You may not have read the much ballyhooed article about selective eating in preschoolers that was distributed to the media prior to publication because it was buried online, but I bet that you have heard or read something about it (“Psychological and Psychosocial Impairment in Preschoolers with Selective Eating” by Zucker et al., [ Pediatrics. 2015 Aug 3. doi: 10.1542/peds.2014-2386 ]). In fact, there were so many news stories, both print and electronic, and the headlines were so divergent that my wife asked me if there were actually two studies released simultaneously.
Some news reports emphasized the reassuring observation by the authors that most picky eating preschoolers will mature into older children with less selective eating habits. However, others highlighted the authors’ primary message that young children with severe selective eating behavior often have significant psychopathology (anxiety, depression, attention-deficit/hyperactivity disorder), and those with even moderate picky eating may be manifesting the effects of living in a dysfunctional family.
The authors recommend that we pediatricians rethink our traditional party line on selective eating. Instead of simply administering frequent doses of reassurance to the parents of “picky eaters,” we should begin to view even moderate selective eating as a red flag that the child and his or her family need help.
This shift in emphasis is long overdue. I always have felt that problem picky eating is an example of normal infant behavior that has been mismanaged by the child’s family. And in some cases physicians also must share in the blame for not having given the most appropriate advice in a timely fashion to parents who have complained about their child’s selective eating.
It would help if we all took a deep breath, stepped back a few steps, and looked at the bigger picture. We are talking about eating, one of the critical life-sustaining activities. One can understand why most infants are wired to initially reject new tastes and textures. Neophobia – fear of anything new – has probably saved millions of infants from the serious consequences of unsupervised foraging. But don’t you think that these aversions are for the most part weak enough to be easily overridden by every child’s innate drive for self-preservation? “I don’t like how this smells, tastes, looks, or feels, but darn it, I’m getting hungry, and I have to eat to survive. So I will eat it.”
The problem is that while some parents can agree with that line of reasoning, many parents, including those who buy the rationale, can’t bring themselves to quietly accept their new role as merely being providers of a healthy diet. For 9 or 10 months, it was their job to get food into their child because the poor little thing lacked the skill to do it himself. But once a child can chew solids and put things in his mouth, he can not only survive but thrive if someone will simply present him a balanced diet of appropriate consistency and volume … and then step back and shut up.
Obviously, this transition is difficult to a significant number of parents. In many cases, it is because no one has told them that toddlers will appear to eat less than they did as infants or that allowing children unlimited access to energy-containing fluid will blunt their appetites. Or that it is okay that a child only eats one-and-a-half meals on some days. Or that it if you wait long enough without resorting to coaxing, bribing, or begging, a child will eat what his body needs. And failing to be patient and instead making an issue of eating (or not eating), what began as a normal infant aversion to new tastes and textures can spiral into a divisive family catastrophe.
Are there some infants who are so hypersensitive to new tastes and textures that waiting will endanger their health? If they exist, in my experience they are very rare. However, there are certainly toddlers who have become hypersensitive. In my opinion, they were always vulnerable and would have been much less of a problem had they been properly managed early on when they were just a little neophobic.
Are there clues during the child’s infancy that his family is more likely to have significant difficulty making the transition from “feeding” to “presenting” food? This new study observed that high maternal anxiety was frequently observed in both moderate and severe selective-eating children. This is another example of how we need to be aware from a very early stage when a parent is anxious or depressed. The failure to identify and see that those issues are addressed can seriously impair the whole family’s wellness.
Finally, on the other end of the spectrum, is usual garden variety selective eating outgrown? Have you tried to host a dinner party lately? I don’t mean a pot luck supper – I’m talking about a sit-down meal with a single menu. My wife and I have almost given up trying. “Martha is gluten free (without a diagnosis), Bob is watching his cholesterol, Rachel is pretty sure she is lactose intolerant, and you know Charlie hates vegetables. The Wilsons only do organic and are vegetarians.”
Next time we are considering mailing them gift certificates for their favorite restaurants along with an invitation to come over to our place for an after dinner drink. BYOB.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.”