Diet fortification for mild and moderate picky eating in typically developed children: Opinion review of Middle East consensus

Abstract

BACKGROUND

Picky eating is a commonly observed behavior among children globally, negatively impacting their physical and mental growth. Although common characteristics distinguish peaky eaters, including food selectivity, food neophobia, and food avoidance, there is no clear definition to assess this behavior. Due to the unavailability of data regarding picky eating, it wasn’t easy to estimate its prevalence.

AIM

To develop a regional protocol to help healthcare professionals identify and manage mild and moderate picky eating cases.

METHODS

A virtual roundtable discussion was held in April 2021 to gather the opinions of seven pediatricians and two pediatric dietitians from eight Middle Eastern countries who had great experience in the management of picky eating. The discussion covered different topics, including clearly defining mild and moderate picky eating, identifying the role of diet fortification in these cases, and the possibility of developing a systematic approach to diet fortification.

RESULTS

The panel identified picky eating as consuming an inadequate amount and variety of foods by rejecting familiar and unfamiliar food. Most of the time, moderate picky eating cases had micronutrient deficiencies with over- or undernutrition; the mild cases only showed inadequate food consumption and/or poor diet quality. Paying attention to the organic red flags like growth faltering and development delay and behavioral red flags, including food fixation and anticipatory gagging, will help healthcare professionals evaluate the picky eaters and the caregivers to care for their children. Although dietary supplementation and commercial food fortification play an important role in picky eating, they were no benefit in the Middle East.

CONCLUSION

The panel agreed that food fortification through a food-first approach and oral nutritional supplements would be the best for Middle Eastern children. These recommendations would facilitate identifying and managing picky-eating children in the Middle East.

Key Words: Picky eating; Diet fortification; Children; Protocol; Roundtable discussion; Middle East

Core Tip: Picky eating among typically developed children is a growing concern in the Middle East, where micronutrient deficiencies are common in moderate cases. This review highlights insights from a virtual roundtable discussion of experts in the region who emphasized the importance of a food-first approach to diet fortification. They identified key red flags, such as growth faltering and food fixation, to aid in early identification. While dietary supplementation is crucial, the panel found commercial food fortification less effective in the region. Their recommendations aim to guide healthcare professionals in managing picky eating by prioritizing balanced nutrition and systematic intervention.

INTRODUCTION

Picky eating, known as selective, choosy, or fussy eating[1], is a common behavioural problem and parental concern that affects up to 70% of children globally[2-4]. Picky eating may lead to substantial stress for parents, negatively impacting family relationships[5]. Although there is no formal definition of picky eating, it is characterized by restricting or refusing familiar or unfamiliar foods[1]. Picky eaters share some common characteristics, including food selectivity, food neophobia, and food avoidance[1,4,6,7]. Most studies report a reduction in overall food quantity, variety, and quality[1], putting picky eaters at a higher risk for macro and micronutrient deficiencies, physical and cognitive developmental issues, and altered immunity[8]. Therefore, picky eating is not a transient problem; it may persist into adolescence, leading to physical, behavioural, and functional impairments if not adequately addressed by healthcare professionals early on[1].

Significant variability exists in the reported prevalence of picky eating, depending on the definition used, the tools to identify it, and the age of the studied cohort. In Saudi Arabia, Kutbi et al[9] found that 89.8% of children aged 3-7 were picky eaters. Another study by Hegazi et al[10] found picky eating in 85.5% of preschool children[10]. Additionally, a study in Iraq demonstrated that 77% of preschoolers were picky eaters[11]. Studies illustrate that picky eaters consume less fruit, vegetables[12-16], fish, and meat[14,16], while tending to eat more sweets, savoury snacks, French fries, and sugary drinks[12,14,17]. A recent review, including data from Jordan, Lebanon, the Kingdom of Saudi Arabia, and the United Arab Emirates, revealed inadequate intake of iron, calcium, zinc, folic acid, vitamin A, and vitamin D, concurrent with high intakes of fat, saturated fat, and sugar in children up to 12 years old[18].

Diet fortification and food supplementation are key strategies to address these nutritional inadequacies in picky eaters, especially in regions like the Middle East, where improper dietary practices are widespread. Food supplements, including oral nutritional supplements (ONS), can play a vital role in filling nutrient gaps for children who exhibit selective eating behaviors. While diet fortification aims to enhance the nutritional value of foods consumed, supplements provide a more targeted approach to ensure children receive essential micronutrients, such as iron, zinc, and vitamins, that may be lacking in their diets. This approach has effectively combat micronutrient deficiencies prevalent among picky eaters[19].

Picky eating is notably more common among children with autism spectrum disorder (ASD) compared to typically developing children[20]. Up to 89% of children with ASD exhibit issues with food selectivity, odd eating patterns, and rituals[21]. Moreover, delayed weaning has been debated as a contributing factor to picky eating. While some studies suggest that reduced breastfeeding duration and late introduction of complementary feeding predict later picky eating, other research shows no significant difference based on the feeding method[1]. Picky eating can be classified by duration, such as short-term (1-2 years) and long-term (3-10 years). Long-term picky eating may increase the likelihood of co-occurring mental health disorders[1].

Several studies have highlighted a concerning rise in picky eating among children in different countries across the Middle East[12,22,23]. Given the high prevalence of picky eating and the nutritional risks it poses, there is an urgent need for clear guidelines to manage these cases. This is particularly crucial in the Middle East, where improper nutritional practices are common and picky eaters are at risk for both macro and micronutrient deficiencies[13]. Researchers emphasize early detection and intervention to prevent these deficiencies[24]. In this article, experts aimed to develop a protocol to help regional pediatricians and healthcare professionals in the Middle East identify and manage mild and moderate picky eating in typically developing children.

MATERIALS AND METHODS

This consensus statement was created through a virtual roundtable discussion held in April 2021. The expert panel comprised nine healthcare specialists from diverse Middle Eastern nations, including Bahrain, Egypt, Jordan, Lebanon, Oman, and Saudi Arabia. Panel members were selected based on their extensive expertise in pediatrics, nutrition, and/or the management of picky eating. The selection criteria included the experts’ years of clinical experience, academic contributions, and previous involvement in regional or international conferences related to pediatric nutrition. Additionally, each panelist represented different geographical and cultural backgrounds within the Middle East, ensuring a broad and culturally diverse perspective. The nine experts were deemed sufficient to address regional variations while focusing on practical and unified recommendations for picky eating management.

A comprehensive literature search was conducted using multiple databases, including PubMed, Scopus, EMBASE, Google Scholar, and Web of Science, with predefined keywords related to picky eating and diet fortification. The search strategy employed a combination of Medical Subject Headings terms and relevant keywords, such as “picky eating,” “diet fortification,” and “typically developed children.” These keywords were selected based on their relevance to the topic, following a review of prior studies and terminology used in the field.

Inclusion criteria

Included studies published in peer-reviewed journals focusing on children aged 2-12 years in Middle Eastern countries or those with a specific focus on Middle Eastern populations. Only studies available in English or with English translations were considered.

Exclusion criteria

Including studies conducted outside the Middle East, those lacking sufficient data or methodology, non-peer-reviewed literature (e.g., conference abstracts, editorials, and letters to the editor), and studies published before 2000.

During the initial search, 256 articles were identified. After applying the inclusion and exclusion criteria, 123 articles were selected for full-text review. Finally, 42 articles were deemed eligible for data extraction and analysis. Reference lists of included studies were also manually searched, and an additional 5 articles were included. This systematic process ensured a thorough and rigorous literature review.

The panel discussion followed a structured approach to address picky eating in Middle Eastern children. First, an evidence-based overview of picky eating and its impact on nutritional inadequacies was presented. Then, existing strategies for managing picky eating in the Middle East were discussed, acknowledging regional challenges. The debate focused on identifying potential ways to address picky eating behaviors within this demographic effectively.

Consensus formation

After the presentation, iterative rounds of discussion were conducted to reach a consensus on key recommendations. The consensus was reached through group agreement after multiple rounds of voting and structured debates. The key components of the final protocol were agreed upon after each member critically evaluated the evidence presented.

Panel duration

The panel lasted approximately four hours in a single session.

Core team and expertise

The core team included pediatricians and pediatric dietitians with expertise in picky eating, pediatric nutrition, and gastroenterology. Their role was to compile the literature, organize the roundtable, and prepare materials for discussion. They also oversaw manuscript preparation, ensuring that the final recommendations reflected the consensus reached during the panel.

Picky eaters vs problem feeders questionnaire

The questionnaire was developed based on previous research and clinical tools used to distinguish picky eaters from problem feeders. These tools, including the “Steps to Eating Hierarchy,” were adapted to identify specific symptoms, such as food selectivity, refusal of food groups, and mealtime behaviors, ensuring clear differentiation between mild picky eating and more severe feeding problems.

RESULTS

The panel participated in a virtual roundtable discussion in April 2021. The meeting began with a presentation on picky eating in children, followed by a structured discussion to define mild and moderate picky eating in Middle Eastern children and explore the role of diet fortification in managing these behaviors. The panel also examined behavioral strategies and the value of ONS in improving nutritional intake for picky eaters.

At the conclusion of the discussion, the panel agreed upon key components for developing a simplified algorithm to manage mild and moderate picky eaters, focusing on the role of diet fortification. This algorithm is outlined in Table 1, which provides detailed guidance on identifying and managing picky eaters. It includes protocols for screening children for nutritional risk, using growth charts and nutrition screening tools, identifying organic and behavioral red flags, and implementing behavioral strategies for caregivers. For example, the table highlights that mild picky eaters may have poor diet quality without overt signs of undernutrition, whereas moderate picky eaters may display evidence of micronutrient deficiencies. Additionally, the table underscores the importance of behavioral strategies such as involving children in meal preparation, offering healthy food choices, and avoiding power struggles at mealtime.

Table 1 Protocol for identifying and managing children with mild-to-moderate picky eating in the Middle East.

Topic	Protocol recommendations
Identifying the picky eater	Picky eaters are “children who consume an inadequate amount and variety of foods through rejection of foods that are familiar, as well as unfamiliar, to them”
	Mild picky eating was defined as inadequate food consumption and/or poor diet quality and/or variety without over- or undernutrition or evidence of micronutrient deficiencies
	The moderate picky eating definition resembled the mild picky eating in food intake pattern but with over- or undernutrition or evidence of micronutrient deficiencies
Evaluating the picky eater	Once identified, a picky-eating child should be systematically screened for nutritional risk
	Assessing the growth pattern using a growth chart alone is not enough to identify the severity of nutritional risk, as many of the children showed a normal growth curve; in addition, a nutrition screening tool (i.e., nutrition screening tool for every preschooler, nutrition screening tool for every preschooler-toddler) should be used to identify the severity
	Organic red flags include: (1) Unintentional weight loss or failure to thrive; (2) Feeding difficulties with gastrointestinal symptoms; (3) Oral-motor issues impacting eating; (4) Nutritional deficiencies or signs of malnutrition, concurrent medical conditions (e.g., gastrointestinal disorders); (5) Dysphagia; (6) Aspiration; (7) Apparent pain with feeding; (8) Diarrhea and vomiting; (9) Developmental delay; (10) Cardio-respiratory symptoms; and (11) Growth faltering
	Behavioral red flags include: (1) Food fixation; (2) Noxious (harmful or unpleasant), for example, forceful feeding; (3) Abrupt cessation of feeding after a trigger event; (4) Anticipatory gagging; (5) Persistent refusal to eat or extreme food aversions; (6) Behavioral challenges during mealtime (tantrums, anxiety); (7) Avoidance behaviors related to food; and (8) Emotional distress during mealtimes
Behavioral strategies	It is important to provide parents and caregivers with feeding and behavioral strategies that can be implemented for both mild and moderate picky eaters
	The panel suggested providing parents/caregivers with some feeding rules and behavioral strategies for the management of childhood picky eating as follows: (1) Serve age-appropriate portions; (2) Get children acquainted with foods through meal planning and preparation; (3) Involve children in menu planning; (4) Provide healthy food choices to children (e.g., fruits, vegetables, and other healthy snacks); (5) Avoid the power struggle; (6) Give kids the opportunity to participate in food preparation (let children touch, smell, and feel food); (7) Abstain from labelling children; (8) Build up on progress as it occurs; (9) Regularly expose children to new foods; (10) Avoid bribing children to eat; (11) Be wary of over-snacking; (12) Establish bottom-line limits; (13) Become a positive role model to children; and (14) Given enough time for children to change their eating habits
Nutritional intervention	Nutritional management of mild and moderate picky eaters should include diet fortification through the food-first approach. However, it can be challenging to implement these strategies in the Middle East
	Time constraints for meal preparation and working mothers, nannies, or other caregivers assigned to meal preparation are some of the nutrition challenges faced in the Middle East
	Nutritional management of mild and moderate picky eaters should include diet fortification through the food-first approach. However, it can be challenging to implement these strategies in the Middle East
	Unfortunately, according to the available data, the Middle East region suffers from micronutrient deficiency that needs an immediate solution to improve children’s health. However, the use of dietary supplements in the region is low, and adherence is poor
	Dietary supplementation provides an individually targeted approach to addressing micronutrient inadequacies and deficiencies
	Commercial food fortification in the Middle East has been sporadic and ineffective
	The diet of picky eaters can be fortified using a food-first approach and oral nutritional supplements
	Oral nutritional supplements, in liquid and powder forms, can be used to fortify the food of mild and moderate picky eaters in a much easier way
	Ultimately, in mild and moderate picky eaters, offering liked foods with enhanced nutritional value through a food-first approach or using oral nutritional supplements can help meet the child’s nutritional requirements for growth and development, stop the food fight, and soothe the parent-child relationship

Table 2 presents a concise comparative analysis of the characteristics of mild, moderate, and severe picky eaters[22,25-27]. The panel defined each level of picky eating based on nutritional status, impact on growth and development, behavioral traits, and the necessary level of intervention. Mild picky eaters generally maintain adequate nutritional status with minimal impact on growth and development. However, moderate picky eaters may show signs of malnutrition, including poor growth and cognitive impairments, and require more comprehensive interventions such as behavioral therapy and family support. Severe picky eaters, on the other hand, face extreme food selectivity and refusal, which can lead to significant nutritional deficiencies and psychosocial issues. The table also highlights the escalating risk factors for each group, with severe picky eaters being at the highest risk for growth faltering, developmental delays, and health complications. Clinical management strategies for each category are also detailed, from dietary counseling for mild cases to intensive, multidisciplinary care for severe cases.

Table 2 Characteristics of different grades of picky eaters.

Characteristic	Mild picky eaters	Moderate picky eaters	Severe picky eaters
Definition	Children consume inadequate amounts and variety of foods without evidence of over- or undernutrition or micronutrient deficiencies	Children consume inadequate amounts and variety of foods with evidence of over- or undernutrition or micronutrient deficiencies	Extreme food selectivity and refusal leading to significant nutritional deficiencies, growth impairment, and/or psychosocial issues
Nutritional status	Generally adequate nutritional status	Signs of malnutrition, such as poor growth or micronutrient deficiencies	Severe malnutrition, including faltering growth, severe micronutrient deficiencies, and/or significant weight loss
Impact on growth and development	Minimal impact on growth and development	May experience delayed growth, developmental delays, or cognitive impairments	Severe growth impairment, developmental delays, and cognitive deficits requiring urgent intervention
Behavioral characteristics	Mild food selectivity, reluctance to try new foods, flexible eating habits	Moderate food selectivity, avoidance behaviors, mealtime struggles	Extreme food refusal, sensory sensitivities, intense anxiety around eating
Intervention needs	Dietary counselling, nutritional education, minor dietary modifications	Comprehensive nutritional interventions, behavioral therapy, family support	Intensive multidisciplinary intervention, medical evaluation, feeding therapy, psychological support
Risk factors	Fewer risk factors for severe malnutrition compared to moderate and severe picky eaters	A higher risk of nutritional deficiencies, growth faltering, and health complications	The highest risk of severe malnutrition, developmental delays, and psychosocial issues
Clinical management	Managed with dietary counselling, nutritional monitoring, and reassurance	Coordinated approach involving healthcare professionals, addressing nutritional deficiencies, feeding difficulties, family stressors	Specialized care from a multidisciplinary team, addressing complex feeding issues, nutritional rehabilitation, psychosocial support

Table 3 clearly distinguishes between “picky eaters” and “problem feeders”[28-30]. Problem feeders typically display more severe symptoms and have a restricted range of foods-often fewer than 20, which can severely impact their nutritional intake and mealtime behaviors. The table outlines key characteristics that differentiate picky eaters from problem feeders, such as their reaction to new foods, their ability to eat from various food textures and nutrition groups, and their mealtime habits. For example, while picky eaters might accept a previously rejected food after a break, problem feeders are less likely to reintroduce rejected foods, decreasing food variety. Additionally, problem feeders tend to refuse entire categories of food textures or nutrition groups, and they may exhibit more extreme behavioral responses, such as crying or gagging, when presented with new foods. This table emphasizes the need for early identification and tailored intervention for problem feeders, often involving a multidisciplinary approach that includes specialists like speech pathologists.

Table 3 Symptoms generally distinguish a “picky eater” from a problem feeder.

	Picky eaters	Problem feeders
Number of food that the child eats	Picky eaters generally eat at least 30 different foods	Problem feeders have a very restricted range or variety of foods and usually eat less than 20
What happens when people go on a food jag (eat the same food over and over, then suddenly stop eating it)?	Picky eaters will generally accept and eat that food after taking a 2-week break without eating it	Problem feeders will rarely ever accept that food again, even after taking a break, and this often results in a decrease in the number of foods in a child’s food range
Reaction to a new food on the plate	Tolerate new foods on their plate, and can usually touch or taste a new food, even if they do so very reluctantly	Cry, protest, and “fall apart” when presented with new foods. They completely refuse to do anything with the food
Do they eat at least one food from each nutrition (proteins, vegetables, etc.) and texture (purees, soft foods, chewy foods, etc.) categories?	Picky eaters eat at least one food from most food texture and nutrition groups	Problem feeders refuse entire categories of food textures or nutrition groups
Meal time	Frequently, they eat different foods at a meal than the rest of the family, but they usually eat with the family	They almost always eat different foods at a meal than the rest of the family and often don’t eat with the family (either eat at separate times or eat alone in a separate space)
How hard is it for them to learn about new foods?	Picky eaters will add new foods to their repertoire in 20-25 steps on the steps to eating hierarchy	Problem feeders add new foods in more than 25 steps on the steps to eating hierarchy
How often has the child been reported as a “picky eater” at well-child check-ups?	Picky eaters are sometimes reported by a parent as a “picky eater” at well-child check-ups. Picky eating has been happening for less than two years	Problem feeders are persistently reported by a parent as “picky eaters” across multiple well-child check-ups. Picky eating has been happening for more than two years

The picky eaters vs problem feeders questionnaire was created to assist healthcare providers in differentiating between picky eaters and children with more severe feeding disorders. This tool includes specific criteria, such as food variety, reactions to new foods, and behavioral symptoms during meals. For example, a key difference noted in the questionnaire is that picky eaters can typically tolerate or try new foods, even reluctantly. In contrast, problem feeders consistently refuse new foods and may experience distress when presented with them. The questionnaire guides healthcare providers in assessing accurately and developing appropriate treatment plans.

DISCUSSION

The round table discussion

This collaborative effort aimed to establish the first standardized regional protocol for diet fortification in the Middle East, specifically tailored to address the needs of children with mild to moderate picky eating behaviors. The virtual roundtable included regional experts with experience in nutrition and pediatric medicine, as well as insights into the Middle Eastern pediatric population. This enabled the development of regionally relevant recommendations that can be easily incorporated into the daily practices of pediatricians across the Middle East. The outcomes of this effort provide a foundation for improving the nutritional well-being of children with picky eating, offering practical and actionable strategies that healthcare professionals can adopt.

Strategies for the management of mild and moderate picky eaters

Identifying the picky eater: There has been no universally accepted definition for picky eating, making it challenging to identify and manage these cases[1,31]. The roundtable panel agreed on defining picky eaters as “Children who consume an inadequate amount and variety of foods through rejection of foods that are familiar, as well as unfamiliar, to them”, based on the definition by Dovey et al[31]. This definition provides a foundation for healthcare professionals to systematically screen for picky eating in clinical settings. By categorizing picky eating into mild, moderate, and severe forms[32], this protocol allows clinicians to better tailor interventions based on the severity of the child’s eating behavior. The severe type of picky eating, including avoidant restrictive food intake disorder with evidence of faltering growth[33], was not discussed in this article.

Evaluating the picky eater: Feeding difficulties in children can arise from various factors, and it is important to distinguish between non-organic causes and underlying medical conditions that may contribute to inadequate nutrition. The protocol recommends the use of growth charts and nutritional screening tools, such as nutrition screening tool for every preschooler, to assess the severity of the child’s nutritional risk[34]. This approach ensures that early intervention is prioritized, with prompt referrals for specialist evaluation when organic or behavioral red flags are detected. This systematic process of evaluation helps to improve clinical outcomes by addressing the underlying causes of picky eating behaviors.

Behavioral strategies: Picky eating not only affects the child but also significantly impacts parents and caregivers, often creating stressful mealtime interactions[35]. Behavioral strategies are key to helping parents and caregivers manage picky eating without exacerbating the issue. The protocol emphasizes the importance of positive reinforcement, meal planning, and avoiding pressure tactics, which have been shown to contribute to eating disorders in children[36,37]. Healthcare professionals can use these behavioral strategies to guide parents on how to create a supportive and low-stress environment for their child, encouraging better eating habits over time.

Nutritional intervention: Nutritional deficiencies are common among picky eaters, particularly for micronutrients such as zinc and iron[13]. Many strategies have been employed globally to address poor nutrition in picky eaters, including dietary supplements. Evidence from a recent study showed that children receiving both nutritional supplements and dietary counseling experienced significant improvements in their weight-for-height and body mass index compared to those receiving counseling alone. This finding underscores the value of targeted supplementation to address the specific nutrient gaps found in picky eaters.

However, in the Middle East, micronutrient deficiencies remain a persistent problem, and adherence to dietary supplements is low[18]. The use of food fortification-adding essential nutrients to commonly consumed foods-has been successful in many countries since the early 1900s, improving population-level health and nutrition[38,39]. For the Middle Eastern context, food fortification can serve as a viable public health strategy to prevent nutrient deficiencies in picky eaters. By incorporating fortified foods into their daily diets, children can meet their nutritional needs without the reliance on supplements, which have had low adherence rates in the region.

Nutrition care plan/pathway: The panel emphasized that while food fortification can help address general population-level nutritional gaps, it may not sufficiently target the specific needs of children with restricted dietary intakes. For picky eaters, individualized nutritional supplementation, such as ONS, offers a more precise intervention strategy[19]. ONS can be especially useful in ensuring that children with limited food variety receive the essential nutrients they might be missing[40]. The panel discussed the role of ONS in managing picky eaters, noting its advantages in providing concentrated sources of micronutrients that may not be consumed through regular meals[38]. This personalized approach allows healthcare professionals to create a tailored nutrition plan that aligns with the child’s specific dietary needs.

However, challenges remain with the long-term use of ONS, particularly in ensuring taste acceptance and adherence. Children may struggle with the taste or texture of ONS products, which can limit compliance[4]. Therefore, healthcare professionals must work closely with parents to explore strategies for improving adherence, such as incorporating ONS into familiar foods or using flavors children find acceptable. Additionally, ONS’s cost and availability may vary across Middle Eastern countries, which presents a barrier to access for some families[41].

Practical applications of the findings: The findings from this roundtable provide a clear, structured approach to managing mild and moderate picky eating in children. Pediatricians and healthcare providers can use the protocol to better identify children at risk of nutritional deficiencies, using growth charts and nutritional screening tools as outlined. By employing the behavioral strategies recommended, healthcare providers can educate parents on how to manage picky eating in a positive and supportive manner, reducing stress and improving the child’s relationship with food. The integration of food fortification and ONS into the care plan provides additional strategies for addressing micronutrient deficiencies, ensuring that picky eaters receive adequate nutrition for growth and development.

Limitations of the study

While this consensus statement offers a framework for dealing with picky eating in Middle Eastern children, there are several drawbacks. Generalizability may be reduced due to regional, cultural, and contextual differences. The policy recognizes the importance of cultural beliefs, but further research is needed to educate culturally sensitive practices. Resource limits in healthcare access and specialist availability need adaptability for a variety of environments. Furthermore, potential diversity in clinician judgment emphasizes the importance of standardized tools and training. Finally, being the first regional consensus, constant evaluation and modification are critical to the Middle East’s future efficacy.

CONCLUSION

This virtual roundtable discussion brought together experts to exchange opinions and review both nutritional and non-nutritional evidence-based strategies, current regional practices for diet fortification in picky eaters, and methods for developing a systematic approach to managing picky eating in the Middle East. The panel emphasized the need for a region-specific protocol to guide pediatricians and healthcare providers in effectively addressing the nutritional challenges mild and moderately picky eaters face. The panel agreed that for mild and moderate picky eaters, offering liked foods with enhanced nutritional value—whether through a food-first approach or the use of ONS can help meet the child’s nutritional needs, support growth and development, and alleviate mealtime conflicts. By providing this clear guidance, the protocol offers a practical and evidence-based tool for healthcare professionals to implement in their daily practice. These findings provide actionable strategies that pediatricians and healthcare providers in the Middle East can adopt to improve the nutritional outcomes of children with picky eating behaviors. The food-first approach, complemented by ONS where necessary, ensures that picky eaters receive essential nutrients while minimizing parental stress during mealtimes. Moreover, the structured nutritional care pathway and behavioral strategies recommended by the panel offer a comprehensive framework that can be applied to diverse clinical settings. This protocol addresses the current gaps in managing picky eaters and promotes long-term adherence to healthier eating habits by integrating culturally relevant recommendations. Healthcare providers can utilize the resulting algorithm to systematically assess picky eating in children, identify potential nutritional deficiencies, and develop individualized care plans that meet each child’s unique needs. The protocol equips pediatricians with practical tools to intervene early, preventing further nutritional deficiencies and mitigating the potential long-term impacts of picky eating on growth and cognitive development. Furthermore, using ONS as part of the intervention provides an effective solution for children who cannot meet their nutritional requirements through food alone. By implementing the findings from this roundtable discussion, healthcare professionals can improve their ability to manage picky eating in their patients, fostering better growth and development outcomes. The protocol also has the potential to shape future public health initiatives to address pediatric nutrition challenges in the Middle East. With its detailed and nuanced approach to diet fortification, the resulting algorithm is poised to provide practical, evidence-based guidance for pediatricians, nutritionists, and other healthcare providers. This protocol offers valuable insights for both regional practitioners and the broader global community engaged in pediatric nutrition, ultimately improving the health and well-being of children with picky eating behaviors.

ACKNOWLEDGEMENTS

Medical writing assistance for this manuscript was provided by the Medical Affairs Team at RAY-CRO under the supervision of Dr. Elgarhy R, Dr. Mokbel O, and Dr. Abotaleb O.