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

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 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 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