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Proc Nutr Soc. Author manuscript; available in PMC 2020 May 05.
Published in final edited form as:
Proc Nutr Soc. ; : 1–9. doi:10.1017/S0029665118002586.
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Picky eating in children: causes and consequences

Caroline M Taylor* and Pauline M Emmett
Centre for Academic Child Health, Bristol Medical School, University of Bristol, UK

Abstract
Picky eating is a common behaviour in early childhood. There is no universally accepted definition
of picky eating, nor is there agreement on the best tool to identify it. ‘Causes’ of picky eating
include early feeding difficulties, late introduction of lumpy foods at weaning, pressure to eat, and
early choosiness especially if the mother is worried by this; protective factors include provision of
fresh foods and eating the same meal as the child. The ‘consequences’ for the child’s diet include
poor dietary variety and a possible distortion of nutrient intakes, with low intakes of iron and zinc
(associated with low intakes of meat, and fruits and vegetables) being of particular concern. Low
intakes of dietary fibre as a result of low intakes of fruit and vegetables are associated with
constipation in picky eaters. There may be developmental difficulties in some children with
persistent picky eating. There is little evidence, however, for a consistent effect of being a picky
eater on growth trajectories. There may be a small subgroup of children in whom picky eating
does not resolve who might be at risk of thinness during adolescence, or of developing an eating
disorder or adult picky eating: these children need to be identified at an early age to enable
support, monitoring and advice to be offered to parents. Strategies for avoiding or ameliorating
picky eating include repeated exposures to unfamiliar foods, parental modelling of eating fruits
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and vegetables and unfamiliar foods, and creation of positive social experiences around mealtimes.

Keywords
Picky eating; Child; Diet; Fussy eating; Selective eating; Child development; Growth

Introduction
Picky eating (alternatively known as fussy, faddy, choosy or selective eating) is a common
behaviour in early childhood. It can cause considerable stress to parents/caregivers and have
a negative impact on family relationships(1), but it generally resolves with minimal or no
intervention by healthcare providers.(2) It is largely a phenomenon of developed countries
and involves a complex set of interactions between parents/carers and children centred
around food selection and consumption.(3)

*
Corresponding author: Academic Centre for Child Health, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road,
Bristol BS8 1NU, UK, [email protected], 0117 42 83099.
Conflict of interest
PME has from time to time received research funding and consultancy funding from Pfizer Nutrition Ltd, Danone Baby Nutrition
(Nutricia Ltd) and Nestle Nutrition. CMT has received research funding from Nestle Nutrition.
Authorship
CMT wrote the manuscript and PME critically revised it. Both authors have read and approved the final version.
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There is no agreement on a formal definition of picky eating, although it is generally

accepted to include rejection or restriction of familiar foods and unfamiliar foods, and thus
including an element of neophobia.(3) To add further complication, there are a variety of
tools used for the assessment of picky eating and consequently there is a wide range of
prevalence reported.(2) The ‘causes’ and ‘consequences’ of picky eating are not well
understood because of these inconsistencies and because of heterogeneity in study designs.
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This is further compounded by a lack of longitudinal observational data, with most studies
using only cross-sectional data. Addressing these problems would enable evidence-based
contributions to inform more consistent advice for parents and carers from healthcare
providers.

This review will first consider the effects of the variety of definitions and assessment tools
on the reported prevalence of picky eating. The possible ‘causes’ of picky eating, including
demographics, parental characteristics, early feeding practices and psychosocial factors, will
be described. Knowledge of the effects on the child’s diet, both as nutrients and diet quality,
and in relation to recommended daily intakes will be described, with a focus on the few data
available on longer-term patterns of intake. The ‘consequences’ likely to result from any
dietary differences between picky and non-picky children, including effects on body weight
and composition, growth, eating disorders and psychosocial difficulties will be outlined.
There will be a particular focus on data from the UK Avon Longitudinal Study of Parents
and Children (ALSPAC)(4), which is one of the most comprehensive sources of longitudinal
data on the causes and consequences of picky eating, both short- and long-term. The review
will conclude with suggestions for parents/carers and professionals to avert or ameliorate
picky eating behaviour.

Definition and prevalence

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The most commonly accepted definition of picky eating was proposed by Dovey et al. (3) in
which picky/fussy eaters are children ‘who consume an inadequate variety of foods though
rejection of a substantial amount of food that are familiar (as well as unfamiliar) to them’.
Dovey et al.(3) regard food neophobia (reluctance to eat, or the avoidance of, new foods) as
a somewhat separate construct, while recognising that the two factors are inter-related, and
that both contribute to the rejection or acceptance of foods, particularly of fruits and
vegetables. Alternative definitions include specific mention of restriction of intake of
vegetables, strong food preferences, provision of meals that are different from those of the
caregivers, special methods of food preparation, consumption of inadequate amounts of
food, and disruption of daily routines that are problematic to the child, parent or parent–
child relationship(5; 6; 7; 8; 9). It is clear, however, that picky eating is not synonymous with
Avoidant/Restrictive Food Intake Disorder (ARFID; previously known as Selective Eating
Disorder), which has a very specific definition in the Diagnostic and Statistical Manual of
Mental Disorders (DSM)-V, including the presence of nutritional deficiency as a result of
inadequate food intake, failure to gain weight in children, a decline in psychological
function, and a dependency on supplements to maintain nutritional health.(10)

There are several questionnaires available to identify picky eating, designed for completion
by the parent/carer, in which multiple aspects of the child’s feeding behaviour are assessed.

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Several of these questionnaires have been validated. Examples include the Children’s Eating
Behavior Questionnaire (CEBQ), the Child Feeding Questionnaire, the Lifestyle Behaviour
Questionnaire, the Stanford Feeding Questionnaire and the Preschooler Feeding
questionnaire.(2) Despite Dovey’s caution about the inclusion of food neophobia in the
definition of picky eating, several of the questionnaires have subscales that include elements
of neophobia. For example, the ‘fussiness’ subscale of the Children’s Eating Behaviour
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Questionnaire includes three out of six statement questions that relate directly to neophobia
(‘My child enjoys tasting new foods’/‘My child refuses new foods at first’/‘My child is
interested in tasting food s/he hasn’t tasted before’) (used for example by Hendy et al. (11);
Morrison et al. (12); Tharner et al. (13)). An alternative approach to multi-element
questionnaires is to ask the caregiver a single question on whether their child is a picky eater
(used for example by Mascola et al. (5); van der Horst et al. (14); Orun et al. (15)). Although
this approach is straightforward and enables clear classifications, it has the disadvantage of
requiring the carer to create their own definition of picky eating, which may or may not align
with the definition that the researcher intends. To address this, studies from ALSPAC have
used a single question asking whether the child has definite likes and dislikes for food, with
the responses ‘No/Yes, quite choosy/Yes, very choosy’. Although this does not capture all
the proposed facets of picky eating behaviour, it does avoid the difficulty of forcing the
caregiver to use their own definition of picky eating, and is similar to what might be asked of
a parent by a healthcare provider.(2) This question, which is similar to that used in other
recent studies (5; 14; 15), was asked at four timepoints in ALSPAC (24, 38, 54 and 65
months old), which enables both identification of picky eaters at a single time point and
identification of persistent picky eaters, who may be more at risk of adverse health and
developmental outcomes than transient picky eaters. It also enables modelling of outcomes
that occur after the exposure, enabling a greater degree of confidence in the causality of
associations than in a strictly cross-sectional approach. The lack of an accepted definition of
picky eating amongst researchers and the lack of an accepted and validated method of
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identification that is used universally is a hinderance to further research: it makes it difficult

to compare the results of studies effectively.

There is a wide range of prevalence found in different studies (6%–50%)(2), which is likely
to reflect differences in study design and assessment tools, but may also be due to social or
cultural factors. There is more consensus on the relation of prevalence to the child’s age: in
ALSPAC prevalence was 10% at age 24 months, peaking at 38 months (15%) and then
declining at 54 and 65 months (14% and 12%, respectively). Other studies have also found
the peak age to be at about 3 years old(7; 16) although one found the peak age to be at 6
years(5).

There is little known about whether some children sustain picky eating behaviour once it is
established, or how this relates to later outcomes such as eating disorders or adult picky
eating. Although some studies have found the prevalence to be stable with increasing age
(15; 17; 18), in ALSPAC it was found that children with picky eating identified at the
earliest time point at which it was measured (24 months) were more likely to be picky at the
next time point than if the picky eating was newly incident at a later time point, suggesting
that early picky eating behaviour is more persistent(2). The prevalence of picky eating was
moderately stable between age 4 and 6 years in a group of Norwegian children, with 50%

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being picky at both ages.(19) Some studies have shown the prevalence to be stable beyond
the age of 3 years (15; 20), even up to age 11 years (18). In the study in which the
prevalence increased up to 6 years of age and then plateaued (USA), this was interpreted as
evidence of two groups of picky eaters: one in whom recovery was relatively swift and
another in whom the behaviour persisted (5). Few studies have attempted to identify
persistent picky eaters systematically and it is difficult to do, bearing in mind that it requires
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a longitudinal study and a consistent identification strategy, as well as a definition of

persistence and a means of categorisation. Cardona Cano et al. (16); (21) identified four
picky eating trajectories (persistent/remitting/late onset/never) from assessments at age 1.5,
3 and 6 years, and used the classification to look at associations with child mental health.
Children in the ALSPAC cohort have been identified as early or late onset picky eaters, and
the early picky eaters into subcategories of persistent or non-persistent, based on the scoring
patterns for the identifying questions: this categorisation has been used to date for diet
analysis (22), but could also be used in studies of predictors of picky eating, and of growth
and body composition and other health outcomes.

Causes of picky eating

Accepting that the peak prevalence of picky eating occurs at about age 3 years, factors that
are predictive of a child becoming a picky eater as a pre-schooler can occur during three
distinct phases: before and during pregnancy, in the early feeding phase (first year of life,
reflecting early feeding practices), and in the second year of life (reflecting parental feeding
styles in response to increasing child autonomy). They can alternatively be categorised as
factors related to the child, to the parent/caregiver, and to child–parent interaction. Some of
these predictors are ‘fixed’, but others can inform the development of advice and strategies
for parents and caregiver to avert or ameliorate picky eating behaviour in their child. It is
unlikely, however, that any of these predictors acts in isolation: rather, there is a complex
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mix of parental and child-related characteristics that interact.

With regard to ‘fixed’ predictors, picky eating at 38 months in ALSPAC was associated with
a greater maternal age, maternal smoking (yes), higher maternal social class, lower pre-
pregnancy body mass index, higher maternal educational attainment, lower parity, and the
infant being of lighter birthweight and male.(2) Other studies, however, have found boys and
girls to be equally affected,(23) with the presence of siblings being protective(7). Several
studies have investigated familial similarity for food neophobia (rather than picky eating per
se) and found low to moderate similarity, suggesting a moderate degree of heritability. In a
study of more than 5000 twin pairs and their parents, it was found that neophobia was highly
heritable, with a heritability estimate of 0.78 (95% CI 0.76, 0.79), although about one-
quarter of the phenotypic variation was accounted for by environmental factors(24). Genetic
variation in sensitivity to bitterness (classified by being tasters/non-tasters of 6-n-
propylthiouracil) may play a role in the development of vegetable acceptance and
consumption in early childhood(25). These studies endorse the call by de Barse et al. (26)
that parental picky eating should ideally be accounted for in statistical analyses.

As early as the first month of life, babies aged 2 and 4 weeks who were later identified as
picky eaters had a different sucking pattern from non-picky eaters, with fewer sucks per

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session(27). Reduced duration of breast-feeding and late introduction of complementary

feeding have been shown to predict later picky eating in some studies(28; 29), but another
study found no difference in picky eating prevalence in children who were breast fed,
formula fed, or a mixture of both(30). Evidence from the Generation R study in the
Netherlands suggests that breastfeeding does not predict later picky eating. Breastfeeding
prevalence, early feeding practices and timing of complementary feeding were assessed in
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nearly 5000 infants at 2, 6 and 12 months old and picky eating was assessed at 4 years old
with the food fussiness subscale of the CEBQ. In adjusted analyses, there was no difference
in the prevalence of picky eating in children who were never breastfed compared with those
who were breastfed for 6 months or more. However, those who were breastfed for less than
2 months had a higher food fussiness score than those who were breastfed for 6 months or
more. Early feeding of vegetables, however, was protective against later picky eating: those
children who had vegetables introduced into their diets between 4 and 5 months of age had
lower scores than those who had their introduction delayed until after 6 months. Early
introduction of fruit or other solids were not associated with picky eating.

Modelling of positive maternal eating behaviour is frequently cited as being important in

averting picky eating in the child. Indeed, in a study of Australian mother–child pairs,
maternal healthy eating when the child was 1 year old was predictive of vegetable
consumption when the child was 2 years old(31). Further, when the children were 2–4 years
old, maternal healthy eating was associated with a lower prevalence of picky eating in the
children 1 year later (32). Maternal pressure to eat in this study was also associated with
picky eating, and this was mediated by concern about the child being underweight (33). In a
more detailed study of pressure to eat, data from the Generation R study showed a
bidirectional association with picky eating behaviour: picky eating in 4-year-olds
prospectively predicted parental pressure to eat at age 6 years, and pressure to eat at age 4
years predicted picky eating at age 6 years. This was interpreted as suggesting that parental
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feeding strategies were developed in response to children’s food avoidant behaviour, whilst
having a counterproductive effect on picky eating behaviour (34). Combining some of these
traits in a study of girls only, mothers who provided a positive model of eating behaviour by
consuming more fruits and vegetables were less likely to pressure their children who in turn,
were less likely to be picky eaters (35).

In a study of Norwegian mothers and children, both child and maternal temperament (child
emotionality and maternal negative affectivity, respectively) when the child was age 1.5
years were found to increase the risk of later picky eating(7). Maternal and paternal
internalising problems, which are symptoms of anxiety and depression, during pregnancy
and in the child’s early years, were prospectively associated with picky eating in preschool
in the Generation R study.(36) Children who had more sensory sensitivity are at greater risk
of becoming a picky eater, as are those whose parents have higher levels of sensitivity and
lower levels of structuring.(19)

Bringing data together from these three phases, a study from ALSPAC modelled predictors
in about 6000 children for each of these phases separately and then brought the predictors
that were significant together into a final model.(37) During the first year of life, feeding
difficulties and late introduction of lumpy food (>9 months) was associated with an

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increased likelihood of the child being a picky eater at 38 months. In the second year, the
strongest predictor was the child being choosy at 15 months old. 56% of children were
classified as being choosy at this time point. If the mother was not worried by this, then only
17% went on to be a picky eater at 38 months, but this rose to 50% if the mother was
worried by this choosiness. Provision of fresh fruit and eating the same meal as the child
were protective against later picky eating, while providing ready-prepared food predicted
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later picky eating. In contrast to the finding in Generation R(36), maternal anxiety and
depression during pregnancy or during the first years of the child’s life were not associated
with picky eating in the child in the model adjusted for all the predictors listed above.

Consequences of picky eating

Diet: nutrients, food groups/foods and diversity
The primary consequence of being a child who is a picky eater is the effect it has on dietary
intake, and this is a potential mediator for adverse health and development outcomes.
Indeed, adverse effects on diet are encompassed in the proposed definitions of picky eating
behaviour. Overall, picky eating could be hypothecated to lead to a reduction of food intake
with a distortion of nutrient intake though poor dietary variety. The evidence for these
effects, however, is inconclusive, with the exception of a lower intake of vegetables in picky
eaters, which is a frequent finding(14; 16; 17; 22; 27; 35; 38; 39; 40; 41) although not
universal (42; 43). There are several reasons for these disparities. As described earlier, there
are several different tools used to identify picky eaters, and different methods of grouping
categories of respondents. Results may also vary by country, reflecting differences in food
cultures and feeding practices. Methods of collection of dietary data vary, and include
standard methods such as 24-h recalls (e.g. van der Horst et al. (14); Dubois et al. (17)), food
frequency questionnaires (FFQ) (e.g. Taylor et al. (40); Antoniou et al. (44)), 2-, 3- or 4-day
food diaries (e.g. Taylor et al. (22); Rohde et al. (42)), and combinations of methods(45; 46),
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as well as alternative methods such as recording food selection from a pre-stocked chiller
box (27). ALSPAC includes data from both 3-day diet diaries and FFQ at regular time points
from early infancy up to age 13 years.(47) Some studies have not included a control group of
non-picky eaters, which limits synthesis of data to comparisons with recommended dietary
allowances and estimated average requirements, which are not always available for the
country in which the study is carried out. It is also important to know what proportion of
children have intakes that are below recommended daily allowances to enable interpretation
of the intakes.

Many studies have reported that energy intakes in picky children are not different from those
of non-picky children and adequate in comparison with reference nutrient intakes (RNIs)
(22; 35; 41; 42; 45; 46). However, others have reported a higher energy intake in picky eaters
(30), perhaps due to a high intake of energy-dense foods such as confectionary and savoury
snacks (41), or intakes lower than non-picky children (16; 17; 48) or substantially below the
RNI (49). ALSPAC, using 3-day diet diaries, did not find any differences in energy intakes
between picky eaters and non-picky eaters at ages 3.5, 10 and 13 years(50). Other studies
have suggested that energy intakes are not affected at some ages, but adversely affected at
others: at 7–8 months old, the children of caregivers who had reported that they considered

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their child to be a picky eater had a similar energy intake to non-picky children, but at 9–11
months old, intakes of energy and other nutrients were significantly lower (43). However, at
ages below 12 months children are still learning about food tastes and textures and are too
young to experience neophobia, so should not be considered picky eaters in the sense
described in this paper. Protein intakes generally mirror those of energy, so that studies
showing lower energy intakes in picky eaters than non-picky eaters tend also show lower
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protein intakes (17; 48), although it is not always clear whether the protein intake is
adequate in regard to RNIs or not.

There is a similar mixed picture for micronutrients, but with some consensus around low
intakes of zinc and iron in picky eaters (22; 39; 45; 46; 49). In the few studies that have
reported on dietary fibre intakes, there is consensus that intakes in almost all children are
low but they are particularly low in picky eaters, reflecting their low intakes of vegetables
and fruits (40; 48; 50). Low intakes of meat, especially carcass meat (rather than processed
meat) often contribute to low intakes of zinc and iron (14; 22; 30; 38; 48; 50).

The impact of picky eating on dietary diversity and variety has been studied less frequently,
but picky eaters have been shown to have less diversity and variety at 24–36 months of
age(45) or to eat fewer different items of food (16). At a younger age of 12–16 months,
perhaps before picky eating behaviour is fully expressed, Byrne et al. (51) found no
difference in dietary diversity score, or intakes of fruit, vegetables or meat, between picky
and non-picky eaters. Brown et al. (39) used the Healthy Eating Index-2010 (HEI) to
evaluate the overall dietary quality of low-income pre-schoolers identified as picky eaters
with the CEBQ food fussiness subscale: there was a negative relationship with the overall
HEI with scores driven by lower intakes of whole fruit, total vegetables and total protein
foods in picky eaters than in non-picky eaters. The authors noted that their results were
consistent with the reports of a lower number of foods eaten, especially fruits and
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vegetables. In a smaller study in girls up to age 15 years reporting only on fruit and
vegetable intakes, both picky and non-picky children consumed less than the recommended
amount of fruits and vegetables, but picky eaters ate slightly less vegetables than the non-
picky eaters at all ages (38).

ALSPAC is one of the very few studies that has been able to document detailed long-term
differences in diet (including nutrients, comparisons with RNIs, and foods/food groups) in a
large group of children identified as picky or non-picky eaters, with a single question at age
3 years, using both FFQ and 3-day food records at intervals up to age 13 years (see Table 1).
At age 3.5 and 7.5 years, using the 3-day food record, picky eaters had lower intakes of
meat, fish, fruit and vegetables than non-picky eaters, and this was reflected in lower intakes
of iron, zinc, carotene and dietary fibre, with substantial proportions below the RNI for iron,
zinc and dietary fibre. There were no significant differences in energy intake, which was
adequate in comparison with estimated average requirements. The differences in intakes of
the food groups was also evidenced at age 10 and 13 years, particularly for meat and
vegetables, although less so at age 13 years(50). Similar results were obtained using data
from the FFQ. Using a longitudinal classification between age 2 and 5.5 years to identify
persistent picky eaters, there were again, no significant differences in energy intakes
between any of the groups. Mean protein intake was 8% lower in children who were

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‘persistent’ picky eaters than those who had ‘never’ been a picky eater, but no child had an
inadequate intake. Mean intakes of carotene, vitamin D, iron, zinc and selenium were all
lower (3%–16%) in the ‘persistent’ group than in the ‘never’ group, with substantial
proportions having intakes below the lower RNI for retinol and zinc. Intakes in the ‘non-
persistent’ group were generally intermediate between the ‘persistent’ and ‘never’ groups.
The ‘persistent’ group ate 40% less carcass meat, 48% less vegetables and 33% less fruit
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than the ‘never’ group. Similar results to those for the ‘persistent’ group were found for a
group classified as ‘late-onset’ picky eaters. Overall, picky eating did not result in a
comprised macronutrient intake, but there were concerns about intakes of zinc and iron.

These studies indicate long-term effects on diet that point to an important role for early
intervention by parents to increase the quality of their children’s diets from an early age.
This should include more nutrient-rich and fibre-rich foods, especially fruits and vegetables.

Health and development

There has been little systematic study of health outcomes of picky eating other than growth
and to a lesser extent body composition. Several studies have shown that picky eating is
associated with a greater risk of being underweight and having poor growth (6; 20; 52; 53;
54; 55). This could be driven by energy intakes lower than requirements, possibly in
combination with low intakes of zinc and iron(22; 35), which are critical for optimal growth.
Others, however, have found an association of picky eating with being overweight(30). As
discussed by Berger et al. (38) the interpretation of most of these studies are limited by their
cross-sectional design, meaning that it is not possible to establish causation. In a longitudinal
study of weight, height, BMI and body composition in ALSPAC, the growth of children
(boys and girls) up to age 17 years who were identified as picky eaters at age 3 years were
assessed against reference growth charts for British children (52). The mean weights, heights
and BMIs of the picky eaters were consistently above the 50th centile, even though they were
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below those of the non-picky eaters, providing reassurance that their growth trajectories are
normal (52). However, there was evidence of a slightly increased prevalence of thinness in
picky eaters. It is also of note that the non-picky children in ALSPAC had a growth
trajectory well above the 50th centile of the growth charts so it is possible that in a
population in which the children’s growth was generally closer to the 50th centile the
trajectories of the picky eaters would be below the 50th centile and therefore of greater
concern. Similar results to those in the ALSPAC study in the UK were found in a group of
US girls up to age 15 years, in whom picky eaters tracked about 15 centile points below the
non-picky girls who tracked along the 65th centile (38). This difference in the location of the
trajectories relative to the centiles could reflect a difference in the prevalence of overweight
and obesity in the two cohorts and/or the use of different centile charts.

With regard to body composition in the ALSPAC study, being a male picky eater was
associated with a lower lean mass index than being a non-picky eater, but there was no
association with percentage body fat or fat mass index and there were no associations at all
in females (52). Participants identified as picky eaters at age 4 years in the Generation R
study in the Netherlands had lower standard deviation scores for BMI, fat mass index and
fat-free mass index at age 6 years than non-picky eaters, and, as in ALSPAC, a higher risk of

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being underweight(56). There is a need for further longitudinal data on this point, but it
seems likely that there is a subsection of picky eaters who are at risk of being underweight
who need early identification and intervention or surveillance.

Picky eating has been identified as a risk factor for subsequent anorexia nervosa in one
observational study (18), although in a later extension of that study picky eating was not
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found to be associated with later anorexia or bulimia (57) making interpretation difficult. In
addition, the statistical power of these studies has been questioned and this highlights the
limitations of observational studies for studying outcomes that are relatively rare(58). Adult
picky eating does occur and has been shown to cause distress and social impairment(59): it
has been shown to be associated with parental feeding practices in childhood (particularly
pressure to eat), childhood picky eating, higher disgust sensitivity and experiencing an
adverse food event(60).

Picky eating has been associated with a range of other adverse behavioural outcomes,
compromising both externalising and internalising behaviours (61). Longitudinal data on
picky eating at 1.5, 3 and 6 years old from nearly 4000 participants in Generation R
classified into four trajectories of picky eating (persistent/remitting/late-onset/never) were
used to identify any associations with emotional problems, behavioural problems and
pervasive developmental problems at 7 years old (21). Persistent picky eating predicted
pervasive developmental problems, but not behavioural or emotional problems. The other
trajectories were not predictive of any adverse outcomes and so it was concluded that
remitting picky eating was part of normal development.

Constipation in a common condition in children, affecting up to 30% of school-age children

in the UK and accounting for about 3% of paediatric consultations (62; 63), and seems to
affect children who are picky eaters disproportionately. In a Korean paediatric
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gastroenterology clinic, constipation was mentioned as a characteristic of being a picky eater

by about 27% of caregivers compared with 13% in a control group. Constipation was more
common in picky eaters than non-picky eaters in Taiwan (prevalence of 19% vs 10%)(64). In
Generation R, Tharner et al. (13) showed a bidirectional relationship between picky eating
and constipation with a ‘vicious circle’ being set up between them. Although low dietary
fibre intakes have been documented in picky eaters, with intakes found to be lower in picky
eaters than non-picky eaters, intakes in both groups are generally below those recommended
(35; 48; 65). In the ALSPAC study the difference in intake for picky eaters compared with
non-picky eaters at age 3.5 years was –1.4 (95% CI –1.6, –1.2) g non-starch polysaccharide
(NSP) fibre/day and dietary fibre intake was strongly associated with picky eating. Picky
eating was also associated with an increase in the odds of having hard stools of about 30%,
and this relationship was mediated by dietary fibre.(40) Dietary fibre intake in children who
were not picky eaters was 9.1 g NSP fibre/day (about 11 g AOAC fibre/day), which is below
the UK Scientific Advisory Committee on Nutrition (SACN) guideline of 15 g AOAC
fibre/day for children aged 2–5 years old(66). The even lower intake of the picky eaters was
largely a consequence of a lower intake of vegetables and fruit than the non-picky eaters.
The difference between the groups in dietary fibre intake was still evident at age 13
years(50). The primary cause of constipation is lack of dietary fibre, and thus all children,

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 Taylor and Emmett Page 10

but particularly picky eaters, would benefit from increasing their fruit and vegetable intakes
and other foods rich in fibre.

Advice for health professionals and caregivers

Many children go through a period of time as a picky eater and it can be difficult for health
Europe PMC Funders Author Manuscripts

providers to judge when intervention is needed. It has been suggested this decision should be
based on whether the child’s feeding behaviour is problematic for health, development,
education, psychological wellbeing and socialisation(67). Referral to a paediatric dietician
or psychologist is recommended for children who fulfil the diagnostic criteria for ARFID or
who have special dietary requirements for a chronic disease such as type 1 diabetes, a
metabolic disorder or cystic fibrosis, or who have learning difficulties or autistic spectrum
disorders. However, there is also a need to identify persistent picky eaters, who may need
surveillance of growth and development and detailed advice on management. Many children
will not present to a healthcare provider and there is also a need for more general advice for
caregivers that is consistent and practical and that can be readily accessed as public health
information.

Caregivers should be reassured that picky eating is a common stage of development that is
unlikely to cause any permanent harm to the child’s long-term development. Levene and
Williams (67) have set out detailed strategies for parents/caregivers and include information
on sample portion sizes for preschool children, a sample plan for graded exposure to food
items, and a list of resources for parents and health professionals. Key strategies described in
greater detail include: (1) having realistic expectations of children’s portion sizes; (2) graded
and repeated exposure to unfamiliar foods (10–15 positive experiences may be needed); (3)
using non-food rewards to provide motivation; (4) having a positive approach, avoiding
negativity and pressure to eat; (5) parental modelling of eating fruit and vegetables and
Europe PMC Funders Author Manuscripts

trying unfamiliar foods; (6) promoting appetite by limiting snacks and energy-providing
drinks such as milk, juice and soft drinks in between meals; (7) having social food
experiences such as family meals with all members eating the same food; (8) focusing on
long-term goals and being consistent.

Conclusion
The identification of picky eating in children is hampered by the lack of a universally
accepted definition and assessment tool. Their children’s picky eating can cause stress to
parents/caregivers and may have a negative impact on family relationships, and so it is
important that health providers are able to identify picky eating confidently and provide
caregivers with appropriate advice. For most children, the behaviour seems to resolve
spontaneously, perhaps because the child is exposed to a wider range of foods through
gradually being more socially active at pre-school, toddler group, school and getting to know
a wider range of peers with growing independence and autonomy. The evidence for an
impact of being a picky eater on health and development is mostly limited to studies on
growth, but these are generally reassuring. However, there may be a subsample of picky
eaters in whom the behaviour does become embedded and they may be at risk of being thin
during adolescence or may emerge later with an eating disorder or as an adult picky eater.

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 Taylor and Emmett Page 11

Identification, support and parental advice at an early age in this small group of children is
very important to be able to avert these more serious outcomes.

Acknowledgements
N/A
Europe PMC Funders Author Manuscripts

Funding

CMT was supported by a Wellcome Trust Career Re-Entry Fellowship (Grant ref: 104077/Z/14/Z).

References
1. 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; 11:5. [PubMed: 22816553]
2. Taylor CM, Wernimont S, Northstone K, et al. Picky/fussy eating in children: a review of definitions
and assessment measures, and prevalence in a UK longitudinal cohort. Appetite. 2015; 95:349–359.
[PubMed: 26232139]
3. Dovey TM, Staples PA, Gibson EL, et al. Food neophobia and 'picky/fussy' eating in children: a
review. Appetite. 2008; 50:181–193. [PubMed: 17997196]
4. University of Bristol. [accessed 1 August 2018] Avon Longitudinal Study of Parents and Children.
2018. http://www.bristol.ac.uk/alspac/
5. Mascola AJ, Bryson SW, Agras WS. Picky eating during childhood: a longitudinal study to age 11
years. Eating behaviors. 2010; 11:253–257. [PubMed: 20850060]
6. Ekstein S, Laniado D, Glick B. Does picky eating affect weight-for-length measurements in young
children? Clinical pediatrics. 2010; 49:217–220. [PubMed: 19483138]
7. Hafstad GS, Abebe DS, Torgersen L, et al. Picky eating in preschool children: the predictive role of
the child's temperament and mother's negative affectivity. Eating behaviors. 2013; 14:274–277.
[PubMed: 23910765]
8. van der Horst K. Overcoming picky eating. Eating enjoyment as a central aspect of children’s eating
behaviors. Appetite. 2012; 58:567–574. [PubMed: 22245133]
9. van der Horst K, Eldridge A, Deming D, et al. Caregivers’ perceptions about picky eating:
Europe PMC Funders Author Manuscripts

associations with texture acceptance and food intake (379.3). The FASEB Journal. 2014; 28
10. Zimmerman J, Fisher M. Avoidant/Restrictive Food Intake Disorder (ARFID). Current problems in
pediatric and adolescent health care. 2017; 47:95–103. [PubMed: 28532967]
11. Hendy HM, Williams KE, Riegel K, et al. Parent mealtime actions that mediate associations
between children's fussy-eating and their weight and diet. Appetite. 2010; 54:191–195. [PubMed:
19887094]
12. Morrison H, Power TG, Nicklas T, et al. Exploring the effects of maternal eating patterns on
maternal feeding and child eating. Appetite. 2013; 63:77–83. [PubMed: 23291285]
13. Tharner A, Jansen PW, Kiefte-de Jong JC, et al. Bidirectional associations between fussy eating
and functional constipation in preschool children. The Journal of pediatrics. 2015; 166:91–96.e91.
[PubMed: 25443999]
14. van der Horst K, Deming DM, Lesniauskas R, et al. Picky eating: Associations with child eating
characteristics and food intake. Appetite. 2016; 103:286–293. [PubMed: 27120094]
15. Orun E, Erdil Z, Cetinkaya S, et al. Problematic eating behaviour in Turkish children aged 12-72
months: characteristics of mothers and children. Central European journal of public health. 2012;
20:257–261. [PubMed: 23441389]
16. Cardona Cano S, Tiemeier H, Van Hoeken D, et al. Trajectories of picky eating during childhood:
A general population study. International Journal of Eating Disorders. 2015; 48:570–579.
[PubMed: 25644130]
17. Dubois L, Farmer AP, Girard M, et al. Preschool children's eating behaviours are related to dietary
adequacy and body weight. European journal of clinical nutrition. 2007; 61:846–855. [PubMed:
17180152]

Proc Nutr Soc. Author manuscript; available in PMC 2020 May 05.
 Taylor and Emmett Page 12

18. Marchi M, Cohen P. Early childhood eating behaviors and adolescent eating disorders. Journal of
the American Academy of Child and Adolescent Psychiatry. 1990; 29:112–117. [PubMed:
2295562]
19. Steinsbekk S, Bonneville-Roussy A, Fildes A, et al. Child and parent predictors of picky eating
from preschool to school age. The international journal of behavioral nutrition and physical
activity. 2017; 14:87. [PubMed: 28679411]
20. Dubois L, Farmer A, Girard M, et al. Problem eating behaviors related to social factors and body
Europe PMC Funders Author Manuscripts

weight in preschool children: A longitudinal study. The international journal of behavioral

nutrition and physical activity. 2007; 4:9. [PubMed: 17408478]
21. Cardona Cano S, Hoek HW, van Hoeken D, et al. Behavioral outcomes of picky eating in
childhood: a prospective study in the general population. Journal of child psychology and
psychiatry, and allied disciplines. 2016; 57:1239–1246.
22. Taylor CM, Northstone K, Wernimont SM, et al. Macro- and micronutrient intakes in picky eaters:
a cause for concern. The American journal of clinical nutrition. 2016; 104:1647–1656. [PubMed:
27935522]
23. Moroshko I, Brennan L. Maternal controlling feeding behaviours and child eating in preschool-
aged children. Nutrition & Dietetics. 2013; 70:49–53.
24. Cooke LJ, Haworth CM, Wardle J. Genetic and environmental influences on children's food
neophobia. The American journal of clinical nutrition. 2007; 86:428–433. [PubMed: 17684215]
25. Bell KI, Tepper BJ. Short-term vegetable intake by young children classified by 6-n-
propylthoiuracil bitter-taste phenotype. The American journal of clinical nutrition. 2006; 84:245–
251. [PubMed: 16825702]
26. de Barse LM, Jansen PW, Edelson-Fries LR, et al. Infant feeding and child fussy eating: The
Generation R Study. Appetite. 2017; 114:374–381. [PubMed: 28400303]
27. Jacobi C, Agras WS, Bryson S, et al. Behavioral validation, precursors, and concomitants of picky
eating in childhood. Journal of the American Academy of Child and Adolescent Psychiatry. 2003;
42:76–84. [PubMed: 12500079]
28. Galloway AT, Lee Y, Birch LL. Predictors and consequences of food neophobia and pickiness in
young girls. J Am Diet Assoc. 2003; 103:692–698. [PubMed: 12778039]
29. Shim JE, Kim J, Mathai RA, et al. Associations of infant feeding practices and picky eating
behaviors of preschool children. J Am Diet Assoc. 2011; 111:1363–1368. [PubMed: 21872699]
30. Finistrella V, Manco M, Ferrara A, et al. Cross-sectional exploration of maternal reports of food
Europe PMC Funders Author Manuscripts

neophobia and pickiness in preschooler-mother dyads. Journal of the American College of

Nutrition. 2012; 31:152–159. [PubMed: 23204151]
31. Gregory JE, Paxton SJ, Brozovic AM. Maternal feeding practices predict fruit and vegetable
consumption in young children. Results of a 12-month longitudinal study. Appetite. 2011; 57:167–
172. [PubMed: 21569809]
32. Gregory JE, Paxton SJ, Brozovic AM. Maternal feeding practices, child eating behaviour and body
mass index in preschool-aged children: a prospective analysis. The international journal of
behavioral nutrition and physical activity. 2010; 7:55. [PubMed: 20579397]
33. Gregory JE, Paxton SJ, Brozovic AM. Pressure to eat and restriction are associated with child
eating behaviours and maternal concern about child weight, but not child body mass index, in 2- to
4-year-old children. Appetite. 2010; 54:550–556. [PubMed: 20219609]
34. Jansen PW, de Barse LM, Jaddoe VWV, et al. Bi-directional associations between child fussy
eating and parents' pressure to eat: Who influences whom? Physiology & behavior. 2017;
176:101–106. [PubMed: 28215424]
35. Galloway AT, Fiorito L, Lee Y, et al. Parental pressure, dietary patterns, and weight status among
girls who are “picky eaters”. J Am Diet Assoc. 2005; 105:541–548. [PubMed: 15800554]
36. de Barse LM, Cardona Cano S, Jansen PW, et al. Are parents' anxiety and depression related to
child fussy eating? Arch Dis Child. 2016; 101:533–538. [PubMed: 26916538]
37. Emmett PM, Hays NP, Taylor CM. Antecedents of picky eating behaviour in young children.
Appetite. 2018; doi: 10.1016/j.appet.2018.07.032

Proc Nutr Soc. Author manuscript; available in PMC 2020 May 05.
 Taylor and Emmett Page 13

38. Berger PK, Hohman EE, Marini ME, et al. Girls' picky eating in childhood is associated with
normal weight status from ages 5 to 15 y. The American journal of clinical nutrition. 2016;
104:1577–1582. [PubMed: 27797710]
39. Brown CL, Perrin EM, Peterson KE, et al. Association of picky eating with weight status and
dietary quality among low-income preschoolers. Acad Pediatr. 2017; doi: 10.1016/j.acap.
2017.08.014
40. Taylor CM, Northstone K, Wernimont SM, et al. Picky eating in preschool children: Associations
Europe PMC Funders Author Manuscripts

with dietary fibre intakes and stool hardness. Appetite. 2016; 100:263–271. [PubMed: 26879221]
41. Tharner A, Jansen PW, Kiefte-de Jong JC, et al. Toward an operative diagnosis of fussy/picky
eating: a latent profile approach in a population-based cohort. Int J Behav Nutr Phy. 2014; 11:14.
42. Rohde JF, Handel MN, Stougaard M, et al. Relationship between pickiness and subsequent
development in body mass index and diet intake in obesity prone normal weight preschool
children. PloS one. 2017; 12:e0172772. [PubMed: 28296896]
43. Carruth BR, Ziegler PJ, Gordon A, et al. Prevalence of picky eaters among infants and toddlers and
their caregivers' decisions about offering a new food. J Am Diet Assoc. 2004; 104:s57–64.
[PubMed: 14702019]
44. Antoniou EE, Roefs A, Kremers SP, et al. Picky eating and child weight status development: a
longitudinal study. Journal of human nutrition and dietetics : the official journal of the British
Dietetic Association. 2016; 29:298–307. [PubMed: 25988483]
45. Carruth BR, Skinner J, Houck K, et al. The phenomenon of "picky eater": a behavioral marker in
eating patterns of toddlers. Journal of the American College of Nutrition. 1998; 17:180–186.
[PubMed: 9550462]
46. Carruth BR, Skinner JD. Revisiting the picky eater phenomenon: neophobic behaviors of young
children. Journal of the American College of Nutrition. 2000; 19:771–780. [PubMed: 11194531]
47. Emmett PM, Jones LR. Diet, growth, and obesity development throughout childhood in the Avon
Longitudinal Study of Parents and Children. Nutrition reviews. 2015; 73(Suppl 3):175–206.
48. Xue Y, Zhao A, Cai L, et al. Growth and development in chinese pre-schoolers with picky eating
behaviour: a cross-sectional study. PloS one. 2015; 10:e0123664. [PubMed: 25875004]
49. Volger S, Sheng X, Tong LM, et al. Nutrient intake and dietary patterns in children 2.5-5 years of
age with picky eating behaviours and low weight-for-height. Asia Pac J Clin Nutr. 2017; 26:104–
109. [PubMed: 28049269]
50. Taylor CM, Emmett P. Diet at 10 and 13 years in children identified as picky eaters at age 3 years
Europe PMC Funders Author Manuscripts

in a longitudinal birth cohort study. Proceedings of the Nutrition Society. 2017; 76:E121.
51. Byrne R, Jansen E, Daniels L. Preceived fussy eating in Australian children at 14 months of age
and subsequent use of maternal feeding practices at 2 years. Int J Behav Nutr Phy. 2017; 14:123.
52. Taylor CM, Steer CD, Hays NP, et al. Growth and body composition in children who are picky
eaters: a longitudinal view. European journal of clinical nutrition. 2018; doi: 10.1038/
s41430-018-0250-7
53. Viana V, Sinde S, Saxton JC. Children's Eating Behaviour Questionnaire: associations with BMI in
Portuguese children. The British journal of nutrition. 2008; 100:445–450. [PubMed: 18275626]
54. Sleddens EF, Kremers SP, Thijs C. The children's eating behaviour questionnaire: factorial validity
and association with Body Mass Index in Dutch children aged 6-7. The international journal of
behavioral nutrition and physical activity. 2008; 5:49. [PubMed: 18937832]
55. Webber L, Hill C, Saxton J, et al. Eating behaviour and weight in children. International Journal of
Obesity (Lond). 2009; 33:21–28.
56. de Barse LM, Tiemeier H, Leermakers ET, et al. Longitudinal association between preschool fussy
eating and body composition at 6 years of age: The Generation R Study. The international journal
of behavioral nutrition and physical activity. 2015; 12:153. [PubMed: 26666996]
57. Kotler LA, Cohen P, Davies M, et al. Longitudinal Relationships Between Childhood, Adolescent,
and Adult Eating Disorders. Journal of the American Academy of Child & Adolescent Psychiatry.
2001; 40:1434–1440. [PubMed: 11765289]
58. Micali N. Childhood risk factors: Longitudinal continuities and eating disorders. Journal of Mental
Health. 2005; 14:567–574.

Proc Nutr Soc. Author manuscript; available in PMC 2020 May 05.
 Taylor and Emmett Page 14

59. Thompson C, Cummins S, Brown T, et al. What does it mean to be a ‘picky eater’? A qualitative
study of food related identities and practices. Appetite. 2015; 84:235–239. [PubMed: 25450986]
60. Ellis JM, Schenk RR, Galloway AT, et al. A multidimensional approach to understanding the
potential risk factors and covariates of adult picky eating. Appetite. 2018; 125:1–9. [PubMed:
29378295]
61. Jacobi C, Schmitz G, Agras WS. Is picky eating an eating disorder? The International journal of
eating disorders. 2008; 41:626–634. [PubMed: 18454484]
Europe PMC Funders Author Manuscripts

62. Auth MK, Vora R, Farrelly P, et al. Childhood constipation. Bmj. 2012; 345:e7309. [PubMed:
23150472]
63. Mugie SM, Di Lorenzo C, Benninga MA. Constipation in childhood. Nat Rev Gastroenterol
Hepatol. 2011; 8:502–511. [PubMed: 21808283]
64. Chao HC. Association of Picky Eating with Growth, Nutritional Status, Development, Physical
Activity, and Health in Preschool Children. Front Pediatr. 2018; 6:22. [PubMed: 29484290]
65. Xue Y, Lee E, Ning K, et al. Prevalence of picky eating behaviour in Chinese school-age children
and associations with anthropometric parameters and intelligence quotient. A cross-sectional
study. Appetite. 2015; 91:248–255. [PubMed: 25934087]
66. Scientific Advisory Committee on Nutrition. Carbohydrates and health. Norwich: TSO; 2015.
67. Levene IR, Williams A. Fifteen-minute consultation: The healthy child: 'My child is a fussy eater!'.
Arch Dis Child Educ Pract Ed. 2018; 2013:71–77.
Europe PMC Funders Author Manuscripts

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Table 1
Effect of picky eating on intakes of nutrients, foods and food groups and comparison with recommended daily allowances: data from the UK
ALSPAC study

Authors/aim Aim Age of n Dietary assessment tool Nutrients Comparison with Foods and food
dietary recommended intakes groups
assessment
Taylor and Emmett

(years)
Taylor et al. (22) Investigate macro- 3.5 a PE: 131 3-day food record b PE had lower intakes of Energy intakes were PE consumed less
and micronutrient Non-PE: 364 protein, carotene, Fe, Zn and adequate in terms of EAR meat, fish, vegetables
intakes in PE and PE assessed cross- Se than non-PE Fe and Zn intakes were more and fruits than non-PE
non-PE sectionally at 3 No differences in energy likely to be below RNI in PE
years intakes between groups than non-PE
Free sugar was much higher
than recommended in both
groups
Taylor et al. (22) Investigate macro- 7.5 c Persistent-PE: 403 3-day food record b Intakes of protein, carotene, Energy intakes were Persistent and late-
and micronutrient Non-persistent-PE: vitamin D, Fe, Zn and Se adequate in terms of EAR onset-PE consumed
intakes in PE and 279 were all highest in non-PE Retinol equivalents, iron and less meat, vegetables
non-PE according Late-onset-PE: 100 and lowest in late-onset-PE zinc were most likely to be and fruits than non-PE
to persistence and Non-PE: 1350 PE and persistent-PE (3–16% below RNI and LRNI for Persistent-PE
timing of onset assessed lower). persistent-PE and late onset- consumed the most
longitudinally Free sugars were lowest in PE than non-PE sweet biscuits and
non-PE and highest in Free sugars were much confectionery
persistent-PE and late-onset- higher than recommended in
PE all groups
Non-persistent-PE were
intermediate
Energy intakes were not
different
Taylor et al.(40) Investigate 3 PE: 1400 FFQ Dietary fibre intake lower in Dietary fibre intake in both PE had a 6.8% lower
association of Non-PE: 4307 PE than in non-PE PE and non-PE below percentage of fibre
dietary fibre intakes PE assessed cross- 12.5% of variation in fibre recommended level from vegetables than
and stool hardness sectionally at 3 intake explained by PE score non-PE
with picky eating years

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Taylor and Investigate diet at 10 and 13 PE: 804, 693 3-day food record Lower intakes of protein, PE more likely than non-PE Lower intakes of
Emmett (50) 10 and 13 years in Non-PE: 2341, 1981 carotene, vitamin D, Se, Zn to be below LRNI for Zn at meat, fish, fruit and
children identified PE assessed cross- and dietary fibre; higher both 10 and 13 years vegetables for PE vs
as PE at age 3 years sectionally at 3 intakes of free sugars in PE Free sugars were much non-PE at 10 years
years vs non-PE at 10 years old. higher than recommended in Similar difference
Difference less evident at 13 all groups persisted at 13 years
years except for higher free
sugars and lower Zn intakes
in PE than non-PE.

EAR, estimated average requirement; FFQ, food frequency questionnaire; LRNI, lower reference nutrient intake; PE, picky eater.
a
Picky eating identified by single question at 3 years old: Does your child have definite likes and dislikes as far as food is concerned? (No/Yes, quite choosy/Yes, very choosy).
b
Similar results obtained from FFQ at 4 years
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 Europe PMC Funders Author Manuscripts Europe PMC Funders Author Manuscripts
c
Picky eating identified longitudinally as ‘never’/‘low’/‘early onset’ (persistent or not persistent)/‘late onset’ at 2–5.5 years old (for details see Taylor et al. (22)).
Taylor and Emmett

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