Picky Eating: A Toddler's Approach to Mealtime

Mary Cathey; Nan Gaylord

Pediatr Nurs. 2004;30(2) 

In This Article

Recommendations for the Picky Eater

Recognizing that dietary behaviors and picky eating habits are a result of development, a child's food preferences, and parental role modeling is important. Bearing these points in mind, appropriate recommendations begin to evolve. The primary care provider's role is to lead this discussion with the frustrated parent in need of sound advice.

Overall, it seems to be most important to reiterate to frustrated parents that toddlers are no longer in a period of rapid growth as they were during the first year of life. Bright Futures in Practice: Nutrition (Story, Holt, Soffka, 2002) reports that children between the ages of 2 and 5 years old gain an average of 4.5 to 6.5 pounds annually. This is a huge growth decline when compared with the first 2 years of life during which time the child is expected to quadruple his or her birth weight. Toddler's nutritional requirements decrease, their appetites decline, and their feeding patterns may become unpredictable (Story et al., 2002). Parents must understand that it is unrealistic to expect a toddler to eat a large amount of food at each meal every day. After all, a toddler's stomach is approximately the same size as his or her clenched fist (Martins, 2002).

The literature supports the idea that picky toddlers require several exposures to novel food items before they will accept them, another important concept to reiterate to the parents of picky eaters. Birch and Marlin (1982) conducted an experiment examining this relationship between exposure to novel foods and acceptance by 2-year-old children. Their results indicated that an increase in exposure frequency helped determine child preferences, and therefore, influenced what the child agreed to eat. Most of these children required as many as 10 exposures to the novel food choice before they were willing to accept it. The authors cautioned that although their results were found to be quite statistically significant, food exposure is not the sole determinant of young children's food acceptance (Birch & Marlin, 1982).

Carruth and colleagues (1998) reported that young children need frequent exposures to new food items both at home and away from home to have the opportunity to learn about them. A child cannot learn to accept a new item without frequent exposure. They describe a lack of offering of specific foods to a young child as the most limiting factor in the development of food choices. In addition, a child may have a tendency to reject additional food items that have a similar visual appearance to that initial item to which he or she was not adequately exposed. These authors suggest that parents need ideas concerning age appropriate experiences needed to help the toddler learn to accept a wide array of foods and to ingest adequate amounts of needed energy and nutrients (Carruth et al., 1998).

Frustrated parents will often describe their toddlers' mealtimes as a battle of wills filled with annoyance, anger, and disappointment. Much of the literature addresses these power struggles that may ensue as the overwhelmed parent attempts to exert control on the young toddler who is willful and stubborn. Parents need to know that forcing a toddler to eat by punishment or threats may only serve to worsen the picky eating habits and the power struggles. Satter (1986) writes that children who are consistently punished or have food forced upon them will come to associate hunger and mealtime with anxiety and frustration, rather than pleasure. Over time, this frustration and anxiety will continue to escalate and worsen those picky eating habits.

The disruptive picky eating behaviors described by parents oftentimes result in unpleasant, anxiety-provoking mealtimes. In a study of 45 children, Sanders and colleagues (1993) clearly showed that parents of children with eating difficulties were more likely to use unsuccessful coercive techniques at mealtimes, which ultimately led to persistence of the child's feeding problems. As the parents used negative prompts, negative physical contact, and negative feeding comments, their children engaged in more disruptive behaviors throughout the meal. These children developed more patterns of food refusal, which escalated the use of coercive techniques by parents. Although the parents' intentions were positive and well meant, mealtimes tended to become virtual war zones as a result of the significant power struggles (Sanders, Patel, Le Grice, & Shepherd, 1993).

In addition to worsening the picky eating behaviors, an exorbitant amount of control over consumption patterns may lead to an inability to respond to self-regulation cues and an increase in distaste for certain foods. Birch and Fisher (1998) report that children who are highly encouraged or forced to consume foods may not be able to use internal signals of hunger and satiety as a means of adjusting energy intake as readily as other children. In addition, they found that strategies forcing a child to consume a particular food may actually increase the child's distaste for that food (Birch & Fisher, 1998).

Johnson and Birch (1994) likewise concluded in their study that there is indeed a link between child-feeding practices and the child's responsiveness to self-regulation cues. They reported that parents who wield a great degree of control over what and how much their children eat will tend to have children who demonstrate low self-control and an inability to self-regulate energy intake (Johnson & Birch, 1994).

Finally, Gottesman (2002) reminds us to reiterate to these frustrated parents that it is their job to determine what, where, and when their child is fed. It is the child's job to determine whether or not he or she will eat and what he or she will ingest. When the well-meaning parent bribes, punishes, demands, or forces the child to eat, he or she crosses the line into the area that the toddler controls. This practice results in the negative behaviors, power struggles, and temper tantrums that characterize mealtimes of picky eating toddlers (Gottesman, 2002). It is important to remember that obtaining a sense of autonomy and independence is a significant feat in a toddler's development and one that parents cannot challenge.

During the infancy stage, children are typically demand feeders, meaning they demonstrate hunger cues when they are ready to eat so the primary caregiver offers them a bottle or the breast and their demands are satisfied. Later, as a child reaches the toddler years, he or she becomes mature enough to accept a schedule and should be expected to follow a routine. This is an important concept for parents of picky eaters to understand. Gottesman (2002) reports that accommodating to the daily schedule of family mealtimes is an important aspect of development that allows the toddler to begin to fit into his or her enlarging social world. The child should be expected to sit with the family at designated mealtimes regardless of whether or not he or she chooses to eat. In addition, the child should be offered the same foods prepared for the entire family as a means of providing exposures in an attempt to diversify the diet.

In an article published in 1986, Satter addresses the issue of establishing a schedule or routine in the toddler who is engaging in aggressive and disruptive behaviors at mealtime. She explains that a toddler tests the limits parents imposed in every aspect of feeding including quantity consumed, preferences ingested, and tempo of food intake. It is the parent's responsibility to allow the developing child to express him or herself in an acceptable manner (Satter, 1986). That is, the child may choose to not consume particular foods offered at mealtime, but he or she is expected to remain at the table during the designated time. The toddler can choose to merely push around and play with the food on his or her plate, but he or she is not allowed to leave the table to play a different game. This is a difficult recommendation to make frustrated parents understand. However, allowing the toddlers' desires to override the limits imposed by parents will result in an exacerbation of negative feeding behaviors and an escalation of picky eating.

Occasionally, parents of children who possess these neophobic behaviors will admit to succumbing to the desires of their toddlers. Tired and frustrated parents may report that they serve their child precisely what he or she demands in an effort to get the child to ingest some nutrients, even if it is not the ones the parent desired. Satter (2002) cautions parents about this practice and about becoming what she terms "the child's short order cook." A child will always take the familiar, easy way out at mealtime if the parent continually fixes the child's entrees of choice. She recommends that a toddler be continually served healthy food choices as part of the family meal until these choices become the familiar and preferred items (Satter, 2002). This concept is important for tired and frustrated parents to understand. Although short order cooking is a quick fix to the power struggles in the present, it may further ingrain food neophobic behaviors that will only become more and more challenging and difficult to change as time goes on.

Oftentimes, well meaning parents of children who are picky eaters will mistakenly offer their children unlimited amounts of fruit juices or milk as a means of providing needed nutrients. Parents have been incorrectly led to believe that juices are a very nutritious addition to their child's diet. When children are allowed to fill up on these items, their appetites for other foods will suffer significantly (Gottesman, 2002). The American Academy of Pediatrics (AAP) (2001) has warned that juices contain excessive amounts of sugar, little or no calcium, no fiber, minute amounts of fluoride, and a high concentration of carbohydrates. Overconsumption of these juices can contribute to undernutrition, diarrhea, and the development of dental caries. The Academy's Committee on Nutrition recommends that children aged 1 to 6 years old be allowed to drink only 4 to 6 ounces of juice per day (AAP, 2001). In addition, experts recommend that toddlers drink 16 to 24 ounces of whole milk daily (Gottesman, 2002). This amount is enough to promote growth, but not so much that it decreases their appetites for other foods.

In addition to limiting the intake of juices and milk, parents need to be reminded of the importance of portion control in managing mealtimes and snack times with their picky eaters. As mentioned earlier, a toddler's stomach is about the size of his or her clenched fist (Martins, 2002). Obviously, youngsters are unable to eat anywhere near the amount of food that adolescents and adults ingest. Also, toddlers are trying to gain a sense of control over their environment. When toddlers are able to clean their plate and ask for more, they have successfully controlled one aspect of the mealtime and have made their own decision to invite the parent to serve them more. These points magnify the value of offering appropriate portion sizes to these young children. Story and colleagues' Bright Futures in Practice: Nutrition (2002) provides a modified food guide for young children. It recommends that children aged 2 to 6 years old eat 5 servings of grains daily, 3 servings of vegetables, 2 servings of fruits, 2 servings of dairy, 2 servings of meat, and sparse amounts of sweets and fats. In addition, it provides a chart of serving sizes appropriate for children in this age group. For instance, a half of a slice of bread, 2 cups of cooked vegetables or canned fruits, 2/3 of a cup of yogurt, and 2 tablespoons of ground meat represent adequate serving sizes from each of the respective groups on the food guide pyramid (Story et al., 2002). Such information is necessary for parents to plan mealtimes and snack times accordingly for their toddlers. In addition, primary care providers can easily access this information and offer it to frustrated parents in the form of an educational handout.

Through discussions with the parents of picky eaters, the primary care provider can begin to gather an idea of what the individualized mealtime in each family entails. This may include the structure of the meal, the presence of distracters such as the television during the meal, and the participants of the meal. Each of these aspects may play a considerable role in a toddler's actions and behaviors during the course of the meal.

Over the past few decades, a wide array of studies concerning the extent to which distracters such as television influence dietary patterns have been conducted. While much of the research has looked at behavioral links between television and children's food consumption patterns, as well as, the content of nutritional messages seen by children, very few have examined the associations between children's overall food consumption and television viewing. Coon, Goldberg, Rogers, and Tucker (2001) set out to test whether routine television viewing during mealtime caused a variation in overall food consumption patterns of young children. In a study of 91 parent-child pairs, they found that children from families who watched television during at least 2 meals per day derived 5% more of their energy from pizza, salty snacks, and soda than those children from families in which television viewing was not a normal part of the mealtime routine. In addition, those same children derived nearly 5% less of their energy intake from fruits and vegetables than the children in low television use families (Coon et al., 2001).

Coon and colleagues' (2001) study implies that television viewing is a powerful influence on a child's eating behavior and needs to be addressed when developing appropriate recommendations for frustrated parents of neophobic toddlers. It is necessary to reiterate to these parents that their child may demonstrate improved mealtime behaviors if the television is turned off when sitting at the table. We know that toddlers are easily enticed by the bright colors and loud noises in commercials and may, therefore, choose not to eat the food provided to them in lieu of demanding what they see on the television. A simple remedy to this is to recommend that mealtime be television free.

The structure of the family meal, that is whether or not the family partakes in meals together, is an important aspect to obtain in the information gathered from the parents of a picky eater. It has been well evidenced throughout this paper that family members, particularly the toddler's parents, exert a huge influence on the eating habits and behaviors of young children. We know that the habits that parents help their children to develop in childhood will influence patterns children demonstrate as they grow up. The family meal is an invaluable time for children to learn what nutrition is and to follow their parents' modeling. Research has shown that meals prepared in the home tend to be higher in fiber, calcium, and iron, and contain less fat, saturated fat, cholesterol, and salt than meals obtained outside the home (Stockmyer, 2001). If children are exposed to these healthier foods during family mealtimes in toddlerhood, they may be more apt to continue these healthy habits in adolescence and adulthood. In addition to improving the intake of nutritious food, the family dinner provides an avenue to give the toddler structure and security. It is a time to foster stronger relationships and to improve family function. It is important to reiterate all these points to parents of picky eaters when recommending the implementation of the family dinner.

Though the toddler years are filled with challenges and frustrations, it is important to help parents focus on the positive and exciting developmental milestones their youngsters achieved. Young children engage in the picky eating habits and the negative mealtime behaviors as a means of demonstrating a sense of control and autonomy over an environment that is very new and scary to them. Parents struggle to provide the tools necessary for their children to grow into healthy, well-adjusted adults. Our responsibility as primary care providers is to offer the families of our small patients the methods and suggestions needed to encourage behaviors to achieve the goals of healthy nutrition and good mealtime behavior. The parent handout (see Table 1 ) lists recommendations based upon the current literature that may provide effective ways to achieve adequate dietary consumption patterns. An annotated bibliography of lay books published in recent years may also be of interest to parents seeking additional nutritional understanding (see Table 2 ). By using what we know and offering solid advice to the families of these toddlers, we will foster an atmosphere of trust, honesty, and well being that will be reflected in the good health of all our patients.

The print version of this article was originally certified for CE credit. For accreditation details, contact the publisher, Janetti Publications, Inc., East Holly Avenue Box 56, Pitman, NJ 08071-0056

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