower average weight-for-age, height-for-age, and BMI-for-age percentiles; Besides, less than fifty was the mean weight- and height-for-age percentiles in picky eaters, while it was greater than fifty (median of population) in non-picky eaters. Picky preschoolers also stated that they had, compared to non-picky eaters, higher rates of weight-for-age, height-for-age, and BMI-for-age percentiles less than fifteen. Considerably greater percentages of children with a weight-for-age percentile less than 15, a height-for-age percentile <15, and a BMI-for-age percentile <15 were picky eaters respectively, (Table 2). The same scenario was with the z-scores, as the average z-scores of weight-for-age, height-for-age, and BMI-forage in picky eaters were all obviously less than those z-scores of non-picky eaters (Table 2).
Development
Table 3 displays differences in the development between picky eaters and non-picky eaters. Attention deficit and low learning ability were the detected low-quality developments in learning ability. Slow verbal development and poor language development were the detected low-quality developments in verbal ability. Afraid of unfamiliar places and afraid of being alone were the detected low-quality developments in interpersonal relationships. Table 3 below demonstrates the prevalence rate of three categorized low-quality developments in picky and non-picky group children. Of the three categories of low-quality development, a significantly higher prevalence of children who had negative interpersonal relationships was found in the picky group. A higher rate of “afraid of unfamiliar places” was reported to be picky eaters (Table 3). Compared to non-picky group, a significantly lower score of all questionnaire items was found in the picky group (26.6 ± 3.1, vs. 20.8 ± 2.8) (Tables 3 & 4).
Table 4: Presentation levels of physical activities and health status among picky and non-picky preschoolers.
Discussion
The American Academy of Pediatrics (AAP),in addition to many world-wide institutions, stated that ,the importance of early detection of psychomotor delay in preschoolers, can be achieved by repeated systematic screening at ages of 9, 18 and 30 months consequently. Therefore, a reliable test to adapt for addressing behavioral and motor development in preschool children is essential. The widely used screening tests is the Denver Developmental Screening Test (DDST) which was first published in 1967. Despite of several studies have illustrated the prevalence of picky eaters among preschoolers, a small number have evaluated the correlation of picky eating with pediatric development, physical activity, and health status. In this study we provide an interesting impression of selective preschoolers aged 2-4 years in Iraq/ Kurdistan region and consider remarkable thoughts regarding the impact on children’s growth, development, physical activity, and disease load. The food preferences, development, and physical activities between picky eaters and non-picky eaters were scored and analyzed statistically. Our study is the first in Iraq to correlate the behaviors of preschoolers with low-quality development and lower performance values of physical activities.
The definition of picky eaters among children is variable. Lots
of studies are available regarding to the prevalence of picky eating
in childhood with a huge difference was shown [19]. The majority
of previous studies use parental views concerning picky children
to recognize child’s selective eating. The core of definition of picky
eating was based on the objective questionnaires of detecting picky
eating, was used in our study, by strong existence of picky eating
behaviors on four queries. As compared to already published papers,
the prevalence of picky behaviors among preschoolers, was
higher, at fifty seven percent [6,7,11]. A new report indicated three
significant parent-reported feeding questions that may identify
persistent picky eaters at an early age [20]. Therefore, based on
parental views, the three questions included a subjective identification
of picky eater by parental thoughts, and two typical and
ordinary picky eating behaviors (strong likes concerning food and
unwillingness to accept new foods). These two picky eating behaviors
were adopted in our questionnaire. We recruited the other two
characteristic fussy eating behaviors which could assist to spot remarkable
precision of picky eating behaviors among preschoolers.
In Hong Kong, a large longitudinal study revealed that forty
three percent among seven thousands children aged 2-7 years, were
reported by their parents as being picky eaters, and forty percent of
children’s picky-eating behavior lasted longer than 2 years [6,11]. A
cross-sectional survey showed that the percentage of picky eaters
increased from nineteen percent at 16 weeks old to fifty percent
by age of 2 years [7]. In addition, another cross-sectional survey
of Chinese preschoolers addressed that prevalence of picky eating
was thirty six percent in 2-3 years olds as compared to twelve
percent in 6-11-month-old ([8]. Therefore, such results indicate
that picky eating is a persistent dilemma [6,7]. In our current study,
correlatively more participants in the younger age group were
picky eaters (50% age 2-3 years vs. 27.5% age 3-4 years). However,
pickiness behavior start to decline with age through early childhood
and reach its peak time ate age of two-four years old according
to previous studies [4,12]. The picky eaters in this group of
preschoolers from Kurdistan/Iraq illustrated vital lower numbers
and values of accepted foods and food preference respectively. The
questionnaire items for the evaluation of pickiness behavior in
the current research study was similar to those questionnaires of
preceding studies [7,16,17].
Therefore, meat, fruit, fish, and specific kinds of vegetables
were the food items that they dislike to consume; parallel pickyeating
behaviors were observed among children in Hong Kong [11].
the most common picky-eating behaviors among preschoolers in
Iraq/Kurdistan region were being unwilling to eat regular meals,
refusing fruit and vegetables, and being likely to eat sweets or
snacks instead of meals. Such results are identical to picky-eating
behaviors conducted in another research study in Singapore [16].
Further research studies revealed that picky eaters were twice as
likely to be underweight at 4.5 years old as non-picky eaters [26].
In the current study, excessive milk-drinking, eating sweets and
snacks were common picky-eating behaviors. In preschoolers and
according to the food records, extreme milk-drinking may result
in low appetite at mealtimes and cause inadequate energy intake.
According to cross-sectional analysis in the United Kingdom and
based on questionnaires completed by parents when their children
were aged 30 months, revealed that seventeen percent eating a
partial quality, thirteen percent preferring drinks to food: therefore,
limited variety and favoring drinks were the most common problem
behaviors [3].
Furthermore, the study pointed that an eating problem, in
children over 2 years, resulted in underweight over the first 2 years;
eleven percent had weight loss compared with three percent of
children who were not diagnosed as having an eating trouble.
Accordingly, weight loss is more common in picky eaters and
excessive milk-drinking may be a cause of low appetite at regular
mealtimes. Currently, there are not enough research studies and
approved information about the impact of picky-eating behavior
on the nutritional and growth status of preschoolers. A study that
compared the weight, height, and weight-for-height percentiles of
thirty four children with picky-eating behavior and 136 healthy
controls concluded that seven of 34 children (20.6%) in the pickyeating
group and nine of 136 (6.6%) in the control group were
underweight; being underweight was found in fifteen children
(14.2%) younger than 3 years old and in one child (1.6%) older
than three years old [21]. The investigators found that children with
picky-eating habits are at an increased risk of being underweight,
particularly in those younger than 3 years old.
According to our data, weight and height of picky eaters were
significantly lower than non-picky eaters: In general, the weightfor-
age, height-for-age, and BMI-for-age percentiles of non-picky
eaters were above 50th, while picky’ eaters were under 50th. Also,
compared with non-picky eaters, z-score of weight-for-age, heightfor-
age, and BMI-for-age in picky eaters was 0.91, 0.73, and 0.44
SD lower, correspondingly (Table2). Furthermore, picky eaters
comprised significantly higher proportions of children who were
underweight, short, and with low BMI (<15 percentiles) compared to non-picky eaters. A negative impact of picky eating behaviors
on growth was found in pre-school and early school-age children.
However, in a study conducted in Saudi Arabia, 315 pre-school
children with eating problems as compared to one hundred health
control revealed that the main feeding problems detected were
picky eating in 85.5% of feeding problem with normal growth
group, these group children were still having normal growth
parameters, but they had significantly lower growth parameters
than healthy children [15].
Moreover, in a China study of nine hundred thirty-seven
recruited healthy children of 3-7 years old concluded the
prevalence of picky eating as reported by parents was fifty four
percent ; the weight for age z-score was significantly lower in picky
eaters compared to non-picky eaters [8]. Furthermore, dietary
consumption in preschoolers might be negatively influenced by
pickiness behavior. A randomized trial of Chinese preschoolers
(aged 2.5-5 years) based on validated dietary analysis software of
local database of recommended nutrient intakes concluded that
median daily energy intake was twenty five percent lower than the
age-appropriate intake in preschool picky eaters, and found that
preschool picky eaters with low weight-for-height index was at risk
for significant dietary and nutrient deficiencies [27]. In that study,
almost fifty percent of the picky eaters met the recommendation for
daily servings of fruit, and fewer in vegetables (14.7%) and dietary
products (6.3%), and grains and cereals (6.3%) [27]. Furthermore,
in Chinese study, preschoolers (ages 3-7 years) concluded that
picky eaters had lower intakes of protein, dietary fiber, vegetables,
fish, and cereals, compared with non-picky eaters [8].
Another study of Chinese young infants and toddlers (6
months-3 years) observed that lower intake of eggs and their food
cohort in picky eaters compared to non-picky eaters [9]. However, in
our study, the common dislike foods among preschool picky eaters
(ages 2-4 years) were meat, vegetables and fruit (37%, 39%, 22%)
respectively. Besides, a research study of four hundred twenty six
German children aged 8-12 years revealed that pickiness behavior
was linked to abnormal behavior for instance, anxiety, depression,
withdrawal and somatic complaints, as compared to normal
behavior in non-picky eaters [4]. The link between numerous
eating disorders (overeating, anorexia, or feeding difficulties)
and development has been reported in children and adolescents
(28-33), while the association between picky-eating habits and
development in preschool children has rarely been documented.
However, in our study, we found positive correlation between
picky-eating behaviors and low-quality general development in
preschoolers with unknown reason due to deficient evidence in
research and literature.
Besides, picky eaters tended to have a greater fear of unfamiliar
places as compared to non-picky preschoolers. A future longitudinal
study and further studies are required to illuminate the underlying
consequence relationship between picky eating and low-quality
of general development. Also, picky eaters tended to have lower
values of the performance in physical activities especially a lower
level of stair-climbing. In addition, picky preschoolers tended
to have higher risk of constipation and acute infectious illness
as compared to non-picky preschoolers. Likewise, Picky eaters
(aged 3-5 years) with growth faltering who were randomized to
receive 3-month oral nutritional supplementation had significantly
greater increases in weight and height than non-supplemented
controls and developed proportionally fewer upper respiratory
tract infections. In Filipino children, long-standing oral nutritional
supplementation helped promote nutritional adequacy and growth
who were at risk of nutritional deficiency. The findings showed that
long-term use of oral nutritional supplement enhanced food variety
and promoted sufficient intake of nutrients that were inadequate
in Filipino children’s diets without interfering the intake of normal
family meals [28].
Therefore, picky preschoolers had improvement in their growth
after consuming oral nutritional supplementation. Another interesting
randomized controlled trial of Chinese picky preschoolers
aged 3-6 years old and weight-for-height ≤25th percentile showed
higher significant changes in growth parameters and nutrient intake
in the group with a nutritional milk supplement than the group
with nutrition counseling alone. As comparison to the children with
nutrition counseling alone, increases in weight-for-age z-scores and
weight-for-height z-scores were significantly better at 3 months,
and increases of intakes in energy, protein, carbohydrate, docosahexaenoic
acid, arachidonic acid, calcium, phosphorous, iron, zinc,
and vitamins (A, C, D, E, B6) were significantly elevated at 2 months
and 4 months in the children with a nutritional milk supplement.
The power of this study included the population-based design in
preschool children and extensive questionnaire to assess picky eating
behavior, growth status, quality of development, level of physical
activity, and health status [29].
To reduce the selection bias, the participants enrolled were
healthy, with good economic state and no need for nutrition
support; the caregivers had sufficient knowledge and perception
in children’s diets, development, and physical activities. Moreover,
our study defined the picky eating by objective questionnaires and
scored the performance on each questionnaire items of development
and physical activity to demonstrate the difference of development
and physical activities between picky and non-picky eaters,
this to empower the scientific credibility. Our study has certain
limitations. The self-rating questionnaires only presented the point
of views from caregivers, over-/underestimation in reporting may
exist due to lack of objective behavioral observations on eating
behaviors, interaction, developments, and physical activities. lastly,
the inclusion of participants from two various places may limit the
generalization of the findings to the whole country [30].
Overall
Pickiness behaviors in preschoolers might have negative impacts and consequences on development quality, physical activity level, and general health status. Therefore, Parents and caregivers need to be well informed and taught about feeding strategies to enhance adequate food variety for their preschoolers and to increase the number of foods accepted by their toddlers and appropriate dietary interventions to develop sound feeding solutions to address pickyeating behaviors. Also, clinicians might play a vital role to guide and support parents and caregivers on the finest approaches to reach the best possible nutrition for their children who are picky eaters, and early diagnosis and clinical intervention of pickiness behavior among preschoolers might help to reduce or limit the negative impacts of such behavior on children’s growth and development.
Availability of Data and Materials
Data for research purposes are available upon request.
Consent for Publication
All participants gave and provided their written consent forms.
Conflict of Interest Statement
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Acknowledgement
We thank and acknowledge all children and their parents or caregivers for their time and efforts to take part in this research project.
Funding
This study was not funded by grants or other financial sponsors. The authors declare that they have no financial arrangement with a company whose product is discussed in the manuscript.
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